Challenging Dogma

Homophobia, Stigmatization and the AIDS Epidemic: A Psychosocial Critique of a Public Health Intervention Failure - Stephanie E. Baker

2006-12-19T23:17:00.000-08:00

Although the rate of HIV infection had declined in the United States between the mid-1980s and the mid-1990s, evidence now suggests that the number of HIV cases, mainly due to high risk sexual practices, is on the rise (CDC. Increases in HIV diagnoses, MMWR, 2003). The current HIV epidemic disproportionately affects men who have sex with men (MSM) by afflicting nearly half a million MSM in the United States alone, a startling figure which represents nearly half of all people living with HIV and 70% of all HIV infected male adults and adolescents (CDC HIV/AIDS fact sheet: HIV/AIDS among men who have sex with men. July, 2006). One way in which public health has responded to this epidemic, through sectors ranging from governmental agencies to religious advocacy groups, is through the implementation of a “use a condom every time” intervention. Given the dire, bleak state of the epidemic, wrought with rising statistics, it is clear that this behavioral change initiative has not been successful in alleviating the problem. Explaining this public health failure using reasons such as “AIDS burnout,” which results from years of exposure to prevention messages and safer sex practices (Ostrow, D.G., Fox, K., et al., 2004), is overly simplistic and could very well lead to an abandonment of the effort to help this at-risk population. Given that public health’s main goal is to promote health, prevent disease and prolong life through organized societal efforts, it is clear that a new approach is now necessary to intervene effectively in the problem. Both in content and delivery, the public health message to “use a condom every time” to reduce the spread of HIV/AIDS through high risk sexual behavior among homosexual men has been ineffective not only through individualizing the problem, but more so, in failing to address the fundamental psychosocial effects of homophobia and stigmatization in society.

One reason why the public health intervention of “Use a condom every time” is failing to reduce high-risk sexual behavior and the spread of HIV/AIDS among homosexuals is due to the message’s emphasis on individual- level risk elimination rather than on fundamental, more deeply routed societal factors. By focusing on total risk elimination rather than a more reasonable and attainable risk reduction strategy, the message lays out unrealistic goals and essentially sets the stage for the individual to fail (Siegel, 2004). If a homosexual has already engaged in sex without using a condom, the moment he hears this message, he views himself as a failure who has already put himself at great risk for HIV or AIDS. The homosexual recipient of this message adopts the fatalistic attitude that he has nothing more to lose and thereby continues to engage in high risk sexual practices. A facet of communication theory that the message to use a condom every time does not uphold is that the message must not cause harm or be offensive to the audience by blaming the victim (McGuire, 2001). By responding to the question of “What do I do if I think I am infected with HIV?” with “Remember, you must have engaged in behaviors that place you at risk for HIV infection…. those behaviors include unprotected sexual intercourse with an infected person,” not only reiterates the point that contracting the disease is the victim’s fault, but also could be perceived as having a parental tone of disappointment and condescension (“Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html). In addition, stating such an obvious fact about sex and condom use is an insult to a homosexual’s intelligence, as most all are certainly aware of the dangers unsafe sex poses. Even more detrimental than insulting homosexuals on an intellectual and emotional level, using the individual-level message to use a condom every time runs the serious risk of blaming the victim, which thereby clouds the more powerful issues of homophobia and stigmatization which need to be addressed. The underlying factors of homophobia and stigmatization in influencing high risk sexual behavior wouldn’t even cross one’s mind after reading intervention materials such as the CDC HIV/AIDS Fact Sheet (2006), which lists solely individual level factors such as “complex sexual decision making, seeking sex partners on the internet, and failure to practice safer sex,” as reasons for the current increase in unprotected anal intercourse. When developing an effective public health intervention, it is important to remember that complicated behaviors are not always simple personal choices but rather are deeply intertwined within a person’s environment, making them difficult to change on one’s own accord. In order to be effective, public health messages must recognize and respond to the influence of a stigmatizing social environment on the behavior of homosexual men and move away from focusing on the individual’s risk eliminating behaviors.

Communication theory (McGuire, 2001) has shown that utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends- it completely turns the recipient off, not only to hearing the message, but also to heading the content or advice contained within that message. The World Health Organization, which states as its main objective “the attainment of the highest possible level of health for all people,” induces this fear to a large extent not only through incessant repetition of the message to use a condom every time (eight times within a six page presentation), but also through the use of capital letters and bold font to strongly and forcefully drive the message home (http://w3.whosea.org/LinkFiles/Flip_chart_14_condoms.ppt.) Inducing fear without providing a way to alleviate such fear or anxiety could lead some homosexual men to engage in unprotected sex more frequently and more often than they would have prior to hearing this message. Admonishing a homosexual to use a condom every time could be perceived as a warning that his sexual partner could very well have HIV/AIDS already, so therefore wearing a condom each and every time for protection is an absolute necessity. In a public health message geared toward homosexual orthodox Jews, the very first sentence states, “Many people think that they won’t get AIDS, but anyone who in engages in sexual behavior with a person infected with HIV can get AIDS” (“Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html). For some homosexuals, this statement could form the fatalistic mindset that the risk of contracting HIV is so great, that they are bound to contract the disease at some point in their life anyway, regardless of how much protection they use and how often they use it. In addition, by bluntly stating that there virtually is no way to tell if the person they are dating has been infected with HIV, and by highlighting the fact that even condom use isn’t fool proof (“…on rare occasions, they can break”), this message heightens the level of fear that it has already begun to convey and leaves the recipient hopeless and understandably confused. Perhaps if a message is conveyed that utilizes softer tactics and provides realistic information which alleviates, rather than induces, fear, the audience would be more apt to comply with the health protection strategies contained within it.

Although most individual level behavior models are not adequate in and of themselves in getting to the root, fundamental causes of public health problems, the Theory of Self-Efficacy (Bandura, 1970) could help to explain part of the failure of the “use a condom every time” message. According to the Theory of Self-efficacy (Bandura, 1970), the extent to which a person believes they can master or be successful a certain behavior, they will perform that behavior. The theory outlines two types of expectancies that exert strong influence over a behavior: perceived outcome expectancy, which states that a certain behavior will lead to a certain outcome, and perceived self efficacy expectancy, which states that one can successfully execute the behavior to bring about the outcome. Any individual, regardless of sexual orientation, could very well not believe or have faith that he is capable of using a condom during every single sexual encounter. Therefore, this person would have a very low level of self-efficacy, and hence, will not perform the behavior of wearing a condom. In addition, if a homosexual’s potential partner dislikes or refuses to engage in sexual interaction using a condom, one perceived outcome of such a behavior could be the lack of an outlet to fulfill a homosexual’s sense of love and belonging, which is often negated within the homophobic surrounding in which he lives. Given that this outcome is far from a desirable one, he knowingly does not engage in the behavior of wearing a condom. It is easy to understand how one wouldn’t heed such an unrealistic, unattainable message as “a condom can’t do you any good if you don’t have one when you need it, so have plenty around where you could have sex” given the fact that a person knows that he isn’t capable such a task (OrthoGays. “Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html, www.OrthoGays.com). In reality, sex can occur in almost all locations, so exhorting someone to be sure they have plenty of condoms around for such times is impractical. By failing to be realistic and making extreme claims which few human beings, gay or straight, could achieve, the likelihood of the message to “use a condom every time” being successful in reducing high risk sexual behavior and HIV infection is minimal at best.

Relaying the message of “wear a condom every time” to homosexuals also could be perceived as making a negative value judgment against the homosexual lifestyle. By clearly outlining in a bullet point that one of the ways in which men who have sex with men (MSM) could prevent the contraction of HIV is to be in a long-term mutually monogamous relationship, the CDC HIV/AIDS Fact Sheet is actually suggesting that not enough homosexuals are involved in a committed, monogamous relationships, in which condom use every time isn’t as necessary or vital to prevent the spread of HIV/AIDS (CDC HIV/AIDS fact sheet, January, 2006). Surely, most everyone is aware that having intercourse with solely one person (who is HIV free) drastically reduces or even eliminates the risk infection, so by actually reiterating that piece of common knowledge on a fact sheet geared solely toward homosexual men could very well leave the recipients with feelings of worthlessness and devaluation by society. Similarly, stating that “If MSM choose to have sex outside a steady relationship, they should always use a condom… (and) should know their HIV status and that of their partner(s),” is a loaded statement that suggests or hypothesizes infidelity and the inability of homosexuals to hold down a stable relationship. As Odets points out, public health, most likely, would not be so free in delivering the same message to heterosexuals due to the fact that society respects the values that heterosexuals place on committed relationships (Odets, 1995). In addition, the message to use a condom every time takes away a homosexual’s informed judgment and the ability to make his own decisions, leaving him with a sense of lack of control, hopelessness and self-doubt. Interventions should give control back to the homosexuals so that they may make informed decisions for themselves, rather than being told from outsiders, who have little understanding what it’s like to be gay in today’s society, what they should or should not do. As one gay activist had powerfully noted regarding HIV prevention messages, “we have been ‘educated’ to death. Under the rubric of ‘safer-sex,’ and ‘HIV prevention,’ we've been told what to do and what not to do, shamed and guilted incessantly. We have been messaged and marketed a million times. We have been directed, instructed, commanded, suggested, harangued and manipulated -- all by people who believe that if you tell people repeatedly what to do or not to do with their sex, they will comply,” (Rofes, 1999). Given the fact that, in this day and age, the majority of homosexual men are well informed of the risks of unsafe sex, having any prevention message which fails to respect this knowledge will, as Adam foresees, “surely fall on deaf ears” (Adam, 2005). In fact, communication theory tells us that one of the criteria that needs to be met in order to develop a persuasive message is that the messenger is seen by the audience as a credible source of information (McGuire, 2001). Although homosexuals may acknowledge that the messenger is knowledgeable in its statistical and scientific information, the two components that comprise credibility- perceived honesty and similarity to the target audience- are not met within the homophobic society in which its is transmitted. It is evident that all individuals must be viewed within their prospective social context so that we in public health can begin to better understand the attitudes and emotions and powerful extenuating circumstances underlying such high risk behavior.

A critical reason why the public health intervention message of “use a condom every time” is currently failing to alleviate the problem of high risk sexual behavior and the spread of HIV/AIDS among the male homosexual population is due to the fact that the message is being conveyed within a homophobic society and ignores the negative psychosocial effects of homophobia and stigmatization of gay men that have a significant impact on problem. Studies have shown that growing up with anti-gay messages and derogatory jokes against gays leads to an internalization of such negative attitudes and results in high levels of psychological distress (D’Augelli & Hershberger, 1993). The presence of anxiety and depression, coupled with low self-esteem, may very well drive homosexuals to engage in self-destructive risky behavior with causal partners in an effort to help validate their attractiveness and self-worth, a validation which they don’t receive within a homophobic society. Homosexual respondents in a study by Stokes & Peterson (1998) emphasized disenfranchisement and hopelessness as reason for their high risk sexual behavior. Given that sex was a way to affirm that they are loved, valued and accepted, the respondents didn’t hesitate to act impulsively and unsafely. A desperate urge to feel needed, coupled with the hope of gaining love through a solid relationship, helped fuel their self-destructive behavior. When one thinks so low of himself, the message to wear a condom each and every time one engages in intimate sexual contact, understandably, wouldn’t hold much weight. Within a hostile, homophobic environment, homosexuals are deprived of the basic human needs of safety and security, love and belonging, and status or self-esteem (Maslow, 1943). In addition to denying homosexuals a sense of safety through the threat of verbal and physical violence and aggression, homophobia denies homosexuals emotionally-based relationships, the need to love and be loved, and to be accepted as a valuable part of the community. If a person is viewed in a negative light, as a homosexual very frequently is, he becomes increasingly susceptible to social anxieties, depression and loneliness, all of which rob him of this basic human needs of security. Even worse, the locations where homosexuals could seek belonging, such as the church and family, are often the very places where homosexuals are made to feel threatened, demeaned and demoralized the most. In one study, gay males indicated higher levels of self esteem and comfort with their sexual orientation if their parents were seen as approving of their sexual orientation and were important in their lives (Savin-Williams, 1995).

Both levels of self-esteem that Abraham Maslow (1943) outlines in his Hierarchy of Human Needs- the lower level comprising the need for respect from others, including positive recognition, attention and reputation, and the higher level consisting of the need for self-respect, including feelings of confidence, independence, and achievement- are also difficult for homosexuals to receive and maintain in today’s society. Low self-esteem and inferiority complexes, which ensue from a homophobic, stigmatizing society, were considered by Maslow to be at the root of most human psychological problems, such as depression. Because society doesn’t respect or value his lifestyle, a homosexual could very well begin to internalize those negative attitudes and feelings and develop self-loathing, which then leads to a search for respect and reassurance from others in order to validate oneself. When this validation isn’t received from outer societal outlets, but rather within the context of unprotected sexual relations, the vicious cycle continues. What’s worse, given that these needs are what Maslow has called deficiency needs, when a homosexual doesn’t receive them, he feels the need for them even more so. Studies have shown that unprotected anal intercourse is associated with high levels of depression and with low self-esteem and that there is clear progression from self-acceptance of homosexuality to increased self-esteem and decreased high risk sexual behaviors (Rotherman-Borus, Ried & Koopman, 1995, In: Stokes & Peterson, 286-287). Rather than leaving the message at “you need to use a condom every time you have sexual intercourse,” public health advocates should convey that they care about homosexuals as people and that they accept and value them for who they are (AVERT, http://www.avert.org/usecond.htm). Positive messages such as these would demonstrate that society wants what’s best for homosexuals and therefore would like them to engage in behaviors to protect their health and well-being. In addition, to maximize the effectiveness of the message, public health could transmit a more flexible, softer tactic that discounts the perceived benefits of the unhealthy practice of sex without a condom rather than solely focusing on negatively attacking the unhealthy behavior. For example, relaying the understanding that unsafe sex does not make someone desirable to their peers or is not the “cool,” or socially acceptable action to take, it could lessen its occurrence. By appealing to the values of the audience- values of love, acceptance and respect- the message is more likely to have a successful outcome. As one gay respondent in a Stokes & Peterson (1998) study aptly stated regarding the effort to decrease high risk sexual behavior among homosexuals, “If you can’t get them to improve on their own self-worth and help them to love themselves, it is a lost cause” (page 285). Lacking a sense of belonging and acceptance, along with adequate levels of self-esteem, the likelihood of a homosexual moving upwards on the hierarchy of human needs toward the human growth need of self-actualization and engaging in self health protection, especially through using a condom every time, is slim.

Homophobic attitudes within society create a “don’t ask don’t tell” atmosphere and very often set the stage for some homosexuals to engage in quick, secretive encounters which occur without protection. According to Labeling Theory (Becker, 1963), the labels applied to individuals influence their behavior. Those who are labeled in a certain way actually take on the characteristics of those labels and live up to them as a self-fulfilling prophecy. Through homophobic stigmatization, homosexuals are labeled as deviant, abnormal and highly promiscuous; therefore, a small subset of the gay community actually confirms, and helps to define, that label through frequent and unsafe causal encounters. Viewing themselves as morally at odds with those members of the rule abiding, normative, and homophobic society in which they live, these homosexuals see themselves as different from the mainstream and thereby feel they have little choice but to conform to the essential meaning of the judgment placed upon them. Focusing attention on the act of the individual by admonishing him to always wear a condom is clearly ineffective in intervening in this problem due to the fact that certain homosexuals, albeit a small sub-population, actually seek out these unsafe sexual encounters- the polar opposite effect that the message intends to bring about. “Barebackers,” men who seek out other men for unsafe sex, have been portrayed within the gay media as rebels who break away from their conformist peers (Suarez, T & Miller, J., 2001). Engaging in such self-deprecating and self-destructive behavior not only affirms the label that has been applied to the gay population by society, but also reveals that these men are actively seeking out attention, love and a sense of belonging, albeit in a fleeting and dangerous manner that ultimately will fail to nourish and sustain such needs. This reckless behavior, which essentially is a game of Russian roulette, displays just how low these men think of themselves and just how little self-worth they hold within them. As Green (1996) appropriately states, “...ignoring the role homophobia plays in the psychology of AIDS means ignoring an element of a disease at least as powerful as biology. If we care about health, there is little choice but to care about people’s feelings, too” (page 84). Rather than endorsing the message of “use a condom every time,” which essentially admonishes homosexual men to behave a specific, predetermined way within their intimate, personal relationships, public health should instead focus on expressing their care, concern and respect of the homosexual lifestyle. This strategy would hold great promise in creating a comfortable atmosphere that fosters open discussion rather than one that dismisses homosexuals as deviant and abnormal. Because the deviant behavior here is labeled as such by persons in positions of power, or our homophobic, masculinized society, the change that is warranted lies with altering society’s views, not with homosexual men’s actions. Perhaps if society’s moral indignation is replaced with tolerance and respect, the desired outcome of less unsafe sexual relations and an alleviation of the AIDS epidemic would be seen.

By shifting our attention away from the current proscriptive message to use a condom every time and toward the more proactive approach of addressing and combating homophobia, perhaps we in public health can begin to see a decline in the high risk sexual behavior and consequential HIV/AIDS epidemic among the homosexual population. One way in which public health could help to diminish or alleviate society’s homophobic attitudes and beliefs is through educational programs geared toward young children. By targeting people at a young age, a time in human development when one’s beliefs, attitudes and values are formed, and shifting the focus away from the dominant, heterosexual norm through an early introduction to alternative lifestyles, children will be much more likely to grow up viewing their homosexual peers with respect and acceptance rather than with disdain or degradation. Given that it is human nature to fear the unknown or that which is different, bringing the homosexual lifestyle to the forefront and shedding light on the fact that homosexuals share the same needs and values as their heterosexual counterparts would be an effective tactic in addressing the problem. Storybooks or television programs which portray healthy, loving relationships within families with homosexual parents could help debunk the negative stereotypes that permeate our society and break down the barriers to foster insightful discussion, both within the classroom and without. It is within this supportive, welcoming atmosphere that strides could be made not only in building up a homosexual’s self-esteem and sense of self-worth, which would help him to refrain from engaging in the unhealthy, self-destructive behavior of unsafe sex, but also in displaying to the greater community that homosexuals are no different than their heterosexual counterparts in their basic human needs for love, protection and respect. In fact, studies have shown that social support plays a prominent role in a gay man’s psychological well-being. It has been found that homosexuals who perceive themselves as having low social support are likely to be depressed and have lower levels of self-acceptance than those with high social support (Vincke & Bolton, 1994). Procuring the assistance of gay role models to invest in an educational, informational intervention would provide them with the confidence and self-respect they need to engage in healthier sexual practices which involve protection rather than destruction. Utilizing an opinion leader within the population to communicate these positive images is a tactic that holds a better chance of a message being accepted and embraced by the homosexual community, as it is known that the more similar in values the communicator is to the audience, the more likely the audience is relate to the communicator and, hence, the more likely they are to comply with the content of the message (Rogers, 1983). Just as homosexuals themselves have been successful in utilizing peer outreach tactics to reduce the rate of unsafe sex among their peers, so can we in public health be successful in reducing society’s homophobic attitudes (Keagles, Hayes & Coates, 1996). Creating a non-stigmatizing environment that provides social support and social networks could aid in the fight against the HIV/AIDS epidemic among MSM and serve as a protective barrier to a homosexual’s societal-induced vulnerability and consequential unsafe sexual practices.

It is clear that addressing the AIDS epidemic among homosexuals by utilizing an intervention which focuses solely on individual behavior modification distracts us, in public health, from seeing the deeper contributing issues of homophobia and stigmatization and their negative effects on homosexuals. Stigmatization and homophobia not only affect the perceptions and practices of individual homosexual men, they also hamper the provision of interventions that are effective, affirming, and tailored to meet the needs of the population (Valdiserri, RO; In Peterson & DiClemente, 2001). The public health message to “use a condom every time” exhorts gays to act safely in the present moment in order to maintain healthy selves for the future, but if life is perceived by them as not worth living in the here and now, the future is irrelevant. Although changing deeply entrenched homophobic attitudes and views is a daunting, difficult task at best, at least our effort to try to address them is a strong step in the right direction.

References

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Underneath the Red Dress: How the ‘Heart Truth’ Campaign Fails through its Rigid Design & Disregard for Social Science Variables-Susan Helwig Svencer

2006-12-19T13:04:00.000-08:00

Since 2003 the National Heart, Lung, and Blood Institute (NHLBI), a division of the U.S. Department of Health and Human Services, has promoted women’s cardiovascular health through a campaign entitled the Heart Truth, with a red dress as its symbol (www.hearttruth.gov ). The campaign focuses on increasing awareness that heart disease is the number one killer of women as a means of inspiring women to take action and lead healthier lives. Studies published on the Heart Truth website note that awareness of heart disease has increased among women since the program’s inception, but that women have not changed their cardiovascular-related health behavior (1). As a fundraising campaign among wealthier, Caucasian women, it appears to be effective, but as a true intervention among all women, it fails for a number of reasons. The campaign’s message will not have a broad reach due to its disregard for sociocultural and economic variables, as demonstrated through its narrow choice of communication channels and the promotional materials content. In addition, the environmental and economic variables that may significantly affect a woman’s receptivity to and ability to act on the recommended behavior changes were also ignored when the campaign materials were developed. And lastly, the theoretical basis on which the campaign is designed assumes awareness equates to action and does not capitalize on women’s stated drivers of and barriers to improved cardiovascular health.

The first means by which the Heart Truth scope is limited is through its prohibitive advertisement placement Women of lower socioeconomic status are considerably less likely to be exposed to the Heart Truth promotional materials as a result of the use of communication channels inaccessible to many women. While many of the campaign materials will reach middle-to-upper class women, others will not come into contact with them, confounding the campaign’s focus on all women.
The hallmark, annual promotional event for the Heart Truth takes place at New York’s Fashion Week, creating collaboration between the campaign and what the Heart Truth’s public relations firm deems “an industry intrinsically tied to the target audience” (2). However, fashion week’s target audience is a small subpopulation of women - mainly Caucasian and upper class – and focusing on fashion as a means of promoting the campaign reinforces the exclusion of the lower class. Furthermore, several high-end brands with upper class association are the primary fashion week sponsors, including Mercedes-Benz, IMG Models, Swarovski, Inc., and Olympus (2). A connection to fashion as well as these brands may reach wealthier women and generate favorable press for the campaign, but less advantaged women will certainly not be exposed to the Heart Truth messages through these fashion-related events.
In addition, large scale advertisements depicting women in red couture or former first ladies dressed in red were placed in 22 US airports. By displaying advertisements in airports rather than in more common locales, the Heart Truth circumvents women of lower socioeconomic status who are less likely to pass through an airport. Air travel frequency is significantly lower in households earning less than $25,000 per year than others, and in total, only 7% of long-distance trips within the US are by air (3, 4). Cost is the most-cited obstacle to increased air travel, meaning women without the expendable income to fly will not see the advertisements.
Public service announcements (PSAs) were also placed in numerous print magazines. While some of these (Essence, People En Español, BabyTalk) boast a relatively ethnically and financially diverse readership, several others do not. With a median household income between $80 and 90K, InStyle and Real Simple, two other magazine featuring Heart Truth PSAs, target affluent readers (5, 6). And arguably anyone reading Health and Balance magazines, where Heart Truth PSAs also appeared, are already proactive about their health and are not the population most in need of the Heart Truth’s messages.
The reach of the Heart Truth message is further restricted because the primary means of disseminating information to women is through the NHLBI’s website. Caucasians are nearly twice as likely to have internet access at home as are Blacks or Hispanics (7), and the same pattern emerges when overall use of the internet is examined. However, internet use is related to more than race: it is highly correlated to income level, education, and geographic region (8), rendering the Heart Truth health information less accessible or even unattainable to a large proportion of women. Moreover, even if women do have internet access, reading health information online has been shown to have little effect on the frequency of physician visits and even on the depth of overall health knowledge of the reader (9).

On top of the exclusionary dissemination of campaign information, the second way the Heart Truth message is constrained is by its disregard for the sociocultural context in which women receive their messages. Even if women are exposed to the Heart Truth materials, the content is not adaptable or even accessible to a diverse population.
Despite a stated focus on Latinas and African American women, the campaign information directed to each of these groups are only marginally different from the materials designed for the broader female population. The only changes made to the Latina and African American specific materials are images of women from each group and statistics specific to each population. Stating that “heart disease is more prevalent among black women than white women” (10) or that “nearly two out of every three Latinas are overweight or obese, increasing their risk of heart disease” (11) is not only uninspiring, it outright ignores the culture nuances that may significantly affect the health behaviors (i.e. level of physical activity and a healthy diet) that led to these statistics and an increased risk of heart disease. For example, Hispanic and Black women’s low level of physical activity has been shown to be influenced by factors different than that of white women, including family health, perceived social norms, access to neighborhood resources and facilities, as well as cost and time (12, 13). And while levels of smoking remain the same for Black and White women, Black women gain substantially more weight after smoking cessation than do white women (14) – a critical factor in getting women to quit smoking not addressed by the Heart Truth. By using race as an individual level, categorical variable, the NHLBI has overlooked the complexities of health disparities that arise when cultural factors are considered.
Intra-racial distinctions are another crucial determinant of health behavior that is overlooked by the Heart Truth. The campaign takes a one size fits all approach to its content, assuming, for example, that all Hispanic women respond and act in a similar way. However, attitudes towards smoking cessation and weight loss have each been shown to vary considerably within the broad Hispanic population, in some cases even by level of acculturation (15). In addition, a recent study among Black women suggests that those with strong religious beliefs have more interest in and higher actual consumption of fruits and vegetables than those with weaker religious beliefs and behaviors (16). Yet the Heart Truth communication materials do not even acknowledge intra-racial differences exist, much less allow their messages to be tailored to subgroups.
The advertisements placed in airports mentioned earlier in this article featured either mannequins dressed in red couture dresses designed for the Heart Truth by 21 prominent fashion designers or US First Ladies dressed in red suits. These images are concerning for several reasons. Rather than motivate women to better heart health, the former may serve to alienate those who cannot afford the glamorous dresses nor have an occasion to wear them. The First Ladies featured in the latter may not be recognizable to a large proportion of women. While these advertisements are no longer displayed in airports, First Lady Laura Bush remains the primary spokeswoman for the Heart Truth campaign, a polarizing figure even among those who can identify her. As purported through McGuire’s Communication / Persuasion Matrix, the source of information strongly affects its reception (17). In this case, women who can identify with Laura Bush and/or women who wear couture are more likely to be persuaded by the message being delivered through these print advertisements than are those who do not relate to the messengers, once again alienating women of lower socioeconomic status and non-white women.
The Heart Truth strongly suggests women develop a healthy relationship with their physician to determine their risk of heart disease and to set goals for achieving heart health. Yet in the general US population, distrust of the healthcare system is high and closely linked to a worse self-reported health, even after adjusting for socioeconomic status and access to health care (18). This distrust and resulting decreased participation in the healthcare system also varies considerably by race and culture – a fact conveniently disregarded by the Heart Truth. Significant racial differences (Caucasian vs. Black) in the level of trust in medical care have also been found to exist (19). Many have cited Tuskegee as a clear determinant of this mistrust among the Black population (20), but differences are also likely due to historical and personal experiences that are broader than that (21). Black and Hispanic residents in the south Bronx have expressed a “deep and pervasive distrust of the health care system, exasperated by difficulties that patients experience in communicating with their providers” (22). Specific to cardiac procedures, Black patients have also been shown to prefer they build a solid relationship with their physician before agreeing to undergo surgery, yet they consistently feel the trust they so desire is absent. These patients also report they are often confused by the cardiovascular health information they do receive, which could be unintentionally fostering these feelings of mistrust (23). Misgivings and suspicion toward organized medicine must be addressed before women can be expected to develop a strong relationship with their physicians, per the Heart Truth’s recommendations.

In addition to the economic and cultural oversights that limit the Heart Truth’s reach, many of the campaign’s lifestyle recommendations discount potential environmental and socioeconomic barriers. The Heart Truth fundamentally oversimplifies these issues by emphasizing, “Protecting your heart can be as simple as taking a brisk walk, whipping up a good vegetable soup, or getting the support you need to maintain a health weight” (24). Women are told to “choose a diet low in saturated fat, trans fat, cholesterol, and moderate in total fat” (25) without being informed how to do so. The Heart Truth website does provide women with recipes for heart healthy food, yet many of these recipes contain ingredients that may be difficult for women of low income and in disadvantaged neighborhoods to obtain, much less afford (i.e. Dijon salmon, zucchini lasagna, and peach cobbler (26). Strong links between socioeconomic status and food purchasing decisions have been found, with those of lower socioeconomic status being less likely to buy high fiber, low fat, salt and sugar foods, as well as fruits and vegetables (27). When low income women are provided financial supplements for the purchase of produce, they come closer to meeting dietary guidelines, as one of the key impediments (cost) to their purchasing is eliminated (28). For all women to adopt heart healthy eating habits, an understanding of the obstacles preventing such lifestyle changes is paramount. Unfortunately, the Heart Truth does not acknowledge that any barriers other than a patient’s willingness to change play a role in health behavior.
Lastly, the Heart Truth campaign was developed under the assumption that all health behaviors are rational, such that basic awareness of women’s heart disease risk will inspire action. Coupling this erroneous postulation, seemingly derived from the Health Belief Model (HBM), with the Heart Truth’s disregard for women’s stated influences of their health behavior has rendered the intervention ineffective at improving women’s overall cardiovascular health.
The Heart Truth campaign appears to have been built on the (HBM), as its primary aim is to make women understand they are highly susceptible to heart disease and that contracting it will cause considerable harm. According to the HBM, internalizing this susceptibility and potential severity should cause women to see the benefit in a behavior (in this case eating healthier, exercising, and visiting their physician regularly to prevent heart disease) and therefore cause them to intend to adopt the behavior (29). Yet this model assumes that obstacles to performing a given health behavior are minimal. It also does not take into account how attitudes and beliefs may affect uptake of a behavior, and assumes that all health behaviors are rational. Because these factors – most notably the existence and impact of obstacles as well as variable attitudes towards health – are excluded from the Heart Truth’s design, its reach is significantly constrained. This, however, could be rectified by incorporating components of other health behavior models (Bandura’s notion of self-efficacy or the social factors and attitudes that comprise part of Azjen and Fishbein’s theory of reasoned action) (30) to address the obstacles women face in adopting behaviors beneficial to their cardiovascular health.
NHBLI surveys suggest awareness that heart disease is the number one killer of women has risen from 34% to 55% since 2000 (1), as well as that women do recognize the red dress as a national symbol of heart health (31). However, data also show that few behavior modifications have been made as a result of this increased awareness (32). Through several studies, women have cited numerous barriers to their taking preventive health measures. First among these is confusion in the media (1, 33). With conflicting information regarding the benefits of various diet changes and exercise regimens, are women supposed to accept the Heart Truth’s recommendations at face value? It is unfair and unrealistic to assume that they will. Caretaking responsibilities and family obligations are also commonly noted impediments to behavior change. And interestingly, women who do take action note that they do so for their family as opposed to for themselves. These attitudes reveal an important driver of health behavior that should be used as a motivator and as a means of helping women address many of the barriers they face. Unfortunately, the Heart Truth has ignored these data points because they are inhibited by the rigid, illogical structure of the HBM.

Through the Heart Truth campaign, the NHBLI has the opportunity to improve the cardiovascular health of considerably more women than it is currently affecting. By expanding its use of communication channels and rethinking its advertisement placement, the Heart Truth could more thoroughly expose women of lower socioeconomic status to its messages. Adjusting the content of promotional materials to take social and cultural as well as environmental and economic factors into account would make the messages and behavior modification recommendations more realistic and accessible to both women of color and disadvantaged women. Incorporating the factors women explicitly say affect their health behavior into the campaign, as well as acknowledging that obstacles to adopting a given health behavior do exist (potentially through the use of behavioral models beyond the HBM), would serve to make the intervention a powerful resource and means of affecting health behavior change. If these modifications can be made, the Heart Truth still has a chance to make a true impact and meet the goal of not only reminding women of the need to protect their heart, but also inspiring them to do so.

References
1 Getting the message: Heart Disease is the #1 Killer of Women. 2005. Available at: http://www.nhlbi.nih.gov/health/hearttruth/whatis/message.htm. Accessed October 22, 2006.
2 Ogilvy Public Relations Worldwide. Case Studies: the Heart Truth. DATE?. Available at: http://www.ogilvypr.com/case-studies/heart-truth.cfm. Accessed November 3, 2006.
3 U.S. Department of Transportation, Bureau of Transportation Statistics. 2001 National Household Travel Survey Data. Long Distance Passenger Travel. Available at: http://www.bts.gov/publications/transportation_statistics_annual_report/2004.Accessed October 29, 2006.
4 U.S. Department of Transportation, Bureau of Transportation Statistics. 2001 National Household Travel Survey Data. Long Distance Travel by Income, Gender, and Age. Available at: http://www.bts.gov/publications/transportation_statistics_annual_report/2004.
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5 Time, Inc. October 18, 2006. In Style secures its third consecutive readership increase. Available at: http://www.timeinc.com.au/news/IN_STYLE_News/10_8_2006_IN_STYLE_secures_its_third_consecutive_readership_increase.aspx. Accessed November 11, 2006.
6 Real Simple Media Kit. Spring 2006. Available at: http://www.realsimplerewards.com/rsn/mediakit/PDFs/RS06demos_0506.pdf. Accessed November 11, 2006.
7 US Census Bureau. Computer and Internet Use in the United States: 2003. Available at: http://www.census.gov/prod/2005pubs/p23-208.pdf. Accessed October 22, 2006.
8 National Telecommunications and Information Administration. US Department of Congress, July 1998. Falling Through the Net: Defining the Digital Divide. Available at: http://www.ntia.doc.gov/NTIAHOME/FTTN99/part2.html. Accessed, October 27, 2006.
9 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and E-mail for Health Care Information. JAMA 2003 May; 289(18):2400-6.
10 U.S. Department of Health and Human Services. September 2003. The Heart Truth for African American Women: An Action Plan. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_aa.pdf. Accessed October 22, 2006.
11 U.S. Department of Health and Human Services. September 2003. The Heart Truth for Latinas: An Action Plan. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_latina.pdf. Accessed October 22, 2006.
12 Keller C, Fleury, J. Factors related to physical activity in Hispanic women. Journal of Cardiovascular Nursing 2006 Mar-Apr; 21(2):142-5.
13 Schrop SL, Pendleton BF, McCord G, Gil K, Stockton L, McNatt J, Gilchrist VJ. The medically underserved: who is likely to exercise and why? Journal of Health Care for the Poor and Underserved 2006 May; 17(2):276-89.
14 Sanchez-Johnsen LA. Smoking cessation, obesity and weight concerns in black women: a call to action for culturally competent interventions. Journal of the National Medical Association 2005 Dec; 97(12):1630-8.
15 Kerner JF, Breen N, Tefft MC, Silsby J. Tobacco use among multi-ethnic Latino populations. Ethnicity & Disease 1998; 8(2):167-83.
16 Holt CL, Haire-Joshu DL, Lukwago SN, Lewellyn LA, Kreuter MW. The role of religiousity in dietary beliefs and behaviors among urban African American women. Cancer Control 2005 Nov;12 Suppl 2:84-90.
17 McGuire WJ. Input and Output Variables Currently Promising for Constructing Persuasive Communications. In R. E. Rice & C. K. Atkin (Eds), Public Communication Campaigns (3rd ed., pp. 22–48). Newbury Park, CA: Sage Publications.
18 Armstrong K, Rose A, Peters N, Long JA, McMurphy S, Shea JA. Distrust of the health care system and self-report health in the United States. Journal of General Internal Medicine 2006 Apr; 21(4):292-7.
19 Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and trust in the health care system. Public Health Reports 2003 Jul-Aug; 118(4):358-65.
20 White, RM. Misinformation and misbeliefs in the Tuskegee Study of Untreated Syphilis fuel mistrust in the healthcare system. Journal of the National Medical Association 2005 Nov; 97(11):1566-73.
21 Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? Journal of the National medical Association 2005 Jul; 97(7):951-6.
22 Kaplan SA, Calman NS, Golub M, Davis JH, Ruddock C, Billings J. Racial and ethnic disparities in health: a view from the South Bronx. Journal of Health Care for the Poor and Underserved 2006 Feb; 7(1):116-27.
23 Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Medical Care 2002 Jan;40(1 Suppl):I27-34.
24 What Are the Risk Factors for Heart Disease? 2003. Available at: http://www.nhlbi.nih.gov/health/hearttruth/lower/risks.htm. Accessed October 22, 2003.
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27 Turrell G, Hewitt B, Patterson C, Oldenburg B, Gould T. Socioeconomic differences in food purchasing behavior and suggested implications for diet-related health promotion. Journal of Human Nutrition and Dietetics 2002, Oct; 15(5):355-64.
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31 Harris Interactive. One in Four U.S. Women Recognize the Red Dress as the National Symbol for Women and Heart Disease Awareness. January 2005 Commissioned by WomenHeart: the National Coalition for Women with Heart Disease. Available at: http://www.nhlbi.nih.gov/health/hearttruth/whatis/reddress_recognized.htm. Accessed October 22, 2006.
32 Lifetime Women’s Pulse Poll. New Lifetime Poll Shows More Than Half of Women Know Heart Disease is their #1 Killer, Yet Only One in Three Believe They are Personally At Risk. Released February 1, 2006. Available at: http://www.nhlbi.nih.gov/health/hearttruth/press/risk_awareness.htm. Accessed Octoer 22, 2006.
33 Mosca L., Mochari H, Christian A, Berra K, Taubert K, Mills T, Burdick KA, Simpson SL. National study of women's awareness, preventive, and barriers to cardiovascular health. Circulation 2006 Jan 31; 113(4):525-34.

How the Framing of Mental Illness in Public Health has Contributed to the Social Problem of Stigma - Lisa Pinnow

2006-12-19T08:46:00.000-08:00

Mental illness, defined by the National Mental Health Association is “a disease that causes mild to severe disturbances in thinking, perception and behavior”. (NMHA) Over 44 million people suffer from mental health disorders each year and yet only one-third are diagnosed. (Bossolo) In this paper I will criticize public health for not including mental illness as an integral part of the public health system. Like cancer and other physical diseases this illness can be stabilized and even cured. However, unlike other chronic and infectious diseases, it bears a heavy stigma due to the prejudice associated with mental illness. The Labeling Theory states that society has certain norms and rules that individuals must follow and failure to adhere to these rules defines abnormal behavior. The mentally ill are often discriminated against because their behavior does not always correspond with that of the general public. (SparkNotes) Limited access to information from the public health community has caused society to fear and reject those with mental illness. The lack of empathy and misunderstanding towards this illness has created emotional, physical, and social barriers.

The treatment of mental illness has come a long way since the prehistoric treatment of spells and rituals and the barbaric lobotomies of the 1940s. (History of Psychiatry) The history of mental illness demonstrates how deep its roots of rejection extend. The first asylums in the United States during the 19th century were established to ‘remove people with mental illness from the flux and disorder of urban life and to provide them with orderly regimens that could bring equilibrium to their disordered minds’. (Link) In 18th century England, the first hospital to accept mentally ill patients allowed the public to pay a penny to see those labeled as ‘lunatics’. (Wikipedia) The stigma of mental illness has been created over time due to society initially believing that mental illness was controlled by the sufferer, however, when it wasn’t, they were labeled as unpredictable and considered a community risk. The portrayal of the mentally ill as violent, erratic, and unstable has contributed to the negative attitude of society, often viewing these individuals as a threat to the community. Over time this negative response has created a stigma of mental illness, which has affected acceptance and course of treatment. These stereotypes have shaped the misconceptions of mental illness and are the basis for related stigma and discrimination.

Public health has fallen short in creating parity between mental, infectious and chronic diseases in terms of discriminatory limits on treatment and insurance. Mental illness is a term that groups together all illnesses affecting the brain, in the same way that heart disease groups together illnesses affecting the heart. With this in mind, shouldn’t mental illness be treated in the same way as infectious and chronic disease? Individuals who have experienced heart attacks often fully recover, which can also be true for someone who has been appropriately diagnosed and treated for a mental illness. But most of the general public is unaware of this because information about mental illness is not readily available. The lack of similarity in treatment of these patients compared to those with other diseases such as diabetes, heart disease, and obesity has contributed to the stigma of mental illness. The significant level of inequality in treatment has enhanced negative public opinion.

Prevention and intervention are major factors in treating physical health, but these factors do not apply in the treatment of mental illness. Obesity is one example of a physical illness that has become a public health precedent. As a result of the growing epidemic of obesity, it has become a priority of public health. The publicity about obesity not only has caused society to become more comfortable discussing it but also the discrimination associated with this topic has declined. Obesity is now considered to be a disease and that being overweight is a symptom. In 1985, Tufts-NEMC’s opened the Obesity Consultation Center, which offers patients several weight loss options to maintain a healthy weight and prevent health problems that can accompany excess weight. (Tufts) The problems of obesity have also created a niche in marketing by selling a range of larger items for those who suffer from this disease. Mental illness is not as highly publicized nor is the general public knowledgeable or comfortable in dealing with the subject. Where is public health’s intervention and prevention for mental illness?

There have been multiple programs launched to educate society, however, the success rate is too small to change the cultures of the time. The public health system has failed in their responsibility to educate the entire population about mental illness. A substantial number of the population with mental illness do not seek medical treatment due to fear of prejudice, rejection, and misunderstanding. Without treatment this can also cause other health risk behaviors such as smoking and binge drinking.

Public health needs to change the way that society and health professionals perceive those who are mentally ill. Health professionals’ awareness and knowledge about the multiple components of treating the mentally ill is inadequate due to the fact that many are misdiagnosed. Incorrect diagnoses and labeling can cause various negative side effects for patients being treated. One major component of treating patients is the many cultures that make up the population within the United States. For instance, some cultures look disapprovingly or do not believe in expressing emotion and/or weakness so they often do not obtain treatment. Public health has failed at properly training and educating professionals in cultural competence. Health professionals have a duty to assist those who are ill however, particularly in treating mental illness some clinicians can sometimes cause more harm than good. It is also important to realize that health professionals are individuals with personal beliefs and opinions too and their attitude may affect those they treat. They also have the task of improving public opinion about mental illness and providing resources to educate and therefore reduce the stigma.

The media is often used to sway public opinion. Unfortunately, the media often belittles and degrades those who are mentally ill therefore influencing society to reject the mentally ill. Frequently, the news portrays those who are mentally ill as violent and dangerous and labels them as ‘crazy’ or ‘mad’. Media adds to the reservoir of this stigma by presenting the mentally ill as unacceptable. Yet public health does nothing to correct the inaccurate information that is communicated to society.

An example of media misrepresenting mental illness is “Crumbs”, a new sitcom about two brothers who return home to deal with their mother who is being discharged from a psychiatric facility. (ABC) The National Mental Health Association (NMHA) requested that ABC pull the sitcom because it did not only make light of someone with a serious mental illness but depicted mental health professionals as unethical. (MHA) One episode revealed the main character having an affair with an orderly while receiving treatment for their mental illness. (MHA) Although this series did not last through its first season it fed on the stigma surrounding mental health by poking fun at it.

According to the American Psychological Association in 2004, 87% of the population lacks insurance coverage and 81% of Americans state that high costs keep them from seeing a mental health specialist. (Bossolo) As a manager in an outpatient psychiatry department I have seen firsthand how caps on inpatient days, outpatient visits, and limited mental health insurance coverage only hurt and financially burdened the mentally ill. By limiting mental health benefits and coverage the public health is setting the example to society that it is less important than other diseases. Even those patients with insurance are often restricted in terms of their treatment options because of the high costs of treatment and the yearly limits on mental health visits with a varying scale in copayments. The public health system has to realize that individuals with mental illness need treatment in order to manage everyday life and some treatments require visiting their clinician weekly for medication and/or psychotherapy. Lack of treatment for mental illness due to the high cost or lack of access can also cause the patient to suffer concurrent physical illnesses such as high blood pressure, and high blood cholesterol and asthma.

Changing the culture of society to accept and equally treat the mentally ill will not occur in one day or one year. The current programs working towards educating the public and reducing the stigma of mental illness are not sufficient enough to accomplish this goal. The American Psychiatric Association’s 2006 Consumer Survey on Mental Health stated that “forty-four percent of American adults report knowing only ‘a little’ or ‘almost nothing at all’ about mental illness”. (2006consumersurveyfacts) There needs to be a large-scale campaign to educate the population and reduce the stigma such as the World Psychiatric Association’s International Programme to Fight the Stigma and Discrimination towards schizophrenia. (Open) This campaign should be about educating society about mental illness and fighting the associated stigma and discrimination of all mental illnesses, not just schizophrenia.

To change culture, the entire population must receive accurate information about mental illness and the seriousness of mental health. The public health system has to study how best to reach different subpopulations within our society and find ways to combat the stigma. Educating society about mental illness will decrease the prejudice and ignorance towards the mentally ill. If mental illness received as much publication as other diseases or even dangerous habits such as smoking, the general public’s negative attitude would change towards the mentally ill. Resources such as presentations, the media, celebrity experiences, posters, ads, newspapers, magazines and in the classroom must be utilized to reach out to the greater population.

One way to reach the general public is through our many avenues of communication and technology that exist today. Each day mass media bombards us with images and messages from the moment we get up in the morning until we drift off to sleep each night. Television for example, can be a positive method to create worldwide awareness. Popular programs such as 60 Minutes, Dateline, sitcoms and the general news should use the fact that they are broadcasting on national television (or even internationally) and use that time to educate the public. By interviewing professionals and the general public about their experiences with mental illness others might be able to understand and learn that they or someone they know needs treatment. Knowledge and information about where to seek treatment would open the door for individuals who need a starting point. Mike Wallace of 60 Minutes is a perfect example of a celebrity who has discussed his experiences with clinical depression and treatment on television and today leads an accomplished life. (NMHA) His message to the world makes people realize that they too could lead a fulfilling life by seeking treatment.

For those who do not watch or own a television other means of teaching the public about mental illness should be emphasized. The public health system needs to promote the importance of mental health and also to teach that mental health disorders are similar to any other disease. Standards need to be established to ensure that accurate and positive information is publicized. Another possibility would be establishing and promoting more advice hotlines, so individuals would have the opportunity to speak with a professional about mental illness. By creating a safe environment for individuals to obtain more information hopefully more will seek help for themselves, family, or friends. The public health system should also educate students about mental illness. Today many children see mental health professionals for a multitude of reasons such as learning disabilities, family issues, peer pressure, attention deficit disorder and attention deficit hyperactivity disorder. Those that do see a mental health professional often feel segregated due to fear of rejection from their peers. However, given positive information about mental health students will learn how to deal with their thoughts and feelings and as a result will therefore gain self confidence. Children must also learn to use and understand the meaning of the correct terminology so they will not label others as crazy, unstable or unusual. Not only will this have a positive impact on their experience at school and their education but also opening them up to treating other individuals equally.

Public health also must educate and train health professionals to clearly diagnose patients. The numerous cultures that exist within the United States are an important dynamic that health care professionals need to focus on in the management of the mentally ill. The need for education and training in cultural competence is essential in order to clearly diagnose and treat patients. (Link) Health professionals need to be aware of the effects of culture and ethnicity particularly in the field of psychiatry since symptoms of mental illness are diagnosed from verbal and nonverbal cues, eye contact and facial expression of the patient. (Vedantam) Due to the difference in cultures, simple facial responses have different meanings, for example for some cultures eye contact is a sign of disrespect. Failing to acknowledge the many differences in cultures that exist not only discourage the mentally ill from seeking help due to fear of misinterpretation but also correlates with the stigma.

Public health officials need to create a uniform policy for both mental and physical health services and the corresponding insurance coverage. This policy should include equality for coinsurance, deductibles, and day and visit limitations and maximum out of pocket caps. (Bossolo) The mentally ill would more apt to seek treatment if insurance coverage and policies for mental health benefits were equivalent to those of infectious and chronic diseases. Mental illness is a disease that requires immediate action and treatment as in any other illness.

The stigma of mental illness began long ago and has not only increased but has become an inherent part of our culture. Negative terminology and labeling that results from discrimination has delayed many individuals and their families from seeking medical and psychiatric care. When you consider the medical advances public health has made in the treatment of infectious and chronic diseases, mental illness has actually progressed very slowly. The stigma associated with this disease has limited the access to care. Although there have been several mental health commissions, policies and procedures created to help the mentally ill these initiatives do not begin to compare to the advances in other biological, physical and environmental illnesses. (WebMD) Going forward public health needs to focus on not only the treatment of the population of the mentally ill, but also work to eliminate the stigma of mental illness. Public health needs to wage an aggressive war to combat the lack of education, knowledge, and prejudice against mental illness.

Bibiolography:

Mental Illness and the Family: Stigma: Building Awareness And Understanding About Mental Illness. National Mental Health Association. Retrieved October 17th, 2006 from, http://www.apa.org/releases/insurance.html

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Pols, Dr. Han. September 1, 2003. History of Psychiatry. Retrieved October 27th, 2006 from, http://www.usyd.edu.au/hps/course2003/3010.html

Link, B. G. PhD, Phelan, J. C. PhD, Bresnahan, M., MPH, Stueve, A., PhD, and Pescosolido, B. A., PhD. Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance. SB780 Course Reader. September 1999. Vol. 89, No. 9. Page 111.

Bethlem Royal Hospital. last modified November 16, 2006. Wikipedia Encyclopedia. Retrieved Nov 3, 2006 from, http://en.wikipedia.org/wiki/Bethlem_Royal_Hospital.

Obesity Consult Center. Tufts-New England Medical Center. Homepage. Retrieved on December 1, 2006 from, http://www.obesityconsult.org/

ABC, Inc. “Crumbs”, About the show. Retreived on November 16, 2006 from, http://abc.go.com/primetime/crumbs/about.html

NMHA Requests That ABC Immediately Pull Crumbs from Broadcast. National Mental Health Association. Retreived on November 16, 2006 from, http://www1.nmha.org/newsroom/stigma/crumbs.cfm

National Mental Health Association Fact Sheet: Mental Illness. National Mental Health Association. Retreived on November 18, 2006 from, www.nmha.org/infoctr/factsheets/14.cfm

American Psychiatric Association. April 25, 2006. American Psychiatric Survey, Fact Sheet: Consumer Survey on Mental Health. Retrieved October 27th, 2006 from, http://healthyminds.org/multimedia/2006consumersurveyfacts.pdf

Open the Doors. Information on the Global Program. Retrieved on December 3, 2006 from, http://www.openthedoors.com/english/01_01.html

Vedantam, Shankar. MIND AND CULTURE: Psychiatry's Missing Diagnosis Racial Disparities Found in Pinpointing Mental Illness. Washington Post. Tuesday, June 28, 2005; Page A01. Retreived on November 20, 2006 from, http://www.washingtonpost.com/wp-dyn/content/article/2005/06/27/AR2005062701496.html

WebMD, Mental Health: Causes of Mental Illness, Medically reviewed by Cynthia Haines, MD, July 2005. Retreived on November 30, 2006 from, http://www.webmd.com/The National Health and Medical Research Council of Australia. 2001. Mental Illness: The Facts. Mental Health Matters. http://www.mental-health-matters.com/articles/print.php?artID=656

HIV Over 50: Stigma leading to insufficiency of prevention-Jessica B. Castronovo

2006-12-19T06:22:00.000-08:00

Introduction
Over the past 25 years, HIV/AIDS has been affecting many aspects of society at astonishing rates. Public health practitioners (doctors, policy makers, educators, etc) in all spheres of influence have been working hard to put together comprehensive and effectual prevention efforts targeting those at risk for HIV/AIDS infection. Unfortunately these care providers have focused on small groups that are considered at risk due to their lifestyle (IV drug users, men who have sex with men etc). Many of these efforts have been considered successful. In their haste to address this very important issue of HIV/AIDS prevention, stigma has prevented practitioners from even identifying people over the age of fifty as a group at risk.

Older adults are living in a society where they are stigmatized because of their age. It is thought by much of society, and often themselves, that older adults are not vital, pleasure seeking individuals. As a result, older adults are not viewed as at risk for a HIV/AIDS, which is often considered a disease of the young and/or risk courting. The stigma of being older, combined with the stigma of the behaviors which put one at risk for HIV/AIDS infection are placing older adults at great and unnecessary risk of infection. Further more, Public Health has failed older adults in the realm of HIV/AIDS prevention. In many of the spheres that impact an individual’s life, where the various types of Public Health practitioners can intervene, there is scarce education, acceptance and care. In this paper I will outline and explore the failures of Public Health utilizing the Social Ecological Model, which draws the spheres of influence in a person’s life, going from the broad world of state and federal policy down to the individual interactions a person has. All spheres are places in which Public Health can intervene with prevention efforts-and often it is done, with other populations-but older adults are failed in multiple spheres.

Statistics
The US Centers for Disease Control and Prevention (CDC, 2003a) estimate that the number of adults over the age of 55 living with HIV/AIDS in the United States increased by at least 107% from 1998-2002. This is a larger increase then any other adult age group. Between 10% and as high as 18% of people living with HIV/AIDS are over the age of fifty and 25% of these cases are in persons over the age of 60 (Feldman, 1994). It can also be assumed that there is actually a higher rate of HIV/AIDS in the older adult population then the statistics reflect, but they have not been tested. Elderly have been found to be less likely to be tested the any other group (Doup, 1994; Feldman, 1994; Jones, 1999). In contrast, the rate of infection of children age 5 and younger is less then 1% of the AIDS cases (CDC, 1998). The level of perception of risk does not coincide with these statistics on infection, the CDC Behavioral Risk Factor Surveillance System, 2000 Survey reveal that among adult respondents age 55-64, 81% reported no risk for HIV and 15.1% reported a low chance of getting HIV (CDC, 2003a).

From the data, it is clear that HIV/AIDS infection is a real issue among older adults and in turn the responsibility of Public Health practitioners.

Societal Sphere of Failure
Social Structure, Policy and Systems are the broadest and largest level of influence when discussing the prevention of a disease from a public health standpoint. These influences may have been local, state or federal policies regulating prevention and care efforts. Overall very little has been done at the societal level to dispel society’s ageist views about older adults and their risk of HIV/AIDS.

When one thinks of HIV prevention campaigns, the most popular methods address the need to use condoms or clean needles. What is also apparent in these campaigns is a younger population is being targeted. There is usually flashy writing and young innocent or confused, attractive looking people making safer sex look enticing. Older adults have been left out of most HIV/AIDS prevention campaigns, including the brochure driven ones. Only 14 states in the United States have print information about HIV/AIDS geared specifically towards older adults (Apreal, et al, 2004). Nancy Oreal, et al also call into question the quality of the printed prevention efforts reaching the intended audience. The availability does not appear widespread or in multiple languages. The exclusive use of print material also leaves out the group of older adults who are illiterate. With the factor of illiteracy comes increased chance of poverty, substance abuse and depression-all increased risk factors for HIV/AIDS.

The lack of literature available has been found to be insufficent in fundamental ways. The focus of the literature geared toward older adults was primarily education. It usually included a list of facts pertaining to older adults higher risk factors for HIV/AIDS. States did include in their literature aimed at older adults myths and stereotypes around HIV/AIDS, basic facts about HIV/AIDS and basic STD prevention strategies (i.e. condom use). There was no mention of physiological aging factors, which have been linked to decreased immune systems; vaginal wall thinning and less vaginal lubrication may increase the risk of HIV in sexually active older women (Zablotsky, 1998). The mere fact that the ads and pamphlets do not generally include older adults perpetuates the normative myths surrounding older adults and their risk for HIV. Our society continues to believe that older adults do not engage in behaviors that put them at risk, which is not true. “An increasingly high percentage of newly identified AIDS cases in older adults are due to HIV transmission through risky sexual behaviors (Maes & Louis, 2003, ” especially male-to-male sexual contact (Strombeck &Levy, 1998). “Despite the dominant stereotypes of an ‘asexual older person’, studies on sexual activity among older adults showed that a high percentage (81.5%) of subjects over age 50 were involved in one or more sexual relationships (Inelmen, et al, 2005).”

Studies have been done to document the lack of impact Public Health prevention campaigns have had on the older adult community. The majority of people over the age of 50 with AIDS reported that they had not received very much information on prevention. When they did report receiving information about HIV/AIDS, it was through the mass media. In a focus group in New York City, older adults over the age of 50 relayed that they did not perceive HIV/AIDS prevention messages as targeted towards them. (Klein, et al, 2001). According to researchers Schable et al,1996 “…older women with heterosexually acquired HIV are less likely to have used a condom before their HIV diagnosis and less likely to have been tested for HIV.” when compared with older groups of women. This is a living example of the need for a condom use message not reaching an at risk population, whether it be not identifying with the issues of risk or not even getting the message of the importance of condom use. Older adults were raised to use condoms as birth control, making post-menopause pregnancy no longer a concern, and an issue that getting addressed. They are instead applying this condom use message to their children and grandchildren, not themselves.

Institutional Sphere of Failure
The medical community is a strong partner when it comes to addressing prevention and treatment of diseases. It is often relied upon to be a place of formal and informal rules and regulations. These are thought of as safety nets to teach people about disease and its prevention or treatment. The main line of defense in the medical community is thought to be the Primary Care Physician (PCP). In the area of HIV/AIDS education, prevention and treatment the PCP has fallen dangerously short.

At the heart of this failure is the issue that PCP’s buy into the ageist myths of older age equaling celibacy and sobriety (Engle, 1998). It remains easy for the PCP to ignore HIV/AIDS as an issue because elements of aging mimic symptoms of HIV/AIDS. Common symptoms of HIV/AIDS that can be attributed to aging are memory loss, loss of muscle tone and fatigue. Some studies show that “…over 90% of those 50 years and older have never had an HIV test (Maes & Louis, 2003).”

The result of ageist views of many PCP’s is a “don’t ask, don’t tell” standard of care around the subject of behaviors that would put an older adult at risk for HIV/AIDS. This can lead to serious consequences. As stated previously in this paper, the number of adults over the age of 55 living with HIV/AIDS increased by 107% from 1998-2002. This is the largest increase of all adult age groups (CDC, 2003a).

It is not to say that PCP’s do not discuss sexuality with their patients. There has been a large increase in the use of and acceptance of sexual enhancement drugs. The introduction of this class of drugs has increased the sexual potency of men and frequency of sexual intercourse. This increase in prescribing appears to have correlated with “an increasingly high percentage of newly identified AIDS cases in older adults “…due to HIV transmission through risky sexual behaviors (Maes & Louis, 2003)”. When paired with the hands off approach PCP’s have had of truly addressing older adult sexuality it can be dangerous. Additionally there does not appear to be a protocol that is followed for pairing education about HIV/AIDS with the prescribing of sexual potency medications.

In regards to the societal sphere’s potential interaction with the PCP’s, there is no current standard public health outreach to the medical community that serves to enhance awareness of older adults as an at risk population for HIV/AIDS. As an example, among PCP’s, there is no push to have the doctors ask a series of risk factor questions during the patient’s medical visit. In contrast, adolescents and young adults are asked standard questions about their sexual behavior and drug use-risk factors that are significant in both young and old.

Individual Sphere Failure
The most pointed and specific level of influence is the individual. This is where prevention efforts incorporate health behavior theory in order for people to change their behaviors. There have been very few interventions that have been implemented to target the older adult and their risk of HIV/AIDS. Among efforts that have been made to target older adults all are lacking in key elements that have made prevention efforts with other groups viable. Studies have shown that HIV/AIDS prevention efforts that teach sexual negotiation skills and increase availability of condoms improve self-efficacy, which is a key element to changing behavior. If an individual believes in a behavior or intervention and feel they can do it then they are more likely to follow through with that healthier behavior.

The theory of reasoned action is a particularly useful and informative way to identify effective intervention programs. In a study done by Jemmott & Jemmott (1991) surveying young black women, those who registered more favorable attitudes toward condoms and those who perceived subjective norms more supportive of condom use reported firmer intentions to use condoms in the next three months. Key behavioral beliefs are related to attitudes centered on the adverse effects of condom use on sexual enjoyment. Key normative influences were respondents' sexual partners and mothers. However, women's own attitudes were a stronger determinant of intentions to use condoms than were their perceptions of normative influences, particularly among women with above average AIDS knowledge. These results suggest that the theory of reasoned action provides a potentially useful conceptual framework for interventions to change a key AIDS risk behavior among women. In turn it can be expanded to other groups who have been stigmatized and disempowered (such as older adults).

In terms of research to establish effective prevention methods, very little HIV research has explored the channels and methods of communication that are more frequently used by, acceptable to, or effective with older people. The biological, psychological and social issues of people over the age of 50 need to be taken into account when developing a prevention program.

Current prevention strategies for older adults are more centered around providing information (safer sex, the etiology of HIV and modes of transmission). An example of this method is the Senior HIV Intervention Project (SHIP) originally located in the Dade, Broward and Palm Beach Counties of Florida. SHIP started in 1997 by the Department of Public Health in response to the dramatic increase in HIV/AIDS among the elders of Dade, Boward and Palm Beach Counties. It was recently discontinued in Palm Beach County due to the person running the program becoming too elderly to do so. There is one Educational Coordinator overseeing the program in Broward and Dade Counties. It is integrated with general HIV/AIDS prevention for all populations. This is a program which trains older adult peer educators to present educational and safer sex seminars at retirement communities, focusing on the etiology of HIV and modes of transmission and the importance of knowing one’s HIV status by testing. Trained AIDS educators meet with health care professionals and aging service workers to help them understand the risks posed to older adults by HIV. This is done in small group meetings (Agate, et al, 2003). While a step in the right direction, this program, along with others that are similar in Chicago, IL and Baltimore, MD, is missing a key element that would cause change on the individual level. While basic education is important, it can be shown repeatedly in public health that simply knowing about something does not guarantee that an individual will translate it into their daily lives. There is no emphasis on the concrete issues that put individuals at risk such as condom availability and sexual negotiation skills. Attacking HIV/AIDS prevention with emphasis on self-efficacy with development of personal attitudes towards condoms, discussing their partner’s status and making decisions based upon the information provided. Simply teaching how to put a condom on and how to ask a partner what their sexual history paired well with the education that SHIP and other programs like it would be the start to a better prevention model.

In discussions with the Educational Coordinator, she did acknowledge this deficit and has been trying to remedy this by offering the prevention education focusing on sexual negotiation and condom use to all ages. Unfortunately she has found that older adults have not been actively participating in these educational sessions. She did acknowledge that this is an issue, but has little funding to expand her programming to be more age and culturally sensitive.

It does not appear that much research has been done on whether the intervention of SHIP has made a real difference in people’s lives. What has been measured after exposure to SHIP and other programs like it are the participant’s level of knowledge about HIV/AIDS. There is no discussion about attitudes towards prevention techniques such as using the condom they are told will prevent HIV and negotiating the use of this condom. There was also no data available on rates of infection after exposure to the program. Incidences of HIV/AIDS have also increased in Dade, Broward and Palm Beach County since the introduction of this prevention program.

Conclusion
In conclusion, HIV/AIDS prevention has failed older adults in many spheres of influence in their lives. On a Systems level prevention efforts are obviously directed towards the young, IV drug users and men who have sex with men. On the organizational level, it is the medical community, captained by PCP’s where HIV/AIDS is rarely discussed with older adults and sexual potency medications are prescribed with little safer sex discussion. In the individual sphere, HIV/AIDS prevention methods are missing as a largely important part of prevention efforts-giving individuals life skills to deal with situations where they could be put at greater risk for HIV exposure. It is well documented in research done on prevention programs and programs aimed at changing people’s behavior that the most important determinant of the impact of a prevention effort is change in important attitudes translated into people’s true actions. There does not appear to be sufficient data to determine if the small prevention efforts have made a true impact, but with their emphasis on education and exclusion of theoretically supported necessary elements such as sexual negotiation and condom availability, they are failing older adults. Public Health must take responsibility for the increase in the HIV infection rate of older adults that is known (i.e. those who have been tested) and for the fact that the data in general on this issue is paltry and then change accordingly.

Bibliography
Agate, L.L, Mullins, J.M., Prudent, E.S & Liberti, T.M. (2003) Strategies for Researching Retirement Communities and Aging Social Networks: HIV/AIDS Prevention Activities Among Seniors in South Florida. JAIDS: Journal of Acquired Immune Deficiency Syndromes, 33 (2): S238-S242.

Centers for Disease Control and Prevention (1998). CDC: Basic Statistic-Cumulative Cases-United States, 2000.

Centers for Disease Control and Prevention. (2003a). Cases of HIV Infection and AIDS in the United States, 2002: Table 10. Estimated numbers of persons living with AIDS by year, and selected characteristics, 1998-2002-United Sates. HIV/AIDS surveillance report edition, 14 (2). Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

Coon, David W. , et al. (2003) Designing Effective HIV/AIDS Social and Behavioral Interventions for the Population of Those Age 50 and Older: Interventions and Research Methods for Use with Older Populations. JAIDS: Journal of Acquired Immune Deficiency Syndrome: 33(2): S194-S205.

Doup, Liz. The Aging of AIDS. Miami Herald: August 28, 1994; Section J; page 1; Column 1.

Engle, Laura. Old AIDS: Body Positive; 11:1. (www.bodypositive.com/bp/jan98/old_aids.html)

Feldman, Mitchell. (1994) Sex, AIDS and the Elderly. Archives of Internal Medicine:15:1, p19.

Gonzalez, Edith. Educational Coordinator of Boward and Dade County Senior HIV Intervention Program, Boward County Department of Public Health. Interview 12/7/2006.

Guiding Principles of the Florida HIV/AIDS and Aging Task Force. (amhserver.fmhi.usf.edu/shapre/HAATF-GuidingPrinciples2000.html)

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Jemmott, L.S. & Jemmott, J.B. 3rd . (1991). Applying the theory of reasoned action to AIDS risk behavior: condom use among black women. Nursing Research, 40(4):228-34.

Klein, S.J., et al (2001). Age-Appropriate HIV Prevention Messages for Older Adults: Finding from Focus Groups in New York State. Journal Public Health Management, 7(3): 11-18.

Maes, C.A. & Louis, M. (2003). Knowledge of AIDS, Perceived Risk of AIDS, and At-Risk Sexual Behaviors Among Older Adults. Journal of the American Academy of Nurse Practitioners, 15(11): 509-516.

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Orel, N.A., Wright, J.M & Wagner, J. (2004). Scarcity of HIV/AIDS Risk-Reduction Materials Targeting the Needs of Older Adults Among State Departments of Public Health. The Gerontologist, 44 (5): 693-696.

Schable, B., Chu, S.Y. & Diaz, T. (1996) Characteristics of women 50 years or older with heterosexually acquired AIDS. American Journal of Public Health, 86 (11): 1616-1618.

Sormanti, M., Wu, E., El-Bassel, N. (2004) Considering HIV Risk and Intimate Partner Violence Among Older Women of Color: A Descriptive Analysis. Women and Health, 39 (1): 45-63.

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Blast from the Past: Bringing Back Community Involvement and Positive Messages in Safer-Sex Interventions among Gay Men - Gadi Niram

2006-12-18T19:22:00.000-08:00

Introduction

The advent of the HIV epidemic among gay men in the 1980s led to strong efforts among gay men to combat HIV infection through the practice of safer sex. These efforts were tremendously successful, and infection rates “dropped precipitously” from the mid 1980s through the early 1990s. (Hammond, 2000). However, as the first generation of men living in the era of HIV have gotten older, the rates of infection among men who have sex with men have climbed, roughly tripling from 4822 new cases in 1993 to 14,819 new cases in 2005. (Centers for Disease Control, 1983-2005).

As the rates of infection have risen, the formerly positive (normative-reeducative) approach taken by those seeking to promote safer sexual practices among gay men has also undergone a drastic change. Early messages were positive in their tone. They recognized men’s need for sexual contact, showed condom use as a pleasurable activity, and addressed the target audience peer-to-peer and man-to-man. Unfortunately, these successful early approaches have largely been abandoned. While recent research has suggested that either a “shocking” (power-coercive) approach (Dahl et al., 2003) or a “rational and direct” (rational-empirical) approach (Marchand & Filiatrault, 2002) would be most effective, this paper will argue, using samples of both early and recent safer-sex messages, that given the fact that such rational or negative ads have predominated during a concomitant rise in HIV infection rates, it is time to consider a return to the earlier strategy of positively-framed HIV prevention messages, delivered from within the target community.

The Role of Human Needs

The early, normative-reeducative safer-sex messages demonstrated a clear understanding of Abraham Maslow’s hierarchy of human needs. Maslow recognized sex itself as a basic human need (Maslow, 1943), a recognition reflected in the early advertisements reviewed below. In these early campaigns, sex is portrayed as pleasurable with and because of—not despite—the use of condoms. “Love and affection, as well as their possible expression in sexuality” warned Maslow, “are generally looked upon with ambivalence and are customarily hedged about with many restrictions and inhibitions.” (Maslow, 1943) The early safer-sex ads recognize Maslow’s observations, and show the sexual needs of the target audience as something inherent to their being, and not as an aberrant behavior to be indulged in only under prescribed circumstances.

The early safer-sex ads also incorporate Maslow’s recognition of higher-order human needs, such as acceptance and self esteem. (Maslow, 1943) They treat the targeted men with respect, and as valued, competent adults. In contrast, the more recent ads reviewed adopt a scolding, coercive tone, fail to support men’s self-esteem as human beings with human needs, and treat them as fundamentally incompetent and in need of supervision in order to care for themselves.

The Power of Positive Messages

Safer-sex messages to gay men in the late 1980s and early 1990s came largely from gay community organizations, and not from public health organizations or practitioners from outside the gay world. The messages represented an in-group perspective, rather than making an appeal from authority. Further, they portrayed—even promoted—sex as a normal, expected behavior among the target audience, and highlighted the pleasure that could be had while still protecting oneself against infection. A 1984 poster shows a naked pair of interracial gay sex partners alongside the caption, “YOU CAN HAVE FUN (and be safe, too)” (San Francisco AIDS Foundation, 1984). A 1990 poster took the message a step further, shifting safer sex from merely being an activity to being a part of a person’s identity. Showing an attractive, shirtless man, the 1990 poster’s caption read, “BE A RUBBERMAN—USE A CONDOM EVERY TIME” (San Francisco AIDS Foundation, 1990). The message: someone who always uses condoms can be sexually desirable, and if you want to be with this “rubberman” you might consider being a rubberman, too.

A 1990 poster, part of a campaign called “red hot + blue”, says it directly: “safe sex is hot sex” (King Cole Inc., 1990). Two naked men are shown in what is clearly a pleasurable embrace. Slogans, including the above, frame the photograph. “USE A CONDOM EVERY TIME”, says the caption, certainly a realistic goal when the result is potentially the pleasurable encounter depicted. (Interestingly, the poster’s Spanish caption translates to “TAKE CARE OF YOURSELF, USE CONDOMS!” with no mention of using them every time. The comparison of English- and Spanish-language messages is beyond the scope of this paper.)

Fear and negativity

The early safer-sex posters carried simple, direct messages that relied on positive images of sex. The posters’ messages used images of the pleasure that could be had in a safer sexual encounter to promote condom use as an inherent component of sexual pleasure rather than as a condition to be fulfilled in order to make the sexual act acceptable. Compare to these earlier messages three more-recent advertisements aimed at preventing the spread of HIV in gay men. A 2001 poster (San Francisco AIDS Foundation, 2001) portrays an unsafe sex act between two men who, from the perspective of preventing HIV transmission, have already failed. In the accompanying caption, each man makes assumptions about the other’s HIV status, based on what he knows about the other man from earlier social encounters, the negative partner assuming he is not at risk of contracting HIV and the positive partner assuming he is not at risk of newly infecting someone. The campaign avoids completely the topic of condom use for protection and instead pleads with its audience to discuss HIV status with their partners before engaging in what it assumes will be unprotected sex. The campaign would appear to have given up, or at least considerably lowered its definition for success among its target audience. This weary advertisement not only promotes risky behavior, but it also subtly promotes the idea that past failure is permanent failure, obviating the need to further concern oneself with matters of health during sex.

A 2003 poster from an Irish organization has the familiar photograph of attractive men, but a radically different tone to its text (Southern Gay Men's Health Project (Ireland), 2003). It adopts the power-coercive tone of a scolding mother whose words carry an implicit assumption of failure: “If you want to be HIV positive”, the caption begins, “you can”:

Fuck without a condom
Assume everyone you have sex with is HIV negative
Assume it will never happen to you

“HIV infections,” it concludes, “are on the increase in young gay men.” The message is both fatalistic and discouraging, almost daring the target audience to violate its tenets. While this and the previous message are from gay or largely-gay organizations, they fail to adopt the in-group perspective of the earlier safer-sex campaigns.

The State of New York, in a 2005 campaign, also denies its target audience a sense of potential safety. “Age won’t protect you from AIDS” says the poster showing a well-dressed older man sitting in front of his birthday cake (New York State Department of Health, 2005). After the poster presents some alarming statistics, there comes this warning: “HIV prevention is a lifelong job.” The individual is told by a judgmental outsider that he has a job to do, with potentially lethal consequences should he fail.

The Limits of Fear

Given the respective changes in HIV infection rates during the reign of each approach, the normative-re-educative safer sex strategy used in the late 1980s and early 1990s would appear to be more effective than the currently recommended rational-empirical and power-coercive strategies used to communicate the benefits of a safer-sex and condom use. Focusing on the positive, communicating from within the target group, and designing messages to resonate primally rather than cognitively may allow future safer-sex campaigns to achieve the success of their predecessors.

Social psychologist Stephen J. Blumberg notes that:

increasing fear and anxiety [in HIV prevention messages] can have unintended consequences. The self-protective behaviors that are stimulated by fear may be fashioned to reduce directly the anxiety itself rather than the risk of contracting the disease (Blumberg, 2000).

Blumberg cites Morris and Swann, who demonstrated that when shown a fear-based HIV-prevention film,

sexually active college students (but not abstainers) reported reduced perceptions of risk for HIV infection, reduced interest in additional information about AIDS, reduced desire to be a peer AIDS educator, and reduced memory for AIDS-relevant information from the film. (Morris & Swann, 1996)

Morris and Swann’s experiment shows that if a fear-based message does not provide a realistic method of countering the risk it presents, the likelihood of these counterproductive behaviors increases (Devos-Comby & Salovey, 2002). Some HIV-prevention messages, including the aforementioned State of New York message targeting older men, fail to present any method of countering risk, or present only the option of abstinence (Ibid). Abstinence is an outstanding method of avoiding sexually-transmitted disease risk, including the risk of HIV, but abstinence is an expression of an existing value, induced by deep personal beliefs (Holman & Harding, 1996). For those people who do not hold abstinent values, an abstinent approach ignores Maslow’s characterization of sex as a basic human need, either physiologically or as an expression of love and affection. (Maslow, 1943) An advertisement or brief film is unlikely to induce sexually abstinent values in a sexually-active target audience, and a fear-based abstinence argument may have an effect opposite of what is desired. The weaknesses of today’s fear-based appeals are compounded by the fact that they very often originate or appear to originate from an authority figure or group external to the target of the prevention appeal.

The Appeal of Community

Community-based appeals have proven effective not only in the early HIV prevention campaigns, but also in communicating other public health messages. When disseminating information about a toxic chemical hazard, community members, including

unofficial local opinion leaders, the media (local and national), and networks of relatives and neighbors […] may have as much credibility with the public as official messengers. In fact, they often enjoy greater credibility (Fessenden-Raden et al., 1987).

A 1999 community-based project to increase mammography among African-American women discovered that when mammography was introduced essentially as a community value through the women’s churches, the participants “significantly increased…their practice of breast self-examination and mammography…compared with the women in the control [group] (Irwin et al., 1999).” The personal experiences of breast cancer survivors, presented to church members after worship as a regular church activity, helped dispel doubts the women had about the ability to cure cancer, and led them in greater numbers to seek medical approaches to dealing with cancer risk (Ibid).

Similarly, the message that gay men should use a condom every time they have sex can be effective (as it was in the past), but not when presented as a judgement by an authority figure external to the target population or as a goal that becomes useless after even a single failure to comply. Instead, as was done in early anti-HIV campaigns, condom use should be presented as an exciting, erotic option, suggested by a member of one’s desired or potential sex-partner pool.

Conclusion

In the late 1980’s and early 1990’s the gay sexual icon of the day was the ACT-UP kid. Clad in jeans, a t-shirt with a safer-sex message, and often sporting a necklace of freedom rings, a set of rainbow-colored rings that symbolized gay pride, these young gay disciples of the AIDS Coalition to Unleash Power conveyed a simple message: They were attractive, and they were potential sexual partners, but they would not engage in sex without the use of a condom.

The late 80s to early 90s was a period of remarkable success for safer-sex messages, as measured by decreasing HIV infection rates; indeed for the ACT-UP kids, the message crossed over from a health message to an essential component of their identity and even their fashion choices. Today, when HIV infection rates are rising, and safer-sex messages are failing to resonate with their target audiences and induce them toward safer sexual behavior, it is essential to reexamine the early period of anti-HIV campaigns and draw lessons on how to repeat that success today.

Among homosexually active men, HIV is perceived as less of a threat than it once was because therapies have improved, men communicate less with their partners about the risks involved in their sexual congresses, and community norms have shifted such that unsafe sex is no longer unacceptable (Morin et al., 2003). Shifting the public health message back to a sex-positive, community-based approach that makes safer sex once again a communal value is an important step in reversing the increase in new HIV infections. As author Douglas Crimp opines,

…AIDS will not be prevented by psychic damage to teenagers caused by ads on TV. It will only be stopped by respecting and celebrating their pleasure in sex by telling them exactly what they need and want to know in order to maintain that pleasure (Crimp, 1987).

Works Cited

Blumberg, S. J. (2000). Guarding against threatening HIV prevention messages: An information-processing model. Health Education and Behavior, 27(6), 780-795.

Centers for Disease Control. (1983-2005). HIV/AIDS surveillance reports.

Crimp, D. (1987). How to have promiscuity in an epidemic. October, 43(AIDS: Cultural Analysis/Cultural Activism), 237-271.

Dahl, D. W., Frankenberger, K. D., & Machanda, R. V. (2003). Does it pay to shock? Reactions to shocking and nonshocking advertising content among university students. Journal of Advertising Research(September 2003), 268-280.

Devos-Comby, L., & Salovey, P. (2002). Applying persuasion strategies to alter HIV-relevant thoughts and behavior. Review of General Psychology, 6(3), 287-304.

Fessenden-Raden, J., Fitchen, J. M., & Heath, J. S. (1987). Providing risk information in communities: Factors influencing what is heard and accepted. Science, Technology, & Human Valued, 12(3 & 4), 94-101.

Hammond, T. (2000). U.S. AIDS cases, deaths, and HIV infections appear stable: Center for the Advancement of Health.

Holman, T. B., & Harding, J. R. (1996). The teaching of nonmarital sexual abstinence and members' sexual attitudes and behaviors: The case of latter-day saints. Review of Religious Research, 38(1), 51-60.

Irwin, D. O., Spatz, T. S., Stotts, R. C., & Hollenberg, J. A. (1999). Increasing mammography practice by african american women. Cancer Practice, 7(2), 78-85.

King Cole Inc. (1990). Safe sex is hot sex.

Marchand, J., & Filiatrault, P. (2002). AIDS prevention advertising: Different message strategies for different communication objectives. International Journal of Nonprofit and Voluntary Sector Marketing, 7(3), 271-287.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Morin, S. F., Vernon, K., Harcourt, J. J., Steward, W. T., Volk, J., Riess, T. H., et al. (2003). Why HIV infections have increased among men who have sex with men and what to do about it: Findings from california focus groups. AIDS and Behavior, 7(4), 353-362.

Morris, K. A., & Swann, W. B., Jr. (1996). Denial and the AIDS crisis: On wishing away the threat of AIDS. In S. Oskamp & S. Thompson (Eds.), Safer sex in the 90's understanding and preventing HIV risk behavior. New York: Sage.

New York State Department of Health. (2005). Age won't protect you from AIDS.

San Francisco AIDS Foundation. (1984). You can have fun (and be safe, too).

San Francisco AIDS Foundation. (1990). Be a rubberman.

San Francisco AIDS Foundation. (2001). How do you know what you know? Phase 2.

Southern Gay Men's Health Project (Ireland). (2003). If you want to be HIV positive.

Exacerbating the Problem: Our Failure to Embrace Mental Health is Hindering Acceptance, Increasing Stigma, and Reducing Access - Justin Nyborn

2006-12-18T18:43:00.000-08:00

“A clear and complete insight into the nature of madness, a correct and distinct conception of what constitutes the difference between the sane and the insane has, as far as I know, not been found.” -Schopenhauer, The World as Will and Idea (as cited in Barlow & Durand, 2000).

Introduction

Open a scholarly journal or the health section of any newspaper in the U.S. and find a collection of highly debated and controversial health topics. The media uses its power of persuasion to dictate trendy and controversial topics and therefore has a powerful influence over the public health opinion of public health issues. Public health practitioners, themselves, the media’s source of public health information, have failed to focus on critical issues in public health. For instance, there are numerous interventions in public health aiming to prevent and treat chronic or infectious disease, but very little is being done to prevent mental illness. In the media, we hear and read about public health wars on drugs, tobacco, and obesity, but we never hear about a war on depression, schizophrenia, or bipolar disorder. We are currently not embracing mental illness with the same vigor and deserving attention as physical disorders. 22% of the U.S adult population has one or more diagnosable mental disorder in a given year and 10 million children in the US have a mental disorder that causes some level of impairment (MMWR, 2005). With numbers as high as these, it is clear that mental health must not be ignored, and further, public health practitioners must scrutinize why mental illnesses have not effectively been treated. Although organizations like the CDC, the nation’s premier public health agency, have begun to address and allocate funding for mental health with its public awareness campaign World Mental Health Day and its collaboration with the World Federation for Mental Health to address stigma, their efforts are secondary compared to their efforts in preventing and treating chronic physical diseases (MMWR, 2005).

Additionally, the failure of public health practitioners to treat mental illness also reflects their inability to treat physical diseases. The mentally ill tend to have higher rates of “all cause” morality (Osborn, 2001). In accordance, it is suggested that individuals with depression and psychosis such as schizophrenia have higher risk for cardiovascular disease (MMWR, 2005; Osborn, 2001). Individual health behaviors such as substance abuse, tobacco abuse, physical inactivity and increased rates of suicide are also correlated with mental illness (MMWR, 2005; Osborn, 2001). Pubic health practitioners spend time and resources searching for causes and treating these physical health conditions, but they ignore a large portion of the population that is at risk for these harmful health behaviors or illnesses.

The failure of public health to embrace mental health has resulted in negative consequences for individuals with a mental illness. The mentally ill feel a lack of acceptance by society and there is a stigma attached to mental illness, which has resulted in discrimination in these individuals (Corrigan, 2004; Barlow & Durand, 2000; Byrne, 2000). This lack of acceptance and discrimination has exacerbated the mental health problem and reduced the access to treatment in the population. Research by authors such as Kessler et al. (2003) have suggested that although there has been an increase in treatment of the mentally ill in the last decade, most mentally ill patients still do not receive treatment. Social and behavioral sciences such as education and psychology are necessary to explain why the failure of public health practitioners to embrace mental health is enhancing stigma associated with mental illness, hindering acceptance of mentally ill individuals, and creating barriers to accessing treatment which is making the problem worse.

Failure to Embrace Mental Health Hinders Acceptance of Individuals with Mental Illness

How does the failure to embrace mental health contribute to lack of acceptance?

Part of the problem with the failure to embrace mental illness is the fact that the public does not visualize themselves in the shoes of the mentally ill. The general public is not accurately informed of the daily struggles, obstacles, or level of functioning in these individuals. Public health practitioners need to further observe these individuals and take the time to understand their feelings and struggles that cause them to engage in negative behaviors or withdraw from society.

The theories of humanist psychologists Carl Rogers and Abraham Maslow explain the behavioral consequences when human beings feel a lack of acceptance. Their theories emphasize human needs one must satisfy to become a whole and adjusted individual (Carver & Scheier, 2000). Rogers believed that there is potential healthy growth in every living creature called self-actualization if there are no strong opposing influences inhibiting one’s potential. If one can maintain self-actualization, it enhances the self towards congruence and minimizes disorganization or incongruence (Carver & Scheier, 2000). This theory encompasses the belief that all individuals have the need for “positive regard”, or love, friendship, and support of others. (Carver & Scheier, 2000). Abraham Maslow elaborated on Rogers’s ideas to form his theory of the hierarchy of needs. The theory implies that all humans have a hierarchy of needs beginning at the most basic level of physiological needs such as food, air, and water leading to the need for self-actualization as the highest level of needs (Carver & Scheir, 2000). Similar to Roger’s positive regard, the third level of the hierarchy is love and belongingness including companionship and acceptance from others. If individuals fail to master the need for love and belongingness, they can’t reach the self-actualizing level of acceptance of self and others and this can result in a breakdown of the unity of self or anxiety.

Although the theories of Rogers and Maslow are merely conceptual and fail to explain all aspects of behavior or behavioral intentions, they both reinforce the idea that acceptance, love, and support from others are crucial for individuals to live healthy and well-adjusted lives. If the mentally ill can’t find love and acceptance or “positive regard”, they are left with only satisfying the most basic needs. Therefore, the failure of public health to embrace mental health contributes to a lack of acceptance, which prevents mentally ill individuals from living healthy lives with strong social support systems.

How does lack of acceptance contribute to decreased access to treatment?

The lack of acceptance of mentally ill individuals has led to barriers for these individuals to access medical care (Kessler et al., 2005; Druss & Rosenheck, 1998; Druss et al., 1998). Druss and Rosenheck (1998) found that the rates of those uninsured or having a primary care provider were the same between those with and without a mental illness, but those with a mental illness were twice as likely to report being denied insurance because of preexisting condition or having stayed in their job for fear of losing their health benefits. Thus, many mentally ill individuals feel they are denied insurance because of their condition. If individuals with a mental illness are unable to obtain love and acceptance, it is logical that they will fail to take the initiative to access medical care. If these individuals felt more fulfilled, congruent, and like equal members of society (i.e. more at ease at their place of employment), they may feel more comfortable and trusting accessing the medical health system. Although researching the access to medical care is of paramount importance, it does not explain why mental health is not embraced. We must first understand the contextual risk factors for why mentally ill individuals continue to engage in what society labels as irrational behavior. If mentally ill individuals feel accepted without a low self-esteem or self-worth, they may be more willing to access care with trust.

Failure to Embrace Mental Health Enhances Stigma Among Individuals with Mental Illness

How does the failure to embrace mental health contribute to increased stigma associated with mental illness?

The failure of public health to embrace mental health has contributed to discrimination and stigma of the mentally ill by their family members and friends, which is largely a reflection of how mental illness is portrayed through mediums such as the media. This continued discrimination is a reflection of the failure by public health practitioners to educate the public. Each culture and society has “norms” or rules of expected or proper behavior (Myers, 2002). These norms are a reflection of how we have been raised and socialized as members of society. Along with social norms is often labeling which leads to stigma and stigma results in stereotypes and often prejudice. The public views mental illness as sign of weakness (Corrigan, 2004). If society creates the label that the mentally ill are weak, it is easy for these individuals to internalize this message and behave according to the norm. In other words, once individuals are labeled, they may identify with the negativity associated with the label (Barlow & Durand, 2000). Human beings should never be affiliated with labels such as “dangerous”, “worthless”, or “dirty”. In order to embrace the mentally ill, public health practitioners must analyze how we can alter our negative social norms.

The failure of public health to embrace mental health has also led to increased stigma from friends and family of the mentally ill. As a result, these individuals feel alienated with a reduced social support networks (Byrne, 2000). Therefore, there is a public stigma of mental illness, which can perpetuate a self-stigma. Public health practitioners have failed to reach the families of the mentally ill to understand how they are torn by the social norms cast by society and their feelings for their loved ones. How are less informed members of society going to change their opinions of mental illness if family members and friends of individuals with a mental illness often feel ashamed of their loved ones? Education will be necessary to erase labels and stereotypes and change social norms.

What is the primary source for mental illness information? Media attention and portrayal of mental illness is largely responsible for why the world has adopted negative associations with the mentally ill and why public health practitioners have not embraced it. Walh (2003) found that in newspapers, the most common source of information about the mentally ill, the numbers of negative stories greatly outnumbered the positive stories. Other research discovered that mentally ill individuals are typically portrayed as violent, a seductress, maniac, or narcissistic parasite (Hyler et al., 1991; Diefenbach, 1996). It is undeniable that the media has extreme power and influence over the opinions of society and for many individuals, television and magazines are their only resources of gaining insight about public health information. The research of public health practitioners is where the media extracts their information. Therefore, the media has a great responsibility to alter their portrayal of the mentally ill as weak and dangerous. Public health practitioners must provide the media with anti-stigma research and effective modes of positively viewing the mentally ill, which they have failed to do. If we can’t change the prejudice and negative behavior of society, we can’t positively change the behavior in mentally ill individuals.

How does increased stigma of mental illness contribute to decreased access to treatment?

As a result of the stigma and discrimination attached to mental illness, the mentally ill often choose not access medical care treatment. Due to negative labels, many mentally ill individuals choose to lead lives of secrecy. Both the public stigma and resulting discrimination (i.e. “I don’t want to work with them”) and self-stigma (i.e. low self esteem, low self-efficacy, shame) contribute to the mentally ill avoiding treatment (Corrigan, 2004).

In order to increase the comfort of the mentally ill to access treatment, public health practitioners need to focus on the positive aspects that mentally ill individuals can contribute to society. Although research is controversial and results are mixed, studies suggest there is a link between mental illness and creativity (Waddell, 1998; Andreasen, 1987). The media and public health practitioners have failed to reach Americans with this message. What about the people with mental illnesses who work for the government, teach at universities, or have won humanitarian prizes? We need to change our outlook and cognitive schema by erasing misconception of mental illness and educate individuals that mentally ill individuals should not be thought of as violent, dangerous, and inferior members of society. By continuing to portray the mentally ill in a negative light, we are only continuing to support the misconception of this stigmatized population and preventing them from seeking treatment.

Increased stigma and decreased treatment are also a reflection of the failure of public health practitioners to educate society about mental illness (Byrne, 2000; Corrigan, 2004). Students should learn about the discrimination of mental illness from youth. If kids or adolescents are not taught the truth about mental illness, their only perceptions are created and distorted through the media. Public health practitioners need to institute the need for education and information about mental illness, so from youth, children and adolescents can obtain a realistic perspective of mental illness. If society is well educated about mental illness it could reduce stigma, and reducing stigma may increase the number of mentally ill individuals willing to access treatment (Corrigan, 2004).

Conclusion

Not to dismiss the importance of focusing public health on physical disease, but the society’s ignorance of mental health and the neglect of public practitioners to address mental health because of the stigma and negative views of society is unacceptable. As human beings, we have lost a sense of altruism and with our neglect of the mentally ill; we have chosen to keep them alienated and labeled inferior simply because society fails to re-shape the image of mental illness. Research focuses on individual risks such as access to mental health care, understanding the brain processes of the mentally ill, or analyzing specific disorders. Although, these are all extremely important contributions to understanding mental health, the problem exists on a much larger scale. The failure of public health to embrace mental health has contributed to the stigma and lack of acceptance associated with mentally ill individuals which results in barriers to necessary treatment. Therefore, public health is exacerbating the mental health crisis by failing to embrace it.

First, we must embrace the individuals who have these disorders. We need to reach out to them and attempt to understand their feelings. They deserve the belongingness and support to feel like integrated and competent individuals. Public health practitioners need to immerse themselves into the community to observe these individuals and learn how they live, what they feel, and why their behaviors prevent them from living healthy lives. Then we can have a better understanding in order to successfully educate society and realistically and positively portray these individuals. We must change the negative attitudes and behaviors of society. We must re-define our social norms for the mentally ill and advocate this change with a positive portrayal through the media. Public practitioners should change their focus on individual risk factors of mental illness and start viewing it as a problem that must encompass social sciences in order to promote health initiatives and efficient and effective intervention strategies. Improving access to mental health will help individuals to seek to healthier lifestyles, but we have to analyze why these individuals choose not to access the care even when they possess the means.

Public health needs to change at the structural level. Health departments should have divisions specifically for mental health awareness and prevention. We must look at improvement of the mental health crisis as societal problem with environmental factors. These divisions can specifically monitor the barriers to improving the health of the mentally ill at the societal level, not just at the individual level. It would be the responsibility of these divisions to educate society on the truth about mental illness and help erase stigma and negative labeling. With structural divisions like this in place working effortlessly to improve mental health at the societal level with the same drive as chronic physical or infectious diseases, we can begin the war on mental illness.

The mentally ill have the right to live healthy lives. Although public health practitioners have their work cut out for them, change is not beyond our reach. However, if public health practitioners continue to fail to embrace public health, a large portion of society will remain stigmatized and unhealthy, which affects the overall health of society.

References

Andreasen, N. C. (1987). Creativity and mental illness: prevalence rates in writers and their first-degree relatives. American Journal of Psychiatry, 144, 1288-1292.

Barlow, D. H., & Durand, V. M. (2002). Abnormal Psychology. (3rd. ed.). California:
Wadsworth.

Byrne, P. (2000). Stigma of mental illness and ways of diminishing it, Advances in Psychiatric Treatment, 6, 65-72.

Carver, C. S. & Scheier, M. F. (2000). Perspectives on personality. (4th ed.). Boston: Allyn and Bacon.

Centers for Disease Control and Prevention. (2005). The role of public health in mental health promotion. (MMWR, 24, 841-842). Washington, DC: U.S. Government Printing Office.

Corrigan, P. (2004). How stigma interferes with mental health care, American Psychological Association, 7, 614-625.

Diefenbach, D. L. (1998). The portrayal of mental illness on prime-time television. Journal of Community Psychology, 25, 289-302.

Druss, B. G. & Rosenheck, R. A. (1998). Mental disorders and access to medical care in the United States. American Journal of Psychiatry, 155, 1775-1777.

Druss, B. G., Harris, M.A. Jr,, & Bruce, M. L. (1998). Physical health, depressive symptoms, and managed care enrolment. American Journal of Psychiatry, 155, 878-882.

Hyler, S. E., Gabbard, G. O., & Schneider, I. (1991). Homicidal maniacs and narcissistic parasites: Stigmatization of mentally ill persons in the movies. American Psychiatric Association, 42, 1044-1048.

Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., Wang, P., Wells, K. B., & Zaslavsky, A. M. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. The New England Journal of Medicine, 352, 2515-2523.

Myers, D. (2002). Social psychology. (7th ed.). Boston: McGraw-Hill.

Osborn, D. P. J. (2001). The poor health of people with mental illness. Western Journal of Medicine, 175, 329-332.

Wahl, O. F. (2003). News media portrayal of mental illness. American Behavioral Sciences, 46, 1594-1600

Waddell, C. (1998). Creativity and mental illness: Is there are link? Canadian Journal of Psychiatry, 43, 166-172.

"Babies Were Born To Be Breastfed": Public Health Campaigns Are Born To Fail When Mothers Are Blamed – SzePui Cheng

2006-12-18T07:27:00.000-08:00

Current public health policy in the United States places expectations on mothers to breastfeed regardless of social and environmental barriers, including lack of support in the workplace. Given the known health benefits of breastfeeding, mothers who do not breastfeed are characterized as making the choice to deprive their children of these benefits. In fact, recent breastfeeding promotion efforts by the U.S. Dept. of Health and Human Services (HHS) targeted mothers who already face obstacles in breastfeeding decision-making.

HHS’ “Babies Were Born To Be Breastfed” campaign emphasized risky behaviors, and sent the message that individuals are solely responsible for their health choices and essentially can be blamed for taking health risks. However, blaming mothers for taking the “risk” of not breastfeeding did not provide any incentive for employers and society in general to make appropriate accommodations that would have allowed all mothers to have a genuine choice about breastfeeding in the first place.

If public health policymakers do not account for societal factors related to breastfeeding behavior and continue to blame mothers for making the “choice” to not breastfeed, then they will continue to fail to achieve optimal rates of breastfeeding in the U.S. In addition, policymakers will continue to perpetuate breastfeeding disparities among certain racial and socioeconomic groups – the same groups that already experience disparities in various education and health services.

History of Breastfeeding in the United States

In the late 19th century, breastfeeding habits in the U.S. began to change due to economic factors for working-class mothers, who switched to “hand-feeding” in order to leave their homes for employment. Evolving social norms also induced middle class women to stop breastfeeding so they could be better “companions” for their husbands. (15) Despite several public health efforts in the early 20th century, the breastfeeding initiation rate steadily declined to an all-time low of 24% in 1971. (15) The subsequent feminist and women’s health movements helped revive interest in breastfeeding practices.

Today there is a wealth of literature that documents the nutritional, immunological, developmental and psychological benefits to infants who are breastfed. Children who are breastfed have lower rates of ear infections, diarrhea, respiratory illnesses, and childhood obesity. Also, there is some evidence that mothers who breastfeed enjoy certain protective health benefits such as reduced risks for breast and ovarian cancers. (2)

In order to maximize these benefits, the American Academy of Pediatrics recommends breastfeeding for the first year of a child’s life, preferably with exclusive breastfeeding for the first six months. (9) Initiation of breastfeeding is often accomplished while the mother and child are still in the hospital setting; however, there is evidence that the duration of breastfeeding has a higher correlation to health benefits. That is, there is a “dose-response relationship” between breast milk and child health. (15)

Currently, breastfeeding is initiated with approximately 70% of all American children, which is a substantial increase from previous decades. (9) However, given the overwhelming evidence that breastfeeding is the optimal form of nutrition for infants, we must examine the reasons why the United States still lags behind other developed nations in rates of breastfeeding. Countries such as Germany, Australia, and Norway have breastfeeding initiation rates of 86%, 87% and 99%, respectively. (5)

In addition, only 17% of all American children are breastfed exclusively at 6 months of age (15), compared to 50% of children in Norway. A large portion of this gap can be attributed to the disparity in rates between certain racial and socioeconomic groups in the U.S. Research has shown that mothers who are black, single, less than 20 yrs, and/or living below the poverty level in the U.S. have substantially lower rates of breastfeeding initiation and continuation. The 2004 National Immunization Survey found that although rates of breastfeeding had increased from 1994 (initiation: 60.3% to 71.5% for white children, 25.5% to 50.1% for black children; continuation of those breastfed to 6 months: 44.4% to 53.9% for white children, 33.3% to 43.2% for black children), there was no significant reduction in the absolute racial disparity. (3) Also, among all racial groups, rates of breastfeeding among lower income groups were approximately 25% less than higher income groups. (3) To increase rates of breastfeeding among these groups, policymakers currently advocate “targeting” these subgroups that are least likely to breastfeed. (3)

Current Efforts

At the national level, agencies such as the Centers for Disease Control and Prevention and the Food and Drug Administration work to support breastfeeding through various strategies such as program evaluation, applied research and regulation of breast pump manufacturers. HHS has attempted to promote breastfeeding through its Blueprint for Action on Breastfeeding, which included recommendations for steps to be taken by health care providers, employers, and families and communities, as well as identification of areas of research. (2)

In 2002, HHS commissioned the Ad Council to create a social marketing campaign, ultimately entitled “Babies Were Born To Be Breastfed”. (2) This series of advertisements appealed to the “common sense” of mothers, stating that since women avoided risky behaviors during pregnancy, it made sense that they would avoid risky behaviors with their infant children. In one television commercial, a “pregnant” woman rode a mechanical bull inside of a bar, while a rowdy audience cheered her on until she was thrown to the ground. The message equated the risks of this behavior with the risks of not breastfeeding, i.e. since a woman can make the choice of whether or not to get on the mechanical bull, she can make the choice of whether or not to breastfeed.

There was a great deal of controversy surrounding this campaign, and its focus on risky behaviors was deemed “scare tactics” by some critics. (13) While it can be argued that individuals must be responsible for making decisions about their own health and those of their dependents, it must be acknowledged that those choices are limited to the set of options that exist in the context of their individual lives. For example, a college-educated, middle class mother is making her choice to breastfeed on a very different contextual basis than a mother with less than a high school education, living below poverty level. The latter often have a less-educated social support network and little choice in employment options, and therefore, little or no negotiating power with their employers. By claiming that all mothers have the same choices, there was clearly a message of blame towards mothers who do not breastfeed embedded in the “Babies Were Born To Be Breastfed” campaign.

The campaign also only addressed individual-level causes of lack of breastfeeding. Practitioners who subscribe to the theory of the Health-Belief Model (10) assume that mothers, once educated about the benefits of breastfeeding and risks of not breastfeeding, will make the rational nutritional choice for their infants. If policymakers wish to assume that mothers make decisions about breastfeeding based upon a risk-benefit analysis, they must consider how to classify risk.

In a discussion about public health education and lifestyle risk, Lupton describes the distinction made by the public health community between risks related to external causes out of the individual’s control and those risks caused by oneself. (6) If there is a moral distinction between these two categories of risk, then an individual can be blamed for taking health risks. Certain poor health outcomes are considered to be self-inflicted.

Proponents of the “Babies Were Born To Be Breastfed” campaign believed that by educating certain mothers about the risk, a moral obligation to breastfeed would arise among those groups. They claimed that mothers should make the responsible choice to eliminate the risks to their children and themselves. Again, by implying that all mothers can make the same choice to avoid risk, there was clearly a message of blame directed towards non-breastfeeding mothers.

The less-than-impressive rates of breastfeeding in the U.S. compared to other nations, as well as the continued disparities among different racial and socioeconomic groups demonstrate that this strategy of blame is not effective. In order to create a successful public health campaign aimed at reducing these disparities, significant societal-level barriers to breastfeeding behavior need to be addressed.

Barriers to Breastfeeding

Social Factors

There are cultural norms within the United States, and its many complex subpopulations, that cause mothers to feel uncomfortable breastfeeding. Mothers who attempt to breastfeed in public areas often face prejudice and discrimination. (4) In addition, most social environments are structured in a way that makes breastfeeding burdensome and inconvenient compared to bottle-feeding.

Federal legislation for breastfeeding policies has been proposed over the years, with little action taken by Congress. Programs and guidelines have been suggested to protect the rights of mothers to breastfeed; however, there has been no movement towards implementation. In fact, the only laws that have been enacted to promote breastfeeding have been by individual states, and pertain only to “permitting” mothers to breastfeed in public and exempting them from charges of indecent exposure. (14) Other laws are primarily symbolic, with no enforcement or realistic guidelines for implementation. (4) The unfortunate state of breastfeeding laws in the United States highlights the cultural norms that dictate priorities for federal programs.

The implied message of current public health policy is that breastfeeding behavior is an individual choice and responsibility, and that interventions should be structured to provide education about the risks of not breastfeeding. As a result of this approach, some of the main barriers to breastfeeding in the U.S. are the attitudes, practices, and lack of knowledge of those who could be the strongest advocates for breastfeeding mothers.

The Healthcare Environment

It should not be unreasonable to expect healthcare providers to provide education and access to support services for mothers considering breastfeeding. Most mothers in the U.S. are dependent upon physicians for peri-natal advice. Unfortunately, there is research that indicates that pediatricians and other physicians are insufficiently educated in this area. (8;11) A survey by the American Academy of Pediatrics found that only 65% of the respondent pediatricians recommended breastfeeding for the first month after birth, clearly indicating that their practices were not aligned with national policy recommendations. The majority of the respondent physicians also stated that they had not recently received, but wanted more breastfeeding management education. (11) In addition, 72% of these pediatricians were unaware of massive worldwide efforts to increase breastfeeding, including the UNICEF Baby Friendly Hospital Initiative. (11) If physicians were unaware of the priority that the global health community has placed upon breastfeeding promotion, it can be assumed that they could not relay that information to their patients.

Furthermore, according to a national assessment of physicians’ breastfeeding attitudes, the best predictor of a physician’s ability and willingness to give breastfeeding advice and support is whether that physician or the physician’s spouse has ever breastfed. (15) This could have significant consequences for mothers who rely upon physicians’ recommendations for infant nutrition. Also, there is evidence that a physician’s perceptions of a patient’s likelihood of having adequate social support, and likelihood of adhering to treatment, will predict his/her recommendations to that patient. (12) Given the influence of these perceptions, along with policymakers’ push to target certain socioeconomic and racial groups (3), we must consider the implications this has for recommendations to mothers that have been labeled as least likely to breastfeed. It is possible that some physicians do not recommend breastfeeding to certain groups of women because they believe that these women will not be successful in breastfeeding. This may significantly reduce the range of “choices” available to these women.

If healthcare providers are to be considered the public’s gatekeepers to health knowledge (12), they must be able to offer appropriate information and support to mothers of all circumstances. Physicians who lend their professional knowledge to the debate surrounding breastfeeding behaviors can help to dispel the blame placed by campaigns such as “Babies Were Born To Be Breastfed”. If healthcare providers do not make recommendations that consider social and environmental barriers, they are contributing to disparities in vital health services.

Employment Settings

Another major factor that affects mothers’ decisions to breastfeed is their work environment. A study in Austin, Texas showed that although employers understood the benefits of breastfeeding for mothers and children, they were not eager to institute breastfeeding policies at their companies. Factors they cited as concerns included the cost of creating lactation facilities, reduced employee productivity, lack of employee demand, and liability issues. (1) Some employers felt it was adequate to accommodate employees on an “as-needed basis”. In addition, mothers have expressed their reluctance to breastfeed because they were concerned that their coworkers would be disgusted, intolerant, or disapproving. (1) The “Babies Were Born To Be Breastfed” campaign did not even acknowledge these physical and social barriers.

At this time, there are inconsistencies in breastfeeding accommodations in various work environments. Although some large corporations have lactation facilities, most of them fail to make appropriate accommodations for all levels of workers. Mothers with high-wage jobs often have private offices or special nursing rooms, whereas mothers with low-wage jobs are not given sufficient privacy and break times. This disparity has been called a “2-Class System” whereby those who are already advantaged continue to receive privileges, while those who are disadvantaged continue to suffer hardships. (4)

In the U.S., more than half of all women with children less than a year old work outside the home. Due to obstacles in the workplace, women who work full-time tend to wean their children earlier. (1;15) Currently the U.S. government only mandates that employers provide 12 weeks of unpaid leave for expectant mothers and fathers. (14) Short-term maternity leaves can often deter mothers from breastfeeding initiation, and more importantly, reduce their duration of breastfeeding. Again, women who are more financially secure have more options to choose from, such as longer unpaid maternity/lactation leaves.

Although many women are not provided with accommodations to pump breast milk at work, the “Babies Were Born To Be Breastfed” campaign implied that mothers should choose to breastfeed regardless of these external constraints. In fact, mothers were encouraged to notify employers of their intent to breastfeed and request that their employers provide appropriate accommodations. (2) If recommendations by HHS were insufficient to convince employers to accommodate breastfeeding practices, then surely individual requests by female employees would be even less persuasive. By implying that all employees have the same power to negotiate with their employers, policymakers again placed the responsibility of breastfeeding decision-making onto mothers without looking at environmental barriers.

The lack of uniform corporate lactation programs in the U.S. should be viewed as a form of workplace discrimination - forcing some mothers to “choose” between earning a living or breastfeeding. The public health community must address employers’ contributions to the disparities in supportive environments for breastfeeding mothers.

Supporting Mothers

The designers of the “Babies Were Born To Be Breastfed” campaign failed to recognize that health behaviors are influenced by many factors such as the external environment, cultural norms, beliefs, and attitudes about self-efficacy, that is, one’s own ability to perform the behavior. (6) As discussed earlier, healthcare providers can also be influenced by their perceptions of populations grouped by race and socioeconomic factors. Mothers who are black, single, young, and/or living below the poverty level may not be expected nor encouraged to breastfeed. In addition, these mothers may not feel a sense of self-efficacy, based on their physicians’ recommendations, as well as social and financial circumstances.

Individuals cannot make choices based solely upon an analysis of the risk of one behavior. When considering breastfeeding, mothers must analyze the constraints of their environment. The context within which choices are made is a significant part of the decision-making process. Without proper support from healthcare providers, employers, policymakers and society in general, mothers of all backgrounds cannot be expected to make rational choices about breastfeeding.

Public health campaigns that continue to blame individuals, such as disadvantaged mothers who do not breastfeed, for “risky” health behaviors will not only alienate the individuals who need the most assistance, but suppress public support for equitable health programs. As a result, racial and socioeconomic disparities will be perpetuated by the same policies that aim to reduce them.

Conclusions

There is a danger that the public health community believes that current breastfeeding promotion efforts are effective. Rates of breastfeeding initiation are increasing, especially among “targeted” mothers. However, rates of breastfeeding duration are quite low, particularly among the same “targeted” mothers, and there has been no reduction in the disparities among racial and socioeconomic groups.

The creators of social marketing campaigns such as “Babies Were Born To Be Breastfed” must learn from their mistakes, and begin to target the correct audiences by first educating healthcare providers, providing incentives for employers, and understanding cultural norms. HHS is getting ready to launch a campaign called “The Business Case for Breastfeeding” which is intended to inform employers about the financial benefits for providing breastfeeding accommodations such as reduced absenteeism and medical bills. (4) Hopefully, this will be a step in the right direction.

Finally, in order to achieve optimal rates of breastfeeding, public health policymakers need to focus on efforts that acknowledge the difficulties that women face in breastfeeding decision-making, and work to reduce and eliminate social and environmental barriers for all mothers who choose to breastfeed.

Sources

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11. Schanler, R., O’Connor, K., and Lawrence, R. (1999). Pediatricians’ Practices and Attitudes Regarding Breastfeeding Promotion. Pediatrics, 103(3).
12. van Ryn, M, and Fu, S. (2003). Paved With Good Intentions: Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health? American Journal of Public Health, 93(2), 248-53.
13. Vargas, E., Hoffman, L., and Varney, A. (2006). Is the Breast Better?: Ad Campaign Rattles Mothers on Breast-Feeding Controversy. Retrieved October 5, 2006 from ABC News: http://abcnews.go.com/2020/story?id=2188066.
14. Weimer, D. (2003). Summary of State Breastfeeding Laws. CRS Report for Congress, The Library of Congress.
15. Wolf, J. (2003). Low Breastfeeding Rates and Public Health in the United States. American Journal of Public Health, 93(12), 2000-10.

HIV Prevention for MSM and women is not as easy as A.B.C.: A Sociological Research Perspective - Rodney VanDerwarker

2006-12-17T23:15:00.000-08:00

Practically since the first documented cases of HIV in the early 1980’s, researchers and policy makers have tried to develop and implement the most cost-efficient and effective HIV prevention strategies. Dramatic declines in infection rates were seen in the late 1980’s among men who have sex with men and other high risk groups in the US in part due to the promotion and adoption of condom use for anal and vaginal sex. Despite a significant amount of effort and funding put into HIV prevention, the Centers for Disease Control and Prevention estimate that there continues to be 40,000 new HIV infections per year in the United States (http://www.cdc.gov/hiv/resources/factsheets/At-A-Glance.htm). Male to male sexual contact continues to be the largest risk category followed by heterosexual transmission and injection drug use. Heterosexual transmission has a disproportional impact on women. There is no doubt that we need to continue to explore new methods of interventions to further reduce the rates of HIV transmission among these populations.

One public health approach to HIV prevention that has received a lot of attention in recent years is called ABC. ABC is an acronym for Abstinence, Be Faithful and Condom use. Abstinence programs focus on encouraging unmarried people to not have sex. This particular piece of ABC is often focused on youth and encourages them to delay sexual debut until marriage. Be Faithful programs encourage people to practice fidelity in marriage and other sexual relationships and to reduce the number of lifetime sexual partners. Condom use programs under ABC are supported as long as the “full and accurate information” about condom use “reducing, but not eliminating, the risk of HIV infection” is presented (Office of the US Global AIDS Coordinator, 2001). Many ABC programs have actually been criticized for being AB programs since C is presented in a manner that makes it seem like condoms are not a good option for preventing HIV infection. PEPFAR funds can only be used for “C” if information about condom use also includes information about abstinence as the only sure way to prevent HIV infection (Office of the US Global AIDS Coordinator, 2001).

In May 2003, Congress approved President Bush’s global HIV/AIDS strategy referred to as PEPFAR (the President’s Emergency Plan for AIDS Relief). This plan was principally created to support projects that would increase access to treatment and primary medical care to people in the hardest hit areas of the world; therefore, 70% of the 15 billion dollar fund was directed to these efforts (http://www.avert.org/pepfar.htm). 20% of the funds were allocated for HIV prevention work that specifically uses the ABC approach as a guiding principle. This requirement has been greatly criticized by those working in global HIV/AIDS programs and it brought to light the administration’s philosophy about HIV prevention. The current administration’s prevention policies, domestically and internationally, have focused on funding abstinence-based programs that don’t address the needs of those most at-risk for HIV.

The ABC approach to HIV prevention assumes that people have control over sexual decision making. Many people do not; this is especially true for women. Amaro (1995) criticizes behavioral approaches to HIV prevention for not taking into account how gender, women’s role and women’s social status affect sexual risk behaviors, sexual decision making and their ability to reduce HIV risks. Abstinence assumes that a woman has the power to decline sex from a partner. Be faithful is something that takes two people to agree upon and in many societies men are given the freedom to have as many sexual relationships as they desire. In India, women must provide children in a relationship or else they are considered a failure in the marriage and could be disowned. They must have sex with their husbands whether he is cheating or even if he is known to be HIV infected. And condoms are not always perceived positively. A study in Brazil found that women feared using condoms because they would be suspected of infidelity, and that men always had the final word in sex (Hebling and Guimaraes, 2004). Financial dependence is an important element in the power relationship between men and women. Without their male partner/husband, the women, and their children, would potentially lose their homes or not have food. So, these women have no choice but to accept his infidelity and/or to give him sex when he desires it.

Another argument against the ABC approach to HIV prevention is that it assumes that all relationships are supported by their culture or society. This is not true for MSM in most parts of the world. Whereas gay people in the United States have gained significant rights over the past two decades, there are still parts of the world where being gay is illegal and in some countries even punishable by death. In the United States, gay rights are inconsistent and dependent on the political climate. Despite the positive feelings many have had about changes that occurred during the November 2006 elections, 7 out of 8 states voted to specifically exclude gay and lesbian couples from marriage rights in their constitutions. This adds to the 20 states that previously adopted these laws. Research tells us that gay men who live with a partner have a higher self concept (Schmitt and Kurdek, 1987). Men who have better gay self-acceptance also have fewer risk behaviors for HIV (Perkins et al, 1993). How does it make sense to include fidelity as part of HIV prevention messages when the societal messages are clearly against the very existence of such relationships? In fact, I believe that promoting an intervention that is so incongruent with the reality of MSM can cause further alienation and possibly lead to more risk for HIV transmission since it works against gay self-acceptance.

ABC has not been rigorously studied to see how effective it is as an approach to HIV prevention. The most information available about ABC is from epidemiological studies in Uganda. There was a sharp decline in HIV prevalence during the 1990s going from about 15% in the early 90’s to 6.5% in 2004 (Office of the US Global AIDS Coordinator, 2003). Research papers reviewed for this blog stated that it was challenging to pinpoint the cause of this decline (Singh et al, 2003; Kurungi et al, 2006). Both papers also showed that there was a decline among younger people in sexual debut, but there was no difference among those over 20. Premarital sex among women declined, but there was no change among men between 1995 and 2000. This, of course, leads me to wonder who the men were having sex with. Did women really stop having premarital sex or were they less likely to report it because of the messages that it was wrong? Earlier statistics reporting casual sex among men at 40% and women at 20% indicate that reporting issues probably were always present in Uganda. There is no mention of male to male sex in any of the ABC research, despite evidence that such behaviors occur. The evidence seems awfully weak to support ABC as an effective intervention and this is concerning since it has been used to form policy for the federal government’s HIV prevention initiatives here and abroad.

This paper has provided me with a good opportunity to understand the ABC approach to HIV prevention better. Despite all of my arguments, I actually think that offering multiple intervention strategies makes sense. However, the interventions need to be appropriate to the population being served by them rather than serving the morals of those creating the intervention. I believe that harm reduction is an important tool in reducing HIV transmission. It cannot be argued that abstinence is the only way to prevent HIV or that two HIV-uninfected partners being monogamous are the most effective ways to avoid HIV acquisition. I think that ABC has some serious problems, as I have argued, but the fatal flaw has been in its implementation. The government contradicts itself when ABC is put forth as an intervention with three good components, but the C part is the only one that must advertise its limitations. It is contradictory to present an intervention with three good components, but the A gets a mandatory cut of the total funding. People don’t need to be graded for their behaviors because an A isn’t possible for everyone and that makes it unfair. We need to eliminate politics and the imposition of values on others and instead develop public health interventions for HIV prevention that consider the context of people’s circumstances. This is the only way we are going to further reduce and someday end this epidemic.

References

Amaro, H. (1995). Love, sex, and power: Considering Women’s Realities in HIV Preveniton. American Psychologis, 50, 437-447.

CDC (April 2006). A Glance at the HIV/AIDS Epidemic. Retrieved November 10, 2006 from http://www.cdc.gov/hiv/resources/factsheets/At-A-Glance.htm.

Hebling, E. M. Guimaraes, I. R. F. (2004). Women and AIDS: gender relations and condom use with steady partners. Cadernos de Saude Publica. 20(5):1211-8, 2004 Sep-Oct.

Kanabus, A. and Noble, R. (2006). President’s Emergency Plan for AIDS Relief. Retrieved November 10, 2006 from http://www.avert.org/pepfar.htm.

Kirungi, W L. Musinguzi, J. Madraa, E. Mulumba, N. Callejja, T. Ghys, P. Bessinger, R. (2006). Trends in antenatal HIV prevalence in urban Uganda associated with uptake of preventive sexual behaviour. Sexually Transmitted Infections. 82 Suppl 1:i36-41.

Office of the US Global AIDS Coordinator (2001). ABC Guidance #1 for United States Government In-Country Staff and Implementing Partners Applying the ABC Apporach to Preventing Sexually Transmitted HIV Infections within the President’s Emergency Plan for AIDS Relief. Washington, DC.

Perkins, D O. Leserman, J. Murphy, C. Evans, D L. (1993). Psychosocial predictors of high-risk sexual behavior among HIV-negative homosexual men. AIDS Education & Prevention. 5(2):141-52.

Schmitt JP. Kurdek L.A. (1987). Personality correlates of positive identity and relationship involvement in gay men. Journal of Homosexuality. 13(4):101-9.

Singh, S. Darroch, J. E. Bankole, A. (2004). A, B and C in Uganda: the roles of abstinence, monogamy and condom use in HIV decline. Reproductive Health Matters. 12(23):129-31.

The Role of Cultural Health Beliefs in Public Health Practice: What the Health Belief Model Isn’t Telling Us– Jessica J. Harvill

2006-12-17T20:06:00.000-08:00

Introduction

The topic for the December 2004 volume of the American Journal of Public Health was “Health Disparities: The Importance of Culture and Health Communication” (Thomas, 2004). In the Editor’s Choice opening section, Stephen B. Thomas, PhD, from the Centre for Minority Health at the Graduate School of Public Health from the University of Pittsburgh decries “Efforts to eliminate health disparities must be informed by the influence of culture on the attitudes, beliefs, and practices of not only minority populations but also public health policymakers and the health professionals responsible for the delivery of medical services and public health interventions designed to close the health gap” (Thomas, 2004). And yet, despite this impassioned cry for consideration to be given to cultural health beliefs and the medical practices that arise from those beliefs there has still been little consideration given to the role of culture and of acculturation when it comes to actually designing public health theoretical models (Abraido-Lanza, 2006). Instead, models of health behaviour such as the Health Belief Model (HBM) remain the cornerstone of public health theory.

I challenge that the Health Belief Model does not give enough cultural consideration to public health practices and interventions. In addition, the HBM does not give enough credence to traditional medical and alternative medical practices that 34% of the adults in the United States currently utilize (Astin, 1998). Rather, it focuses on aspects of health promotion such as “perceived susceptibility”, “perceived severity”, and “perceived benefits” (Rothman, 2006), totally disregarding the fact that in surveys about traditional and alternative medicine usage, most respondents reply that they use those therapies over traditional medical ones because they feel more comfortable with the alternative therapies, and can have more control to personalize their therapies (Park, 2002), reasons that can not be placed within the categories of health determination found in the HBM.

In a 1998 study on the relationship between traditional/alternative treatment use and medical treatments, it was found that “negative attitude towards or experiences with conventional medicine were not predictive of alternative health care use” (Astin, 1998) and that “the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs and philosophical orientations towards health and life” (Astin, 1998). This implies that people are not turning to alternative medical interventions as a desired alternative to western medical treatments, but instead are using them in a combined, hopefully complimentary fashion. This holistic health paradigm does not have a place in the HBM and similar public health theories, and that fact is providing a disservice to ethnic minorities and traditional medical practitioners, as well as to the public health professionals that are attempting to serve them. As seen in the three case examinations below, the HBM does not do enough to legitimately consider alternative health beliefs, especially those related to traditional and alternative medical practices. It is up to current and upcoming public health professionals to acknowledge and consider these limitations, and to work on designing a new theory of health behaviour that better suites the needs of all the people that those in the public health profession serve.

Case 1: Health Beliefs and Home Remedies Among African Americans
In a 2004 study, Becker et al. found that 70% of African Americans reported at their family had utilized home remedies at some point (Becker et al., 2004). Further observation found that home remedies and self-care “develop[ed] throughout the life course, and that such behaviour varies according to an individual’s group affiliation in habits, beliefs, and practices that constitute a cultural way of life” (Becker et al., 2004). Yet, despite these figures, the HBM gives no consideration to these home remedies and they role they play in the overall health paradigm of many African Americans.

Another example of this can be found in analyses of the cultural dimensions of high blood pressure in African Americans. On average, African American males have higher arterial blood pressure than whites, even adjusting for age, socioeconomic status, and access to healthcare (Dressler and Bindon, 2000). Yet, despite these numbers, most public health interventions geared towards African Americans focus on the same behaviour changes as interventions gears towards other primary ethnic groups found in the US. These interventions continue to focus solely on biological aspects of health, such as diet and exercise, without considering crucial cultural aspects, such as the fact that the role of extended family and social support is much more important in African American communities than generally found in white communities with similar socioeconomic backgrounds (Dressler and Bindon, 2000). Anthropological studies on health consequences and cultural consonance in African American communities have shown that “the degree to which an individual is able to approximate in his or her own behaviour the cultural models for the domains of lifestyle and social support” (Dressler and Bindon, 2000) is directly correlated to improvements in overall cardiovascular health, as measured by blood pressure. These cultural factors, independent of the more medically-driven interventions often found in public health, have been shown to help improve health in a demographic that has been continuously shown to be under-served by the public health and medical communities. And yet, public health theories such as the HBM still do not allow for fact that health can be directly correlated to cultural factors, as well as to biologic ones.

Case 2: Traditional Health Beliefs and Ethnomedicine among the Hmong
Like many eastern societies, the Hmong place a particular emphasis on familial relationships. Family groups are generally large with the oldest man serving as the head of the patrilineal/patrilocal household (a wife will change her allegiance to her husband’s male ancestors). In the term of medical care, the patient and immediate family will all have a say, but the final decision for both diagnosis and treatment will come from the head of the household (Rairdan and Higgs, 1992). This group dynamic of medical decision making is an integral part of many Hmong families, but it is something that is given little consideration to in the HBM, which puts great stock in the idea of ‘self-efficacy’, or the belief that an individual must have a belief in their own capabilities in order to institute behavioural changes (Rothman, 2006). In a culture which places greater emphasis on the importance of the group, or family, than the individual, a theory of health behaviour that focuses on the individual and the individual’s ability to motivate him or herself would not effectively communicate desired health behaviours to the target individual.

Another factor which can affect the applicability of aspects of the health belief model such as perceived susceptibility and cues to action is the differences in communication found between the west and traditional Hmong culture. For many Hmong, respect is an important sociocultural factor and age, education and authority all define how Hmong interact with each other and with public health workers. Communication should be formal, and any sense of informality or casual attitude is considered very rude, especially if the person to whom one is conversing is elderly (Raridan, 1992). This can cause complications in communication because it is also considered very impolite to disagree with someone, especially if they are of higher status then yourself. This often results in a positive response to any query or question. For example, is it possible that when asked a question such as “do you think you are likely to contract this disease” or “do you regularly visit a physician for health check-ups” it would be culturally appropriate for a Hmong to reply in the affirmative. Unlike western communication norms this positive response is not considered agreement, but rather acknowledgement that they have heard what was being communicated (Rairdan and Higgs, 1992). A public health worker without knowledge of the cultural implications of these responses may believe that they have managed to engage the Hmong person in a health promotion program, when in fact they were just acknowledging that the public health worker was speaking to them.

The conduction of invasive medical tests, especially those that involve the collection of body fluids, are also a major point of conflict between Hmong patients and western medical practitioners. Hmong beliefs state that there is a finite level of blood available, and that if any is extracted from the body it can never be replaced (Fadiman, 1997, Raridan, 1992, Westmeyer, 1988). Because of this, excessive or unnecessary medical tests should be avoided if at all possible. Many Hmong living in the United States have had enough interactions with western medicine to adapt to their practices, and most will consent to a blood draw if necessary. It is important that the purpose for each test and how that purpose relates to the immediate physical symptoms be explained to the patient in order to obtain consent for the blood or fluid draw. This belief is such an integral part of some Hmong’s spiritual and personal beliefs that it would be culturally incompetent and ethically wrong for a public health professional to dismiss them as irrational or inconsequential to public health practice. Instead, against health belief model’s notion of perceived barriers, public health practitioners should focus on health communication models that allow for cultural flexibility and conservative determination of invasive medical practices. For example, if working on a program for early diabetes detection, the emphasis should be on working with the healthcare providers to draw the minimum amount of blood necessary for accurate testing and work on developing programs of clear communication telling exactly how much blood will be drawn and for what purposes the drawn blood will be used, more than on dissuading Hmong believers that their cultural considerations don’t have a role in the western healthcare system.

By not acknowledging the important role of culture of medicine, the HBM is missing many of these important considerations that public health providers should be aware of when designing, implementing, and evaluating public health interventions. Utilizing a public health policy that takes into consideration cultural competency, ethnomedical practices, and that accepts variations in health culture is a public health approach which can be vital to improving health disparities seen amongst many ethnic minority groups in the US. The lack of consideration given to these points of views in conventional public health theory is not only a disservice to the population that we as public health workers are trying to serve, but harmful to us as a profession by promoting a legacy of arrogance and insensitivity.

Case 3: Health Culture and Treatment Compliance Among Vietnamese Refugees
Like recent Hmong immigrant, many Vietnamese new to the United States and other Western countries find themselves operating within an entirely different health paradigm than they are used to. Key differences in health interpretations between many recent Vietnamese immigrants and the western public health community can include the cultural interpretation of diseases and therapies as ‘hot’ or ‘cold’, the role of family members in encouraging or discouraging initiation of and compliance with western medical care (like the Hmong, most if not all decisions will ultimately be made by the head of the household, and not necessarily the patient or targeted person), and the community perception of the disease and/or treatment (Ito, 1999).

These key differences in the perception of health and wellness can make it difficult for public health officials to not only communicate their own health goals, but to understand the current health practices of the population that they are wishing to intervene in. One public health study on TB beliefs among recent Vietnamese immigrants concluded that there was little or no use of traditional medicine for the disease (Carey et al. 1997), but did not take into consideration that it would have been considered very rude to mention any traditional medicines that were being used to treat the illness to a western healthcare worker. In this case, the absence of reference to traditional or alternative treatments does not necessarily negate their absence, but as the investigator was working within the health belief model, these types of considerations did not enter into their investigation or intervention strategy.

Although the use of competent medical translators can provide basic information on tuberculosis transmission and infections for those who need it, social and cultural views of disease further complicate the issue. However, where the health belief model might block these cultural views as perceived barriers that need to be changed, a culturally sensitive interpretation shows how a competent public health professional can work within the health belief systems of the Vietnamese population to design and implement programs that can communicate the importance of using and adhering to western treatment regimes, while at the same time allowing for traditional treatments that meet other physical, mental, and cultural needs of the target population.

Discussion
As seen in Case 1, too often when public health professional think of alternative and traditional medicine, they do not consider the cultural implications of the healthcare treatments. Instead they focus on scaring, threatening, and blackmailing people into participating in specific health behaviours within the western medical paradigm. Theories such as the HBM consider culture only as an avenue of communication to help ‘convince’ people with alternative belief systems to participate in the health behaviour that they are promoting, without exploring other, more culturally sensitive methods, of achieving the same health behaviour. This approach is seen not only when dealing with groups that are recent immigrants to the US, but in groups that have a long history within the US and a high level of acculturalization, such as African Americans.

The United States currently has a population of approximately 200,000 Hmong people, primarily concentrated in several dozen communities across the country (Fadiman, 1997). As with many groups, minority ethnic people immigrate to new countries and they bring their traditional ways of life with them, including cultural traditions, kin relationships and medical practices. As seen in Case 2, in the case of the Hmong these traditional beliefs vary, in some cases greatly, from the western norm, and there can be a steep learning curve of acculturation especially for individuals who immigrate to western countries in adulthood. These cultural factors can have a large influence on health behaviour and “acculturation may affect health behaviours as a consequence of coping responses to discrimination and poverty: loss of social networks; exposure to different models of health behaviour, and changes in identity, behavioural; and chances in identity, behavioural prescriptions, beliefs, values, or norms” (Abriado-Lanza, 2006). By examining these traditional health practices in comparison to western medical practices and common public health interventions, it is possible to explore how certain aspects of the HBM fail to give proper consideration to culturally imperative health practices and how this lack of consideration results in health disparities amongst immigrant communities.
The notion of perceived susceptibility, or of whether or not an individual feels like they are likely to get a disease, is one of the key concepts of the Health Belief Model (Rothman, 2006). An example of this was found in Case 3 and its examination of perceptions of tuberculosis in recent Vietnamese immigrants. A common illustration of this concept is the statement ‘I’m not gay, so why should I worry about HIV?’ In a case such as this, the traditional intervention would be the development of an education program which explains the many methods of HIV transmission, and how all people who engage in ‘risky behaviours’ have the potential to get the disease, not just those who are gay, or who are junkies. Although this is a good start, when dealing with sociocultural beliefs and interpretation of health and disease, lack of education is not the issue. Instead, it is the “health culture or sociocultural context in which the patient is immersed and how it affects his or her interpretations of the origins and meanings of disease and decisions about compliance or non-compliance with medical treatments” (Ito, 1999) that has the greatest influence on perceived susceptibility.

As all three cases show, the HBM is negligent in a vital area of public health practice: the role of culture on health and healthcare. Instead of relying on the HBM’s narrow views of health and health communication, public health practitioners need to being developing and implementing public health theories and approaches that consider a more holistic approach to health, disease, and communication: approaches that give culture the consideration that it deserves.

Conclusions
Changing US demographics lend need to public health theories that broaden the HBM to incorporate other, non-traditional cultural medical approaches. Although individual public health practitioners have called to integrate cultural sensitivity and public health practice, there has been very little reflection of this call seen in public health theory. Old standbys such as the Health Belief Model continue to disregard the high level of usage of traditional and alternative health practices in the communities which it is supposed to be serving, encouraging public health professionals to develop attitudes where the goal is to communicate around traditional health beliefs, rather than work with those beliefs to develop a holistic health paradigm for ethnic minorities and other people who do not totally ascribe to the western healthcare system. As the three cases examined above show, the health belief model and similar theories are not serving the health needs of, and is even alienating, large chunks of the American public. It is up to public health professionals to research, develop, test, and implement culturally considerate theories of public health belief.

Works Cited

Abraido-Lanza, Ana F, Adria N. Armbrister, Karen R. Florez, and Alejandra N. Aguirre Toward a Theory-Driven Model of Acculturation in Public Health Research. AJPH 2006; 96(8):1342-1346.

Astin, John A. Why Patients Use Alternative Medicine: Results of a National Study. JAMA 1998;279(19):1548-1553.

Becker, Gay, Rahima Jan Gates, and Edwina Newsom Self-Care Among Chronically Ill African Americas: Culture, Health Disparities, and Health Insurance Status. AJPH 2004; 94(12): 2066-2073.

Bodeker, Gerard and Fredi Kronenberg A Public Health Agenda for Traditional, Complementary, and Alternative Medicine. AJPH 2002; 92(10): 1582-1591.

Carey, James W, Margaret J. Oxtoby, Lien Pham Nguyen, Von Hunh, Mark Morgan, and Marva Jeffery Tuberculosis Beliefs Among Recent Vietnamese Refugees in New York State. Public Health Reports 1997; 112:66-72.

Dressler, William W. and James R. Bindon The Health Concequences of Cultural Consonance: Cultural Dimenions of Lifestyle, Social Support, and Arterial Blood Pressure in an African American Community. Am Anthropologist 2000; 102(2): 244-260.

Fadiman, Anne. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux, 1997.

Henry, Rebecca R. Measles, Hmong, and Metaphor: Culture Change and Illness Management Under Conditions of Immigration. Med Anthropol Q 1999; 13(1):32-50.

Ito, Karen L. Health Culture and the Clinical Encounter. Vietnamese Refugees’ Responses to Preventive Drug Treatment of Inactive Tuberculosis. Med Anthropol Q 1999; 13(3): 338-364.

Park, Constance M. Diversity, the Individual, and Proof of Efficacy: Complementary and Alternative Medicine in Medical Education. AJPH 2002; 92(10): 1568-1572.

Rairdan, Betty and Zana Rae Higgs When Your Patient is a Hmong Refugee. Am J of Nursing 1992; 92(3):52-55.

Rothman, EF. The SB 820 Course Reference Book. Boston, MA: Boston University School of Public Health, 2006.

Silenzio, Vincent M.B. What Is the Role of Complementary and Alternative Medicine in Public Health. AJPH; 92(10): 1562-1564.

Thomas, Stephan B, Michael J. Fine and Said A. Ibrahim Health Disparities: The Importance of Culture and Health Communication. AJPH 2004; 94(12):2050.

Westermeyer, Joseph. Folk Medicine in Laos: A Comparison Between Two Ethnic Groups. Soc Sci Med 1988; 27(8):769-778.

The Insurance Industry’s Cost-Sharing Provides Penalties for People who Act to Improve their Health, Discouraging Healthy Behaviors - David Ganick

2006-12-17T16:59:00.000-08:00

The U.S. Insurance model is one in which health insurance is financed through multiple pieces, all paid by the consumer (employer, employee or individual). These pieces are the premium (paid on a monthly basis and making up the bulk of the payment) and the cost-sharing portions (co-pays, coinsurance and deductibles). The vast majority of U.S. workers with job-based insurance coverage face copayments when they go to the doctor; 60% are in plans with a copayment of $15 or $20, and an additional 15% are in a plan with a copayment of $25 (1). Most covered workers also face cost-sharing of prescription drugs; 74% of covered workers in plans with prescription drug copay structures have at least three different copay levels.

Anyone familiar with the U.S. healthcare industry is aware that there is a major push towards preventive care, rather than reactive medicine. The basic assumption is simple; it is better to prevent an illness than to treat it. Not only is it better for the individual to not have to go through the risks and suffering associated with any illness, but it is also more cost-effective to prevent diseases rather than paying for treatments. If preventing illness is a major goal of healthcare, why have we built a healthcare model that creates disincentives for behaving in a manner that would more effectively prevent illness?

Reinforcement Theory is the theory that the consequences of actions will modify behavior (2). Unlike the more famous Classical Conditioning (3), Reinforcement Theory is not invoking a response based on a completely independent stimulus. Reinforcement Theory experiments show that you can increase the occurrence of an action or behavior by linking it with a positive outcome related to the action. Likewise, you can decrease the occurrence of an action or behavior by linking it with a negative outcome. Having to pay money for an action is a negative outcome. On the flip side, getting something for free would be considered a positive outcome.

Now if one accepts those contentions, it is easy to see how going to get a physical and being told by the receptionist that you “don’t owe anything” represents a positive outcome. And certainly if you are told that you owe $20, this would be a negative outcome. Therefore after you have gone to the doctor several times, Reinforcement Theory suggests that you would be less inclined to go to the doctor in the future if you are paying co-pays at the time of your visit.

Now a person would logically ask, if copays prevent the moral hazard (4) associated with “free” services, how do they raise costs? Before answering that question, the more widespread affects of Reinforcement Theory should be reviewed. For example, what happens when a person fills a prescription that their doctor prescribed for cholesterol medicine and is told that they owe $30?
Reinforcement theory tells us that the individual’s behavior will change. In fact, the person may stop taking their prescribed medicine. Reinforcement Theory suggests that if the reinforcement has a large enough impact, the reinforcement will begin to change behavior, such that one may stop filling this prescription. If this person has insurance coverage, but has minimal discretionary income, will the negative outcome of owing $30 have a larger effect than for someone with less financial constraints?

Let’s take this one step further. Assume that every time a primary care physician tells a person to go see a specialist, and the person follows these instructions, the outcome is that they owe $35 (a negative outcome). Now assume that every time the doctor tells them that you need to take a specific prescription, the outcome is that you owe $15 or $30 or $45 (another negative outcome). If the behavior that we look at is listening to your doctor, Reinforcement Theory shows us that behavior will be changed in such a manner that individuals will be less inclined to listen to their doctor. It does not make sense to build a system of care that undermines itself by disengaging individuals through structural barriers. Further, the negative reinforcements are more powerful for those with less discretionary income, meaning the system more negatively influences poorer individuals.

Now I would like to view this argument through the lens of Standpoint Theory. Standpoint Theory states that the social groups to which individuals belong shape experiences, knowledge, and behaviors (5). It is clear that different socio-economic classes will put varying weights on the negative consequence, or punishment, of having to pay for following the advice of their doctor. However, Standpoint Theory tells us that the psychological impact of behavior changing negative reinforcement will have varying effects upon different social groups. If a person has a great amount of trust of their doctor, the negative outcomes of listening to this doctor may have less of an effect on their behavior. However, within minority populations, where there is a well-documented, disproportionate distrust of the doctors and hospitals, these plan structures may have a compounding effect. Therefore, the structure of this insurance system is creating increased barriers for minority populations.

Another relevant article looked at the overall affects of using “carrots” versus “sticks” (6). This article discussed a lab-based experiment showing the different effects of rewards and punishments on an individual’s cooperation with others. One of the central findings of the experiment is that it shows that the amount of behavior change is greatest when individuals are punished for doing the wrong thing, versus when they receive rewards for doing the right thing. Applying this to the cost sharing structures used in the U.S. healthcare system, it suggests that the largest effect on individual’s behavior would be from any punishments. In the case of the healthcare system it is slightly different because the rewards are actually for doing nothing, and the punishments are for following the recommended action (e.g., filling a prescription or going to see a specialist). However, this study shows that “sticks” (punishments) play a large role in shaping individual behavior.

It is important to acknowledge that in healthcare there are clearly positive physical and psychological rewards for acting in a manner suggested by your healthcare provider. However, these rewards may be outweighed by the punishments for behaving in a manner that would bring about positive results. In addition, the rewards are not usually connected to the actions in a clear and immediate way. For example, if a person takes a maintenance prescription drug, the result may be that the person does not have any additional episodes of illness connected to that particular condition. However, the effect of their actions is not necessarily clearly linked to the action of taking the prescription drug. Likewise, if a group of employees from an insurance plan all increase their utilization of the health plan, their costs will go up. This is a negative effect but the individuals may not necessarily see the connection. That is not to suggest that they wouldn’t understand that there is a direct connection, but rather that they do not think in these terms. Unlike these rewards and punishments that are less closely linked to the actions, copays, deductibles and coinsurance at the time of care is clearly on account of the action of utilizing the health plan.

To understand the potential, and likely, implications of copays in healthcare, it is important to look beyond theory to actual practice. A study published in the Journal of the American Medicine Association in 2004 (7) shows that increasing the copays for prescription drugs lead to lower utilization of all classes of drugs. The results of this study raised concerns for the author about the negative affects on health outcomes of higher copays. Assuming that doctors prescribe prescription drugs for clinical reasons, the punishments associated with filling these prescriptions (increased costs) are having a negative effect on these individual’s health. This study does not apply any theories regarding the messages that these copays are sending.

However, it clearly shows that for a group of 528,969 privately insured individuals aged 18 to 64, there are negative impacts of paying for healthcare through these types of copays. It is important to note that the effect of the increased copays was not limited to any specific class of drugs that one might contend are ‘not as important’, or ‘less instrumental to the health of the users’. The biggest factor affecting the decline in prescription drug use was the amount the copay was increased. This shows that once the negative reinforcement reaches a certain threshold, it begins to change the individual’s behavior.

The last piece of evidence I will cite is anecdotal. Pitney Bowes implemented a program reducing copays for employees enrolled in their disease management programs. By encouraging these chronically ill individuals to heed the recommendations of their doctors, Pitney Bowes saved over $1 million dollars. By taking away the disincentives for these high-risk employees to take preventive steps (medications, doctors visits, etc.) they stayed healthier. Once the punishments were removed for acting in a productive manner, people were more inclined to behave in that way.

References

1. http://www.kff.org/insurance/7527/upload/7528.pdf

2. Skinner, B.F. (1969). Contingencies of Reinforcement: A Theoretical Analysis. Englewood Cliffs, NJ: Prentice-Hall.
http://wik.ed.uiuc.edu/index.php/Reinforcement_theory;

3. Pavlov, I. P. (1927). Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex (translated by G. V. Anrep). London: Oxford University Press. http://en.wikipedia.org/wiki/Classical_conditioning

4. Wood, J. T. (1982). Communication and relational culture: Bases for the study of human relationships. Communication Quarterly, 30, 75-82.

5. http://www.gladwell.com/2005/2005_08_29_a_hazard.html and
http://www.ingrimayne.com/econ/RiskExclusion/Risk.html

6. Andreoni et al, The American Economic Review, June 2003, Volume 93, No. 3. http://www.pitt.edu/~vester/AER2003.pdf

7. Pharmacy Benefits and the Use of Drugs by the Chronically Ill. Dana P. Goldman, PhD; Geoffrey F. Joyce, PhD; Jose J. Escarce, MD, PhD; Jennifer E. Pace, BS; Matthew D. Solomon, MA; Marianne Laouri, PhD; Pamela B. Landsman, MPH, DrPH; Steven M. Teutsch, MD, MPH. JAMA. 2004; 291:2344-2350.

WHO Lifts DDT Ban after 30 years. The Chemical Warfare against Malaria will Continue to Fail Unless Affected Communities are Empowered– Lynn Simpson

2006-12-17T16:44:00.000-08:00

On September 15, 2006, the World Health Organization (WHO) announced the re-introduction of DDT for indoor residual spraying (IRS) as the main intervention to fight malaria. Not only is DDT controversial environmentally, but its use in most circumstances disregards the sociocultural behaviors and attitudes of target populations. By doing so, this type of top-down intervention is not sustainable at the community level and in most cases is barely a “quick fix”. In order for a campaign against malaria to be effective, a community level intervention is needed. It should incorporate the population’s needs, assess behaviors and risk factors, and ultimately empower the community to change. Only after a community is invested in the fight, can effective measures against malaria be sustained.

There are three basic strategies for any planned intervention: Empirical-Rational, Normative-Re-educative, and Power-Coercive (Bennis, 1976). By encouraging IRS as a global solution to the malaria problem, the WHO is using the top down, Power-Coercive approach. This initiative ineffectively targets all communities homogeneously, disregarding any underlying environmental and/or socio-economic differences. The WHO is using its influence to encourage the use of DDT for all malaria areas including communities that do not perceive it as a top priority, culturally disagree with the IRS method or fear the economic consequences. The Empirical-Rational intervention approach is also not as effective because the majority of the malaria areas lack education and resources and have difficulty in understanding the impact of malaria on their communities (Gramaccia, 1981). The individuals that contract malaria and cannot work for days realize the economic impact on their own lives and families but do not comprehend the larger impact on their society and more importantly - that malaria is preventable. The success of initiatives such as IRS is vulnerable to incompatible cultural beliefs and lack of understanding and these two strategies continue to fail the communities at risk.

In order to develop a useful intervention, we must consider a general framework applicable to malaria affected populations. This disease is not an individual disease where a single person has the power to change their environment or behavior and effectively eliminate their risk for infection. One house in an entire village cannot be sprayed to eliminate that household’s risk. This health initiative needs to be assessed at the community level and become a collective effort against those environmental and socio-economic factors increasing the risk for malaria. A behavior model originally published by Dahlgren and Whitehead (1991), conceptualizes the determinants of societal health in an onion-like structure. The outer most level includes general socioeconomic, cultural and environmental conditions. The next layer involves living and working conditions. Peeling away another layer incorporates social and community influences and finally, the inner core contains the individual lifestyle factors. The outer layers are wider influences on health that have the potential to be modified to positively impact entire populations. When examining a disease like malaria, it is important to focus initially on those outer layers as opposed to the individual level factors.

If you start at the very outer layer of this model, there are general socio- economic, cultural and environmental factors that are actually comparable across populations. Malaria disproportionately affects underprivileged communities with poor nutrition, inadequate living standards, and a lack of medical care. The perceived seriousness of malaria infection might pale in comparison to the seriousness of starvation. As a result, these societies develop behavioral patterns and social systems to endure their conditions (Heggenhougen, 2003). If malaria is perceived as a tolerable disease, people will continue to live and function without making the effort to eradicate the mosquitoes and ultimately the risk of infection. Larger issues of poverty and community priorities must be addressed within the malaria health initiative in order to be effective.

Cultural differences also inhibit the efficiency of IRS. For IRS to successfully kill the adult vector mosquitoes, professional teams must spray long-acting chemical insecticides on the inside walls and roofs of all houses and domestic animal shelters in throughout the community (WHO, 2006). Spraying has proven difficult in Sri Lanka for Muslim households who believe in the purdah. Because spray teams are all males, they cannot enter the homes where only women are present unless they are related. The residents also believe that spray teams consisting of lower caste members may not enter the homes of higher-caste members (Ault, 1983). This is an example of the cultural barriers involved with the global IRS intervention.

There are also important structural differences that exist at this outer layer. For instance, different environments and agricultural zones affect mosquito breeding habitats. The amount of still water in rice paddies will differ from fruit tree orchards. Even weather patterns, altitudes and seasons influence vector densities (Frumkin, 2005). Using IRS in a Colombian household in the Nava river basin will be completely ineffective unless the fruit trees next to their homes are first removed. The fruit trees are an important source of food but also provide perfect breeding sites for mosquitoes because the leaves collect small pools of water (Sevilla-Casas, 1993). If the WHO does not physically assess these types of structural factors first, IRS will have no impact.
These general oversights can carry into the next “onion” layer: living and working conditions. In order to improve well-being, people will engage in economic activities that increase their risk for malaria out of a sense of necessity (Heggenhougen, 2003). Many populations, for example, are affected by migrant workers. Sometimes fluctuations in migratory workers influence outbreak surveillance. The fisherman of Rameswaram Island, Sri Lanka, fish and contract malaria on the coast, but return to the mainland with the infection (Rajagopalan, 1986). This poses a question for IRS: do spray teams use DDT at the temporary fish camps, at their mainland permanent homes, or both? And if the encampments are open one-sided basic sleep shelters, then IRS is futile. These men could change their behavior by not fishing and not putting themselves at risk for contracting malaria; however, this is not a practical economic solution. Heggenhougen et al (2003) take it one step further and realize that “poverty alleviation programs positively affect malaria treatment and prevalence”. Therefore interventions need to encompass all aspects of a community’s living and working situation.

As demonstrated, different types of populations present different kinds of cultural, economic and environmental risks for contracting malaria, each requiring a unique understanding and solution. Continuing to peel away the layers of Dahlgren and Whitehead’s model (1991), it is essential to examine the social and community influences on health. To change risk behaviors, new norms for behavior and new rules at the social and cultural level need to be established. This has to be a collective effort. First, it is important to asses the community’s perceived seriousness and susceptibility of the disease. As discussed before, many do not perceive its seriousness as a health problem but rather an economic set back or a family monetary crisis. If the community does not perceive the seriousness of the disease as it relates only to their health, their understanding of IRS is limited. The WHO is placing an increased emphasis on malaria prevention alone without any focus on economic reform. This does not coincide with the community’s priorities. It presents an aspect of community disempowerment when outsiders must come in and control for an illness to which they have a limited understanding. This disempowerment affects the autonomy of the community. The community may believe malaria prevention is an impossible task because it appears only the WHO outsiders have practical solutions.

Once a society’s perception becomes incorporated into their belief system, it takes work to re-establish and change that conviction. This is a huge obstacle to overcome, but there are communities that have re-created their social norms, modified their behaviors and increased their community sense of autonomy and efficacy. In Oaxaca State, Mexico, women have made many accomplishments. They changed the social norms involving gender roles, the society’s values and priorities by helping to establish vector control measures (Rodriguez, 2004). In Rusinga Island, Kenya, and Dar es Salaam, Tanzania, programs were initiated and implemented entirely at the local level with help from academic institutions (Mukabana, 2004). These are empowered community based interventions. If more communities are enabled to create grass-root level programs, the potential for sustainability is much greater (Swerssen, 2004).

The IRS initiative has excluded the community from the decision making process but community compliance is still essential to the success of the program. Communities invested in the prevention programs because their own values and goals have been incorporated, help make the behavioral changes desperately needed in a successful campaign against malaria
Even though this type of malaria intervention is a collective effort, the core of the “onion” model, the individual lifestyle factors, cannot be overlooked. Individual lifestyle factors are influenced by the community, core values and social practices. When individuals begin to adapt their behaviors because societal values are changing, the Diffusion Theory suggests more individuals will be influenced to change (Rogers, 1983). The control the individual has on the malaria situation is in motivating the community and creating a collective effort against the disease.

By using the “onion” model to assess the economic, cultural and structural influences on malaria, an intervention incorporating these factors to influence behavioral change will be the most effective strategy. This type of approach is the Normative-Re-educative strategy (Bennis, 1976). Instead of the WHO imposing its commitment of malaria eradication as a separate intervention, it would be incorporated with the economic goals and social values of the community, thereby increasing the stakeholder’s commitment to controlling their environments and participating in the decision making process. The community must be invested in and committed to the fight against malaria to maintain a sustainable successful intervention. By not incorporating a population’s needs into the intervention, or changing the beliefs and attitudes in order to empower the communities overwhelmed by malaria, pesticide use and the strategies used to implement change will continue to be ineffective.

Resources

Dahlgreen,G., & Whitehead, M. Policies and strategies to promote equity in health. Stockholm: Institute for Future Studies 1991.

Frumkin, H. Environmental Health: From Global to Local. San Francisco: Jossey-Bass 2005.

Heggenhougen, HK, Hackenthal V, Vivek P. The behavioural and social aspects of malaria and its control. An introduction and annotated bibliography. Geneva: World Health Organization 2003.

Rogers, E.M. Diffusion of innovations. 3rd ed. New York: Free Press 1983.

WHO. Indoor residual spraying. Use of indoor residual spraying for scaling up global malaria control and elimination. WHO Position Statement 2006. http://malaria.who.int/docs/IRS-position.pdf

Mukabana WR, Kannady K, Kiama GM, Ijumba J, Mathenge EM, Kiche I, Nkwengulila G, Mboera LEG, Mtasiwa D, Yamagata Y, van Schayk I, Knols BGJ, Lindsay SW, Caldas de Castro M, Mshinda H, Tanner M, Fillinger U, Killeen GF. Ecologists can enable communities to implement malaria vector control in Africa. Malar J 2006; 5:9

Bennis, W. G., Benne, K. D., & Chin, R. The planning of change. 3rd ed New York: Holt, Rinehart & Winston 1976.

Ault SK. Anthropological aspects of malaria control planning in Sri Lanka. Medical Anthropology 1983; 7: 28-49.

Rajagopalan PK, Jambulingam P, Sabesan S, Krishnamoorthy K, Rajendran S, Gunasekaran K, Kumar NP. Population movement and malaria persistence in Rameswaram Island. Social Science & Medicine 1986; 22, 879-886.

Sevilla-Casas E. Human mobility and malaria risk in the Naya river basin of Colombia. Social Science & Medicine 1993; 37,1155-1167

Rodriguez, M.H., Hernández-Avila, J.E., Betanzos-Reyes, A.F., Danis-Lozano, R., González-Cerón, L., Durán-Arenas, L.G., Méndez-Galván, J.F., Vázquez-Mellado, R.M., Velásquez-Monroy, O.J., Holguín-Bernal, H., Tapia-Coyner, R., An ecosystem approach study of malaria transmission and control interventions in southern Mexico. Global Forum for Health Research Forum 8, Mexico, 2004

Swerissen, H., Crisp, B.R., The sustainability of health promotion interventions for different levels of social organization. Health Promotion International: Oxford University Press 2004;19, 123-130.

A Critique on Moral Hazard Theory as the Basis for Healthcare Coverage in America -William Cheung

2006-12-17T15:56:00.000-08:00

Healthcare in the United States is highly regarded as the most sophisticated and technologically advanced anywhere in the world, yet the system for financing and delivering care is incredibly complex and convoluted. Almost one in six people in the United States lack health insurance; that equates to over forty five million Americans. Eighty percent, or roughly thirty six million of those who are uninsured, are from working families. “The uninsured are members of every race and ethnic group, every age group and every income level” (Health Coverage In America, 2004). The key point is that the overwhelming majority of the uninsured are from families currently in the labor force, dispelling the common misconception that those without health coverage in America are poor and unemployed.

When compared to other countries, the United States spends much more on healthcare, yet leaves millions uninsured. “The United States spends 15 percent of its Gross Domestic Product (GDP) on health care, which equates to 2.2 trillion dollars, while offering little or marginal care to over forty five million people, while the German system, by far the most expensive of all the countries in the European Union (EU), provides universal coverage for all its citizens for less than 11 percent of its GDP, according to the Organization for Economic Cooperation and Development (OECD). The median for EU nations is 8 percent” (Hujer, 2004). Every other industrialized country in the world provides universal health coverage, yet spends significantly less than the United States. The annual growth in American health spending continually exceeds both the annual growth within our own GDP and per capita health spending in other OECD country by huge margins.

In the United States, the assumption is that better quality and better health results from greater spending on healthcare, but the fact is that the United States does not have anywhere near the best health in the world. “The poor performance of the United States was recently confirmed by the World Health Organization, and the figures regarding the poor position of the United States in health worldwide are robust and not dependent on the particular measures used” (Starfield, 2000). Regardless of the criteria used to measure quality or performance, satisfaction remained lower among people living in the United States. Americans are not happy with the current healthcare system, yet change has been hard to come by.

The fact is, politics have always gotten in the way of healthcare reform. “A powerful impediment to the expansion of health insurance is the idea of moral hazard. Moral Hazard is the term economists use to describe the fact that insurance can change the behavior for the person being insured. Insurance can have the paradoxical effect of producing risky and wasteful behavior” (Gladwell, 2005). As the famous economist Mark Pauly put it, “the individual will alter his or her desired expenditures for medical care because of the fact of insurance. Medical insurance, by lowering the marginal cost of care to the individual, may increase usage”. Moral hazard theory describes the phenomenon in which having insurance causes the insured to engage in riskier behaviors, presumably because his or her personal liability for bad outcomes is now greatly limited. “Health economists in other industrialized nations do not share this obsession. Nor do most Americans. But moral hazard has profoundly shaped the way health care policies have been formulated and the way policymakers have come to think about insurance” (Gladwell, 2005).

Moral hazard underlies cost cutting efforts such as high deductibles, large co-payments, and the utilization reviews that saturate the American healthcare system. These methods were put in place to try and limit moral hazard, on the grounds that if you force personal health liability back onto the individual, he or she will make more economically sensible choices with respect to healthcare. The inefficiency that arises from excessive paperwork is due to the mistrust moral hazard creates. High administrative costs are put in place to ensure that the care and procedures provided are absolutely necessary. Moral hazard is said to occur whenever individuals are not responsible for paying all the costs associated with their medical treatment. But there are profound problems and fundamental flaws with this belief.

Putting economic and administrative roadblocks in front of those trying to get healthcare does not necessarily reduce healthcare costs. Cost cutting efforts that focus on decreasing utilization of health services might sound desirable to the government and to insurers, but this is a very short term view that can end up costing a lot more in the long run. In fact, if people had more access to healthcare, it is more likely that problems will be taken care of earlier, before they progress into chronic conditions. “Increasing people’s out of pocket expenses will make them less likely to seek routine preventive care that might stave off bigger problems down the road” (Freudenheim, 2006). In the long run, if people do not receive adequate preventive care, their health troubles will manifest into bigger problems. Ultimately, this will foster the development of a large population with chronic disease and disability.

One of the reasons why healthcare costs in the United States are so substantial is because there is a tremendous burden of chronic conditions. It is not the case that we are spending most of the money to treat the acute conditions that the government and insurers are trying to reduce; instead, we are paying the most to treat the chronic diseases and disabilities that could have easily been avoided if preventive care had been attained earlier. “The sickest one percent of patients, the chronically ill and those in the intensive care unit, account for over a quarter of all healthcare costs” (Landro, 2003). In trying to reduce the usage of healthcare, moral hazard theory has actually increased the demand and the necessity for more services and care.

From a public health perspective, moral hazard theory serves as a strong deterrent to preventive care. This has severe implications when it comes to healthcare because “better preventive care can dramatically reduce hospitalization” (Landro, 2003). Moral hazard advocates the philosophy that care should not be covered unless it is absolutely necessary. This effectively eliminates preventive care since the effects of good preventive care cannot be seen or measured, causing insurers to disregard it as required and essential. This focus on treatment rather than on prevention might cut costs, but this short term view has blinded them from seeing the big picture. In the long run, the lack of prevention will lead to a huge burden of healthcare costs due to chronic illnesses and disabilities, and therein lies a fundamental flaw in moral hazard theory.

“The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to healthcare, many of the things we do, like engaging in routine preventive care, are anything but wasteful and inefficient” (Gladwell, 2005). Without adequate health insurance, many people would not receive the necessary preventive measures that can avert potentially serious and life threatening complications. Moral hazard outs both unneeded and needed care because we do not know what care is necessary. “How should the average patient be expected to know beforehand what care is frivolous and what care is useful? Medical knowledge is so complicated that the information possessed by the physician as to the consequences and possibilities of treatment is necessarily very much greater than that of the patient” (Millenson, 2001). People who have to pay more for their healthcare use less healthcare regardless of how urgent the need is for medical attention. By shifting the focus from those without insurance to the possibility that people with insurance use too much care, moral hazard theory emphasizes the wrong aspects of health coverage. Instead of focusing on the problem of having over forty five million Americans uninsured, we implement policies that try to reduce usage of medical services, even though not having coverage can be dangerous to your health, as the Institute of Medicine concluded; “health insurance is associated with better health outcomes for both adults and children and with their receipt of appropriate care across a range of preventive, chronic, and acute care services”. When millions of people lack insurance and the necessary funds to pay for healthcare, they rely on emergency rooms as their one source for medical services.

Having over forty five million uninsured people in the United States is causing significant financial burdens on hospital emergency rooms. The strain of caring for the uninsured is forcing many hospitals to close due to the major economic stress they cause. “Virtually all nonprofit community or public hospitals in America where the poor and the uninsured go to be healed are caught in a death spiral. The higher the number of indigent or low paying patients, the more money the hospital loses. So year after year, the hospitals operate in the red” (Schulte, 2003). The economic problems are largely due to the fact that there is a huge pool of free care which hospitals are required to give, simply because there is such a large segment of the population that is uninsured. “The emergency room is the only place an American has a right to medical care. As a result, it has become the portal for healthcare in this country, yet many of these patients could have been seen elsewhere, at far less expense” (Schulte, 2003). The lack of insurance leads millions of Americans with nowhere else to turn, resorting to emergency rooms as their form of primary care, even though treatment in the emergency room is far more expensive than regular outpatient care. “As it stands now, the burden of healthcare falls on hospital emergency rooms. Although they used to be the option of last resort, they have become the line of first defense for the uninsured” (Winokur, 2003). This undue stress on the emergency care system and the huge costs that result could be greatly reduced if more people had healthcare coverage, yet moral hazard theory has induced the government to disregard the problem. What is troubling about this view of healthcare is that policies will focus on reducing moral hazard, instead of trying to extend health coverage to those who lack it.

The political implications of moral hazard theory are vast and far-reaching. Both public and private programs have directed their course of action towards reducing excessive usage instead of concentrating on programs that try to expand coverage. “At the center of the Bush Administration’s plan to address the health insurance mess are Health Savings Accounts, and Health Savings Accounts are exactly what you would come up with if you were concerned, above all else, with minimizing moral hazard (Gladwell, 2005). President Bush believes that Americans currently have too much health insurance, so Health Savings Accounts were created to compel the population to act more prudently when it comes to healthcare. Instead of paying for health insurance to cover medical needs, Health Savings Accounts permit an individual to save a portion of their income, tax free, and use it as needed when medical expenses come about in the future.

To reduce health expenditure in America, the President, an advocate of moral hazard theory, argues that the direct costs that people pay for medicine should be raised, and in doing so they will have more incentive to be careful and spend sparingly. As President Bush explained recently, “Health Savings Accounts are aimed towards empowering the people to make decisions for themselves, owning their own healthcare plan, and at the same time bringing some demand control into the cost of healthcare”. Yet saving for healthcare does not work the same way as saving for consumer goods, and definitely is not the same as insurance. Insurance was created to help equalize financial risk between the healthy and the sick. This social aspect of insurance is based on the idea that transferring resources from those who have them to those who need it will provide people with the security of being safeguarded against severe financial burdens due to serious and chronic illness.

Yet Health Savings Accounts are not based on social insurance; it is instead based on the actuarial model. How much you pay with actuarial insurance is in large part a function of your individual situation and history. Those who are young and healthy will pay little to nothing for healthcare, while those unlucky enough to have serious illnesses will face unmanageably high healthcare costs. “If you are preoccupied with moral hazard, then you want people to pay for care with their own money, and, when you do that, the sick inevitably end up paying more than the healthy” (Gladwell, 2005). Putting more of the costs onto the consumer reduces the social redistributive element of insurance. “In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has over forty five million people without coverage is that its healthcare policy is in the hands of the few people who disagree, and who regard health insurance not as the solution but as the problem” (Gladwell, 2005). This line of thinking does not solve the healthcare problems of the United States as President Bush argues; it really only exacerbates the problem by creating a vicious cycle wherein even more Americans will be uninsured, since those with serious and chronic illnesses are paying more and more, and those who cannot afford will forgo needed care and can only get sicker and sicker.

Private insurance companies have also used moral hazard theory to try and contain costs. Consumer Driven Plans, offered by United Health Group Inc., are based on the principle that “people will shop for the best care at the lowest price if they have to pay more of the cost themselves. The idea is a response to traditional plans in which employers pay most of the bill after modest deductibles and co-payments, leaving consumers with little incentive to curtail their medical spending” (Fuhrmans, 2005). But only if services were thought of as wasteful would such a policy come about. Once again, the moral hazard rationale has created a plan that focuses more on price than on quality and appropriateness of care. By putting the burden of paying the large and hefty fees doctors and hospitals charge back onto the people, many will go without the preventive and routine care that is necessary for health and well being.

Due to the fear of moral hazard, healthcare in the United States is complex, convoluted and fragmented. As it has been pointed out, “health economists in other industrialized nations do not share this obsession” (Gladwell, 2005). Americans spend a lot more, yet receive much less. The fact is, “in most countries, the preponderance of medical care is financed or delivered in the public sector; in the United States however, most people pay for and receive their care through private institutions. Those other countries all provide universal healthcare coverage through government run or government mandated programs” (Bodenheimer, 2005). Germany was the first country to enact universal health coverage legislation; over a century ago, in 1883, the German sickness funds were created to cover the healthcare costs of the entire population. “These funds are not allowed to exclude people due to illness, or to raise contribution rates according to age or medical condition. German health insurance, unlike in the United States, must continue to cover its members whether or not they change jobs or stop working for any reason” (Bodenheimer, 2005). Canada and the United Kingdom have also severed the link between employment and health insurance. “Wealthy or poor, employed or jobless, everyone receives the same health insurance, financed in the same way. No one would even imagine that leaving, changing, retiring from, or losing a job has anything to do with health insurance” (Bodenheimer, 2005). By breaking the connection between employment and healthcare coverage, these countries have integrated medical care directly into the cost of living; everyone contributes through taxes so everyone can benefit. “In Germany, Canada, and the United Kingdom, no distinction is made between the public financing mechanisms of social insurance and public assistance. Such universal insurance programs create a fair system for distributing health services” (Bodenheimer, 2005). In contrast to the United States, these countries and all other industrialized nations have found a way to deliver universal healthcare to their entire populations at far less cost. The United States spends hundreds of billions of dollars extra and more than twice the amount per capita for healthcare annually than any other country in the world, yet does not come close to providing universal coverage. Because the United States is the only country that focuses on moral hazard instead of relying on the social aspect of insurance as every other nation does, we leave millions without health coverage, abandoning Americans who do not have health insurance, forcing them to fend for themselves when it comes to paying for medical care.

Works Cited

Alliance For Health Reform; “Health Coverage In America: Understanding the Issues & Proposed Solutions”; www.CoverTheUninsured.org; 2004

Bodenheimer, Thomas, and Grumbach, Kevin; “Understanding Health Policy: A Clinical Approach”; The McGraw-Hill Companies, Inc. San Francisco, 2005

Fein, Rashi; “Medical Care, Medical Costs: The Search for a Health Insurance Policy”; Harvard University Press. Cambridge, 1986

Freudenheim, Milt; “Prognosis Is Mixed For Health Savings”; The New York Times: January 26, 2006

Fuhrmans, Vanessa; “A Big Insurer Bets On Hot Trend: Shopping Around For Health Care”; The Wall Street Journal: October 24, 2005

Gladwell, Malcolm; “The Moral Hazard Myth”; The New Yorker: August 29, 2005

Hujer, Marc; “Only in America”; Washington Post: May 11, 2004

Landro, Laura; “Six Prescriptions To Ease Rationing In U.S. Healthcare”; The Wall Street Journal: December 22, 2003

Millenson, Michael; “Moral Hazard vs. Real Hazard: Quality of Care Post-Arrow”; Journal of Health Politics, Policy, and Law: Vol. 26, no.5; October 2001

Reinhardt, Uwe, Hussey, Peter, and Anderson, Gerard; “U.S. Health Care Spending in an International Context”; Health Affairs: Vol. 23, no. 3; May/June 2004

Schenk, Robert; “Cyber Economics: An Analysis of Unintended Consequences”; http://ingrimayne.com/econ/index.htm; 2002

Schulte, Brigid; “Saving Lives, Losing Millions at Pr. George’s Hospital”; Washington Post: December 22, 2003

Starfield, Barbara; “Is U.S. Health Really the Best in the World?”; Journal of the American Medical Association: Vol. 284, no. 4; July 26, 2000

Winokur, Julie; “Live Sicker, Die Younger”; www.AlterNet.org; May 16,2003

Fighting obesity through fast food corporate litigation is destined to become another failed public health intervention – Gintas Krisciunas

2006-12-17T15:43:00.000-08:00

Introduction
America has physiologically expanded to epic proportions. An estimated 30% of adults in the United States are obese, and 65% are either overweight or obese.(2) Individuals that are overweight and obese incur a detriment not only to their personal health and lifestyle, but also to our nation’s health care system, a debt that is deferred to every American tax payer. The Center for Disease Control estimated that medical expenditures attributable to overweight and obesity amounted to over $78 billion in 1998, or 9.1% of total US medical expenditures.(1) Historically, numerous public health interventions have attempted to stave off expanding waistlines. Currently, the use of litigation against the fast food industry has become an increasingly popular public health intervention that has gained increasing publicity and popularity, especially among some public health advocacy groups. Pelman v. McDonalds is predicated upon the assumption that fast food corporations are a cause of obesity, and that litigation will allow the general population to become enlightened health food consumers.(8) Inappropriately modeled after tobacco litigation, not only does this approach completely disregard the plethora of social and behavioral factors that influence individual choices and their feasibility, but may also prove detrimental to the war on fat by diverting attention and resources away from public health interventions that appropriately address the fundamental causes of obesity.

Inappropriately Modeling Fast Food Litigation after Tobacco Litigation
After a half a century of litigation against big tobacco corporations that effectively defended their profits and products through “scorched earth” strategies, a process of financially and emotionally wearing down plaintiffs, American consumers and health institutions are finally winning major settlements.(3) The Master Settlement Agreement (MSA) of 1998 resulted in big tobacco companies paying states $10 billion in damages. American citizens harmed by cigarettes are being remunerated, state Medicare and Medicaid programs are receiving compensation, and attorneys are making vast financial gains. Logically, if smoking causes adverse health affects and eating high-fat and high-calorie food causes obesity, and obesity begets adverse health outcomes, why not initiate litigation against fast food corporations modeled after big tobacco? Organizations such as the Public Health Advocacy Institute (PHAI) have made litigation a centerpiece in the crusade against obesity.(5) Alderman and Daynard, who unsurprisingly work for PHAI, published a special article in the American Journal of Preventative Medicine arguing that litigation can “lead to higher prices, decrease consumption, educate the public about the dangers of products, and compel an industry to stop deceptive marketing and misleading public statements.”(3) Realistically however, it is inappropriate to conclude that fast food litigation can successfully emulate tobacco litigation for two important reasons.

Unlike cigarettes, food is not inherently dangerous
One central and inappropriate argument behind fast food litigation that was appropriate and successfully used against big tobacco was that the products being sold are inherently dangerous. There are no known health benefits to smoking, and cigarette smoke contains 4,000 chemicals, 43 of which are known or suspected carcinogens.(5) Approximately 85% of lung cancer cases are directly attributable to smoking cigarettes. While obesity is associated with many adverse health outcomes including hypertension, Type II diabetes, coronary heart disease and stroke, eating a hamburger or French fries is not. Food does not directly cause adverse health outcomes the same way that smoking cigarettes does. There for, the food industry is not selling dangerous products. All food, even high-calorie and high-fat food can be healthy when consumed appropriately. Individuals who make poor choices regarding quantity and nutritional quality of the food they ingest, and who also fail to balance their nutritional consumption with proper lifestyle choices, specifically physical activity, cause their own obesity. In 2000, the CDC Behavioral Risk Factor Surveillance System showed that 26% of adults reported absolutely no physical activity – not even walking – during their spare time.(9) It is important to note that these individual level poor choices are not solely predicated on rational behavior as some public health models – like the health belief model – may suggest. It is a multifaceted, individual and societal level problem, addressed later in this critique. Even if one were to argue that some portion of fast food was unhealthy, such as trans-fats which show some correlation to the increased of heart disease, unlike cigarettes, food menus can change. While there is no current method of making cigarettes and smoking safe or “more healthy” (11), the food industry has the option of introducing lower-calorie menu items, or replacing trans-fats with a healthier alternative. Wendy’s for example, has already eliminated trans-fats from their fries.(12) Finally, unlike cigarettes that are addictive, physiologically forcing people to use a dangerous product even if they choose not to, there is nothing inherently addictive about fat, calories or fast food. After eating fast food even for prolonged times, people are still able to make rational decisions regarding caloric intake, and more importantly, follow through with their decisions thereby avoiding the adverse health outcomes associated with overweight and obesity.(7)

Advertising a burger as delicious is not deceptive marketing or misleading
A second central argument for using litigation against fast food corporations is to inhibit the fast food industry from deceptive marketing strategies and providing consumers with misleading information. These litigious categorizations fall under the consumer protection statutes violated by big tobacco companies.(3) In 1976 Ernest Pepples, Brown & Williamson's Vice President wrote a memo stating that "the smoker of a filter cigarette was getting as much or more nicotine and tar as he would have gotten from a regular cigarette. He had abandoned the regular cigarette, however, on the ground of reduced risk to health."(11) The Pelman v. McDonalds case attempts to exploit the consumer protection statutes by accusing McDonalds of falsely presenting its food as nutritionally beneficial to consumers. No one can deny that fast food corporations are expert advertisers. It has even been shown that people who are exposed to expertly target advertisements show greater preference for the advertised food products than individuals who are unexposed to such media. However, marketing fast food products in a way that makes them attractive and seemingly delicious is not the same as purporting that the food is healthy when it is not. Nor is such advertisement falsely implicating their product as safe when it is indeed harmful. This is not to say that vulnerable populations such as young children are not influenced by provocative advertisement. In a measure of protection, it has been shown that governmental regulation of advertisement locations, especially in schools, has been effective in protecting vulnerable individuals from such media.(10) There fore, arguing the validity of litigation for false advertising appears to be not only unfounded and unnecessary, but ineffective in its ultimate purpose, which is to prevent obesity.

Punishment and Stonewalling
Another lesson from the tobacco litigation era is the power of defensive tactics in response to potential damaging punishments through litigation. Social and economic theory dictates that corporations operate rationally in response to economic incentives. This suggests that a corporation faced with potential revenue loss will attempt to minimize such losses in any way possible. When confronted with lawsuits demanding millions or billions of dollars in damages, it is economically rational for corporations to enact defensive “scorched earth” tactics to protect their current and future assets. It took 50 years of litigation, state involvement as plaintiffs and incriminating industry documents to finally win cases against the tobacco industry. Considering cigarette toxicity and the industry’s deceptive marketing practices, the case against big tobacco is also far more compelling. Most importantly, if the goal of fast food corporation litigation is to address the industry’s promotion of obesity, then the result of any potentially successful litigation must not be solely compensatory remuneration for tangible and intangible costs of adverse health outcomes, but to theoretically impede the spread of the obesity epidemic. This suggests a need for menu reform. However, if fast food corporations are being sued for what is labeled as “dangerous” and unhealthy food, the industry will never change their menus. Doing so may indeed incriminate their current food as being “dangerous” and could subject them to an onslaught of law suits.(11) Litigation in this sense could actually hinder menu reform and the fight against obesity.

The Multifaceted Nature of Obesity
Possibly the biggest flaw in using litigation against fast food corporations to curb the obesity epidemic is the complete disregard of the numerous social and individual level factors that influence the problem. Food high in calories and fat do not cause obesity. Nor do the vendors, restaurants or corporations that sell such food. The fundamental causes of obesity stem from lifestyle choices. While some people may be slightly more susceptible to becoming overweight due to genetic factors, it is the responsibility of the individual to understand how many calories and how much fat they can consume before becoming overweight or obese.(9) A slightly slower metabolism is not an excuse for obesity, and rather, it should become a motivator to live a more active lifestyle. However, there are many factors that influence the feasibility of making appropriate lifestyle choices with regard to proper nutrition and exercise, and many of these factors coincide with socioeconomic status. A single parent working two jobs may not have time to cook meals that are as healthy as those cooked by a middle class or wealthy dual-parent household. The single parent may not even have the time to cook. It has been documented that poor neighborhoods not only contain many fast food restaurants, but also lack grocery stores that stock a variety of healthy produce.(13,14) From personal experience, it is far easier and cheaper to buy two $1 chicken sandwiches from Wendy’s than to spend more time and money searching for produce that needs to be cooked. Those two chicken sandwiches are also far more gastronomically satisfying than a salad that costs two or three times as much, and leaves you feeling hungry an hour later. Litigation does not address why poor neighborhoods do not have the same access to nutritious produce as more affluent communities. It does not address cultural and sub-cultural factors that influence the consumption of fruits and vegetables. The feasibility of making appropriate diet choices also revolves around education, there fore, it remains paramount to present the health implications of a poor diet in a way that is both engaging and culturally / socially relevant for target communities. Obesity is also a problem of feasible lifestyle choices, which can counteract the fattening implications of occasional over consumption of cheap and available fast food. For the affluent, a gym membership is only a credit card swipe away. Affluent communities are safer, and often offer greater access to recreational and outdoor facilities. Even if someone in a poor community wants to go for a run, they may not do so if safety is a problem.(15) Sports equipment and expensive running shoes are far more accessible for the affluent than for those working two minimum wage jobs. Considering the many social and individual level factors that affect obesity, it is evident that engaging in litigation against fast food corporations will solve nothing. By devoting tremendous resources and energy in litigating fast food corporations in the fight against obesity, significant harm will be done by shifting the emphasis and resources away from addressing the actual causes of obesity.

Conclusion and Progressive Suggestions
It is tempting to assume that litigation against fast food corporations to fight obesity can parallel the hard won success against the tobacco industry in the fight against smoking. However, it is important to understand where the parallels end, and to consider the more complex and relevant social and behavioral roots of the problem. Litigation is clearly not the solution. Addressing the underlying issues of socioeconomic status, minimum wage rates, education and social mobility, cultural norms and access to resources which entice and enable healthy individual level decision making is the only way to appropriately address the obesity epidemic. A far more progressive intervention may be to provide fast food corporations with rational economic incentives to change their menus. Let us not waste another half century of time and resources on a misguided crusade against fast food corporations. In the end, litigating fast food corporations has great potential to be frivolous, cumbersome, expensive, and a time consuming venture that ultimately will not solve the problem of obesity. If these lawsuits become more popular, the ultimate result will be nothing but clogged courts and a waste of everyone’s money. (8) The time and money would be far better invested in creating interventions that appropriately address obesity as a function of individual level choices and their feasibility within in an equally important social context.

References
(1) http://www.cdc.gov/nccdphp/dnpa/obesity/economic_consequences.htm

(2) http://www.cdc.gov/nccdphp/dnpa/obesity/faq.htm

(3) Alderman, Jess and Richard Daynard. “Applying Lessons from Tobacco Litigation to Obesity Lawsuits”. American Journal of Preventive Medicine. 2006;30(1) p82-88.

(4) http://www.phaionline.org/about_mission.php

(5) http://www.fda.gov/ohrms/dockets/dailys/02/May02/050202/80045036.pdf

(6) http://www.cdc.gov/nccdphp/dnpa/obesity/consequences.htm

(7) Siegel, Michael. “Obesity lawsuits Trying to Follow Tobacco Model.” July 11, 2005. http://tobaccoanalysis.blogspot.com/2005_07_01_tobaccoanalysis_archive.html

(8) Warner, Melanie. “The Food Industry Empire Strikes Back.” The New York Times. July 7, 2007.

(9) http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.html

(10) Story, Mary & Simone French. “Food Advertising and Marketing Directed at Children and Adolescents in the US.” International Jounral of Behavioral Nutrition and Physical Activity. February 10, 2004, 1:3.

(11) Parker-Pope, Tara. “Cigarettes: Anatomy of an Industry from Seed to Smoke.” New York: The New Press, 2001.

(12) Hellmich, Nanci. “Research: Trans-fat adds more pounds than other fat.” USA Today. October 23rd, 2006. http://www.wbir.com/news/archive.aspx?storyid=38967

(13) Block, J.P. et al. "Fast Food, Race/Ethnicity, and Income." American Journal of Preventive Medicine. October 2004, Vol. 27, No. 3, pp. 211–217.

(14) Sloane et al. “Improving the nutritional resource environment for healthy living through community-based participatory research.” Journal of General Internal Medicine. July 2003;18:568-575.

(15) Cradock AL, Kamachi I, Colditz GA, Hannon C, et al. “Playground
Safety & Access in Boston Neighborhoods.” American Journal of Preventive Medicine. 2005;28(4):357–363.

Where’s the Health in Mental Health? How Current Public Mental Health Mucks up the Prevention Paradox Involving Few to Benefit Few – Esther Hill

2006-12-17T12:52:00.000-08:00

Each year one in two Americans has a diagnosable mental disorder (Office of Minority Health, n.d.). With such a high prevalence of illness, public health practitioners have a hefty responsibility. Epidemiologist C.E.A. Winslow (1920) offers a definition of public health that puts this responsibility into perspective. Winslow states, “Public health is the science and art of preventing disease, prolonging life, and promoting health through organized community effort.” Hence, public health practitioners are responsible for the prevention of mental illness, the prolonging of life and the promotion of mental health through organized community effort. Unfortunately, current public mental health interventions fail to meet these objectives.
In 2006 the federal government allocated $3,206,000,000 to the Substance Abuse and Mental Health Services Administration (SAMHSA) (U.S. Department of Health and Human Services, n.d.). From the Department of Health and Human Services, the Surgeon General’s Report describes how this money is used within the programs and departments to which it is distributed. Funds are used for direct treatment of mental illness including outpatient and inpatient treatment, medication, partial hospitalization, and residential programs. Mental health funds are also used toward interventions, which focus on prevention of physiological developmental conditions such as safe sex education to prevent HIV and syphilis in children and measles vaccinations with the objective of preventing neurobehavioral problems in both incidences. There are also preventative programs such as Head Start, the Carolina Abecedarian Project, and the Infant Health Development Project which all focus on early education of young children. Such programs have been shown to reduce antisocial behavior and improve cognitive functioning. While it is obvious that efforts are being made to address mental health, a closer examination reveals the costly inappropriateness of these interventions.
Epidemiologist Geoffrey Rose’s work provides a framework of social and behavioral theory to identify the primary failures of the current interventions in public mental health. Rose discusses the appropriateness of focusing interventions on a high-risk population versus the entire population. In the case of mental health, current interventions focus solely upon the high-risk group or rather the group with most severe conditions. Yet, examination of Rose’s work reveals that the target population is too limited in current mental health interventions, and a population strategy should be employed. Secondly, Rose points out that public health is responsible for incidence reduction, and the failure of current interventions to reduce incidence fails to address the burden of disease. Aside from the burden of poor mental health, Americans pay a hefty economic price to treat mental illness and account for the lower productivity that results from mentally ill persons inability to function normally. Finally, current interventions commit the ultimate sin in terms of social and behavioral science by neglecting to consider the social context of the disease. Focusing primarily on existing cases and treatment reveals little about the contextual factors leading to the incidence of mental illness. How can public health practitioners prevent future cases if they don’t know who is becoming ill, with what illness and under what conditions?

Where’s the public in public mental health?

When assessing public health intervention, Rose saw value in either focusing efforts on the high-risk population or using a population strategy depending upon the health condition. A recent study (Woodall et al, 2004) evaluating the use of the prevention paradox on a jail/treatment program’s ability to reduce DWI arrests illustrates an appropriate public health condition for applying a population strategy. The study results showed that the intermediate-risk group accounted for the most crashes. Since the courts deal primarily with the high-risk individuals, the researchers concluded that they the court’s intervention will not have a major impact on reducing alcohol-related crashes as a whole. Mental health presents a similar condition in which targeting the intermediate-risk group would yield a greater absolute reduction of cases.
Current interventions in mental health target primarily the population receiving treatment for a mental illness and the children enrolled in the early childhood prevention programs. Unfortunately, fewer than half of adults that are diagnosable with a mental illness get help and only one-third of children get help, so the target group actually includes only a portion of mentally ill and high-risk individuals that need treatment or prevention services (Office of Minority Health, n.d.). The failure to utilize a population strategy results in failure to treat illness and promote health at the level that incorporates large numbers of society or rather at the public level.

Where’s the health in public mental health?

Health promotion at the community level performs the public service of reducing the burden of disease on society and there is great incentive for promoting public mental health. According to the Global Burden of Disease assessment of 1990, five of the ten leading causes of disability in the world were mental illnesses (Murray, 1996). In 1996 alone the United States spent an estimated $150 billion directly and indirectly on mental health (Healthy People 2010, n.d.). Sixty-seven billion dollars went to direct costs, including the 3.2 billion allocated to SAMHSA for programming, and the rest is used in treatments at medical and psychiatric institutions (Department of Health and Human Services n.d.). Indirect costs accumulate from a variety of sources including crime, incarceration, welfare, teenage pregnancy, marital problems, and school dropout. For example, 14% of high school dropouts and 4.7% of college dropouts suffer from a psychiatric disorder (American Psychiatric Association, n.d.). Indirect costs are also accrued from lower productivity of mental ill persons and work absenteeism. Not only is the individual’s personal income affected, their family is affected, the company they work for is affected, and consequently the economy is effected.
The prevention paradox, as proposed by Rose, illustrates how a population strategy can reduce the burden of disease. The paradox is based upon the assumption that what causes an individual case may not be the cause of incidence in the population. Under the prevention paradox the entire population is involved and benefit is bestowed upon the population, not necessarily the individual. For example, Hatziandreu et al (1989) used a cost-effectiveness analysis to estimate the benefits of a population-based health promotion program. The researchers estimated that regular exercise led to a net gain of 1,138.3 Quality Adjusted Life Years (QALYs) over the 30-year study period with the cost per QALY gained of $11,313. As Rose’s theory explains, the individual does not reap economic gain from exercising, but at the population level, s/he is less likely to suffer from CHD which decreases his/her individual burden and societal burden. Focusing on the treatment of illness, such as coronary heart disease, does little to promote health. An intervention that unearths the health in mental health will further augment economic health.

Where’s the disease prevention in public mental health?

“How did this individual get this illness at this particular time?” (Rose, 1985). This is the question that Rose encouraged his medical students to consider. His words outline what public health practitioners need to know in order to prevent a problem. Who is becoming ill? What is the illness? What are the contextual factors, such as social and cultural, causing the illness at this particular time?
The manifestation of mental illness can to some extent be considered a product of the society in which an individual lives. Consider bulimia nervosa. Risk factors for the disorder include individual characteristics chemical imbalance of neurotransmitters, dysfunctional familial patterns, low self-esteem, impulsivity, incompetence of conflict resolution, parental rigidity, and age. (American Psychiatric Association, 2000). However, the disorder is associated with environmental factors such as cultural standards of beauty, culture of dieting, population-wide concern with weight and shape (Austin, 2001). The availability of food is a more logistical factor albeit an environmental characteristic relating to the etiology and prevalence of the disorder. Hence, the behavioral choices and health outcomes of the bulimic are determined by the individual’s predisposition but also by the social and cultural environment in which the individual lives.
Population-based strategies that focus on prevention regardless of risk factors are especially effective in cases of mental illness such as eating disorders due to the population-level epidemiology. One example of this appropriateness is the Planet Health Intervention Study (1997), which divided adolescents into risk groups based on self-reported dieting practices. After controlling for the effects of intervention, the researches found that the largest number of cases occurred in the moderate-risk group, a finding that reiterates Rose’s theory. Had the Planet Health Intervention only focused on the high-risk group, they would have failed to prevent the largest number of cases. In order to prevent mental illness, it is necessary to consider the contextual factors contributing to the etiology and address those factors in the intervention strategy.

Conclusion

The responsibility of public health is to prevent disease and promote health at the population level. In the field of mental health, interventions must not be limited to high-risk individuals but rather must target populations that will reduce the greatest burden on society. This requires consideration of contextual factors influencing the etiology of disease when developing preventative efforts. In closing, current interventions in public mental health fail because they focus upon treatment of mental illness within a small target population when focus upon prevention of illness and promotion of health is what is needed.

References:
American Psychiatric Association (2000). (DSM-IV-TR) Diagnostic and statistical
manual of mental disorders, 4th edition, text revision. Washington, DC: American
Psychiatric Press, Inc.
American Psychiatric Association (n.d.) Primary Care Docs Report Poor Access to
Quality Mental Health Care. Retrieved from American Psychiatric Association Web site: http://www.psych.org/pnews/97-11-07/primary.html
Austin S.B. (2001). Population-Based Prevention of Eating Disorders: An Application of
the Rose Prevention. Preventive Medicine (32): 268–283.
Healthy People 2010 (n.d.). Leading health indicators. Retrieved November
10, 2006, from Healthy People 2010 Web site: http://www.healthypeople.gov/document/html/uih/uih_4.htm#mentalhealth
Htziandreu E.I., Koplan J.P., Weinstein M.C., Casperse C.J., & Warner K.E. (1989). A
cost-effectiveness analysis of exercise as a health promotion activity. American
Journal of Public health, 79(3): 273.
Jenkins, C. D. (2003). Principles and methods of behavior change. In Building better
health: A handbook of behavioral change (pp. 255-286). Pan American Health
Organization. Retrieved November 6, 2006, from Boston University Medical
Library Web site:
http://www.ingentaconnect.com/content/paho/paho590/2003/00000001/0000000
Jenkins, C. D. (2003). Principles of community health intervention. In Building better
health: A handbook of behavioral change (pp. 11-30). Pan American Health
Organization. Retrieved November 6, 2006, from Boston University Medical
Library Web site:
http://www.ingentaconnect.com/content/paho/paho590/2003/00000001/000000
Murray C.J.L. & Lopez A.D. (1996). The global burden of disease: Summary. World
Health Organization (pp. 1-39). Retrieved September 6, 2006, from Harvard
School of Public Health Web site:
http://www.hsph.harvard.edu/organizations/bdu/GBDseries.html
National Institute of Mental Health (2006). The numbers count: Mental disorders in
America. Retrieved November 10, 2006, from the National Institute of Mental
Health Web site: http://www.nimh.nih.gov/publicat/numbers.cfm#Intro
Office of Minority Health. (n.d.). Eliminate disparities in mental health. Retrieved
November 10, 2006, from the Center for Disease Control Web site: www.cdc.gov/omh/AMH/factsheets/mental.html
Office of the Surgeon General (n.d.). Public Health Priorities. Retrieved November 10,
2006, from the United States Department of Health & Human Services Web site: http://www.surgeongeneral.gov/publichealthpriorities.html
Rose G. (1985). Sick individuals and sick populations. International Journal of
Epidemiology, 14, 32-38.
Rose G. (1992). The Strategy of Preventative Medicine. Oxford: Oxford University
Press.
United States Department of Health and Human Services (n.d.) Substance Abuse and
Mental Health Services Administration Overview Table. Retrieved November 30,
2006 from Department of Health and Human Services Web site: www.hhs.gov/budget/07budget/subabuse.htm

Gift-Giving to Physicians & its Repercussions on a Preventive Approach to Medicine: Identification of a Public Health Problem – Meghan McCutcheon

2006-12-17T12:05:00.000-08:00

The manner in which public health is intervening upon the pharmaceutical industry influence on physician prescribing patterns needs to be altered in order to affect greater change and ensure the public is receiving comprehensive preventive care. Pharmaceutical promotion should not guide clinical practice. Regrettably, this is occurring within the practice of medicine and a different approach to intervention needs to be enacted to protect the public from pharmaceutical influence through the physicians’ pen – notably emblazoned with the brand-name drug and provided by the last pharmaceutical detailer to visit the office.

The number of detailers, or representatives, from pharmaceutical companies has grown at an alarming rate in comparison with that of physicians. Since 1995, the physician population has grown just 15%, according to the American Medical Association (AMA); however, over the same period, the number of pharmaceutical reps has grown 94% (MD NetGuide). The discovery by a McKinsey Consulting study that high-prescribing physicians receive “three to five times as many calls from sales reps as they did 10 years ago” (MD NetGuide) adds additional evidence to the escalating presence and influence of pharma on physicians. A more striking example is exhibited by the sheer data on expenditure for this influence by the industry. Drug companies spent more than $7 billion (not including drug samples) in 2003 on one-on-one marketing to doctors, which represents a 78% increase over 1999 levels and works out to about $8,400 to $15,400 per doctor per year (Consumers Union).

The purpose of pharmaceutical detailing is to influence physician behavior and prescribing practices, and medical literature suggests that doctor’s prescribing behavior is influenced by this promotion (Wazana). Additional reviews of the literature have confirmed a direct relationship between the frequency of contact with reps and the likelihood that physicians will behave in ways favorable to the pharmaceutical industry; physicians who spend more time with reps are less likely to prescribe rationally (Howard). Physicians not only need to engage rationally with their patients, but act in the utmost best interest of the individual in order to provide an optimal health outcome. Physicians need to get to the root cause of a patient’s health issue and increase behavioral interventions that will provide a healthier, long-term life solution. The quick fix of having the patient pop a pill is not the most efficacious solution. The fiduciary relationship between both parties warrants the physician to hold to a higher criterion of conduct. Gift-giving of pharmaceutical detailers to physicians undermines the doctor-patient relationship and creates a level of impropriety.

To date, the provision of evidence-based prescribing information to physicians has been the answer most applied to this current public health problem. However, according to medical literature, providing doctors with knowledge on how to treat diseases in accordance with research evidence and guideline recommendations seldom changes the way doctors prescribe drugs (Lagerlov). This educational outreach process known as “academic detailing” or “counterdetailing” needs to be altered through the use of social and behavioral sciences evidence and theory in order to more effectively address this public health issue of patients not being provided accurate, preventive care by their physicians.
This paper will address three aspects of this intervention change and prove the necessity of evoking behavior change in physicians so that a greater focus is subsequently on effective patient behavior change toward a more positive, healthy way of life.

The Dominant Model of Disease Today is Biomedical and it Leaves No Room Within Its Framework for the Social, Psychological, and Behavioral Dimensions of Health

A change from the current biomedical model to a biopsychosocial model is imperative in order to ensure that all aspects of treatment for a patient’s illness will be examined and included, such as behavior modification. If physicians focused on this model, their mindset would be concentrated more on what is best for the patient by taking into account a health psychology perspective. This approach considers the biological, cognitive, behavioral, emotional, social, psychosomatic and environmental factors as they relate to health, illness and health care at the level of individuals (Wikipedia). In identifying patient experiences and behaviors affecting the cause of illness, physicians could more effectively tailor treatment based on behavior change for the patient. With this change in medical model, physicians would not simply look to implement a medication treatment for patients or be as influenced by the latest pharmaceutical detailing visit.

For example, if a physician took a health psychology approach to her patient experiencing high cholesterol, she could talk to the patient about his current eating and exercise habits, educate the patient on the healthy, life benefits of a low-fat diet or a regular exercise regimen and suggest these behavioral changes that will not only aid in the reduction of high cholesterol, but also provide the patient with a more health-conscious way to live life. If the physician simply followed the biomedical approach, she would have easily prescribed a statin, such as Lipitor if a detailer from Pfizer had recently met with the physician.

According to a physician, who is also experiencing life as a patient with cancer, “…mind (and stress) affect the body-machine and how so many of the illnesses people suffer stem from behavioral causes with physiological correlates” (Dyer). Ignoring behavior change in patient treatments is clearly detrimental, as it excludes what could be the most important factors in the cause of illness. The health of the public is on the line, and it in great part depends on how the physician determines treatment, and ultimately what treatment is selected.
The affect physicians have on their patients is immense. “We know that when a doctor recommends something, patients start doing it…there’s almost nothing as powerful as a doctor’s advice,” states Tim Church, MD, PhD, MPH, Medical Director of the Cooper Institute of Dallas (Heubeck). This potential influence of behavior change would have a direct correlation with increasing healthy activities and quality of life in a population by getting to the root of the illness and attacking negative health issues through a more preventive approach.

The Deterioration of Trust in the Doctor-Patient Relationship Can Lead to Negative Health Seeking Behaviors (i.e. Less Patients Seeking Services and Following Recommended Treatments)

Trust is a fundamentally important aspect of medical treatment relationships, and studies have established that patient trust predicts instrumental variables such as use of preventive services, adherence, and continued enrollment (Thom). In addition, an article in The European Journal of Public Health states that “without trust patients may well not access services at all…” (Rowe). Research clearly shows that public health is in jeopardy if there is an erosion of trust in the fiduciary relationship with physicians.

The physician commitment to the well-being of the patient can be compromised, and the doctor-patient relationship undermined, by pharmaceutical detailing practices. Physicians have a professional and ethical duty to their patients. If they choose to disregard behavior modification in prescribed treatment and succumb to the influence of pharma and medication treatment, physicians also choose to disregard their fiduciary obligations to their patients. A physician ignoring preventive, behavioral interventions for his patients is an immense detriment to the patients’ overall health and way of life, as the physician is most easily compelled to put his pen to the prescription pad.

According to medical literature, 70% of subjects involved in a study on patients’ attitudes about pharmaceutical company gifts to physicians believed that gifts sometimes or frequently influence a physician’s prescribing of medication (Blake). If patients view a strong relationship between their physician and the pharmaceutical industry, they would be left to believe that their physician is not acting in their own best health interest. These personal beliefs and attitudes would lead to an increased lack of trust for the physician, and the public could consciously choose to forgo care based on its change in attitude toward physicians.
As an example that exhibits the significance of trust within the doctor-patient relationship, one can look to a study conducted on the influence on trust and the acceptance of and adherence to antiretroviral therapy, as presented in the Journal of Acquired Immune Deficiency Syndromes. Antiretroviral therapy (ART) has resulted in reduced AIDS incidence and mortality, which adds to the worth and value of those aspects that contribute to acceptance of and adherence to this treatment for infected patients (Altice). The literature in JAIDS concerning the highly important therapy found that the acceptance of (80%) and adherence to (84%) ART among the group studied was high and that acceptance was associated with trust in physician (8% increase for each unit increase with trust in physician scale) (Altice). The study concluded that trust and the therapeutic relationship between patient and physician remain central in the ART initiation process (Altice).

Current Intervention (i.e. Evidence-Based Prescribing Information) is Ineffective Because It Fails to Take Into Account the Importance of Physician Self-Efficacy

As previously stated from medical literature, the provision of evidence-based prescribing information to physicians, which has been the most applied public health intervention on the issue of pharmaceutical detailing influence, does not necessarily promote a high level of change in physician prescribing patterns. To reiterate the specific point: Providing doctors with knowledge on how to treat diseases in accordance with research evidence and guideline recommendations seldom changes the way doctors prescribe drugs (Lagerlov). Improved knowledge does not…necessarily lead to a corresponding change in behavior (Lagerlov).
Research has shown problem based learning, or “problem first learning,” which places the emphasis on the learner’s own initiative to discover problems and how to improve, to be effective in altering prescribing behaviors by physicians. This example of how self-efficacy can play a role in physician prescribing behavior has been explored in a study conducted in Norway by Lagerlov and colleagues that initially derived quality criteria of prescribing by discussing guideline recommendations that formed the basis for the physicians to judge their treatment of individual patients as acceptable or unacceptable (Lagerlov). Presented with feedback on their own prescribing, they learned what they did right and wrong, which provided a foundation for improvement and resulted in the physicians providing better quality patient care (Lagerlov).

Through the discussion and comparison of actual practices to established guidelines within peer review groups, the individual doctor’s self-efficacy, defined as one’s ability to organize and execute a course of action required to produce given results, was substantially increased (Lagerlov). The process documented in this Norwegian study is a prime exhibition of the Theory of Self-Efficacy, in which the basic premise is that the expectation of personal mastery and success determines whether or not an individual will engage in a particular behavior (Salazar). Expectations of personal self-efficacy are based on four major sources of information with the most dependable being performance accomplishments, referring to the learning (successful mastery) that results through personal experience (Salazar). Performance accomplishment tends to increase perceived self-efficacy (Salazar). This aspect of performance accomplishment relates directly to the study conducted by Lagerlov and his colleagues. As physicians investigate their own individual prescribing pattern, their personal motivation to master and succeed takes hold and therefore influences them to change their behavior toward a higher level of patient care and instituting better health actions within the public if they find prescribing was unwarranted for certain patients.

In conclusion, this paper has established that the current approach and intervention on pharmaceutical detailing on physician prescribing practices and provision of preventive care is not the most effective means in order to achieve the ultimate health outcome of patients living healthier lives through positive behaviors. The health of the public would increasingly benefit from a greater focus on health psychology and a biopsychosocial medical model, the establishment of trust in the doctor-patient relationship, and a self-efficacy approach for physicians in order to more positively change their prescribing behaviors.

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Racial Disparities Are Not The Principal Factors In Understanding Why Black Men Have Advanced Stage Diagnosis Of Prostate Cancer- Priya Desai

2006-12-17T11:45:00.000-08:00

Introduction: The Issue At Hand
Prostate cancer is the most frequently diagnosed visceral cancer and the second leading cause of cancer death in men. The American Cancer Society estimated that 184,500 new cases were diagnosed in 2000 and that the morbidity and mortality rates are significantly elevated among black americans. They are less likely to be screened for prostate cancer than whites and more likely to have advanced disease at the time of diagnosis (Ashford, 2001).

Prostate cancer screening is controversial because the combination of the disparities in incidence, mortality, and five year survival rates with the uncertain benefits associated with screening poses a difficult decision for black American men (Hoffman, 2001). There are a number of explanations that have been proposed to account for the advanced stage diagnosis of prostate cancer in black men. For example, demographic characteristics, socioeconomic status, level of education, and comorbidity may limit cancer screening in the black American population and possibly contribute to a delayed diagnosis. This paper argues that these factors, while important, are not the only reasons for advanced stage diagnosis. The issues of race, within the broader context of social power relations, are vital to understanding why such a disparity exists. Perhaps, as a legacy of racism, black Americans’ distrust invasive diagnostic and therapeutic procedures and this inhibits them from seeking or accepting this type of care. Given that black men are at such high risk for prostate cancer, it is imperative that interventions be made to shift the focus toward a greater emphasis on the cultural and behavioral attitudes, beliefs, and lifestyle patterns of black men to better understand the delays in prostate cancer screening.

Historical Influence on Black American Perspective of The Medical Community
Before examining the methods of prostate cancer screening, the historical context shaping the black American perspective of the biomedical community should be addressed. Gamble (1997) describes the Tuskegee Syphilis Study as the principal reason behind the black communities’ distrust of the institutions of medicine and public health. After the study had been exposed, charges of black genocide surfaced. Many blacks believed that this was a government plot for racial extermination. The biggest fear is that they will become victims of some misfortune like the Tuskegee incident where black men were infected with syphilis and left untreated to die of the disease. The cultural impact of this study explains several factors that have influenced and continue to impact black americans’ thoughts on the biomedical community. Fears about exploitation by the medical profession date back to when slaves and free black people were used as subjects for dissection and medical experimentation (Gamble, 1997). Slaves were used as subjects for medical experiments because physicians needed bodies to practice newly acquired surgical skills such as hysterectomies and caesarians. The state viewed the subjects as property and they could not refuse to participate (Gamble, 1997).
Feelings of paranoia, distrust, and anxiety after Tuskegee still resonate in the black American community. As a result, black people are cautious when interacting with the medical profession because sentiments of having been a guinea pig and the fear of potentially becoming a guinea pig still plague them. This leads to beliefs that they are devalued by white society and this exacerbates the contentious relationship they have with the medical profession (Corbie-Smith, 1999).

Beyond Tuskegee, revelations of about a measles vaccine financed by the Centers for Disease Control and Prevention (CDC) demonstrate that medical racism and exploitation of black people are evident as recent as 1991. In 1989 in the midst of a measles epidemic in Los Angeles, the CDC began a study to test whether the experimental Edmonston Zagreb vaccine could be used to immunized children to young for the standard vaccine. The experimental vaccine was given to both hispanic and black infants. After the 1996 disclosure of the study, it was found that the parents had not been informed that the vaccine was not licensed in the United States or that it had been associated with an increase in death rates in Africa. This further fueled the negative perspective of medical professionals in black American culture (Gamble, 1997).

Screening Behavior influenced by Social Systems
The challenge facing interventions for prostate cancer screening is to deviate from the focus of educational and socioeconomic disparities as explanations for advanced stage diagnosis in black men (Chan et al, 2003). Health initiatives will be more successful if they are informed by cultural competence and health literacy issues (Cowart, 2004). As illustrated, historical aspects contribute to the black communities’ perceptions of the medical profession. This further extends to negative perceptions of the physician and the hospital. Hospitals are primarily looked upon as “white institutions,” while physicians are seen as white researchers motivated by their drive for money, status and prestige (Corbie-Smith et al, 1999). Being predisposed to these health beliefs and perceptions influence the behavior of black men towards prostate cancer screening.

Emile Durkheim believed that social systems and human behavior are not mutually exclusive, but human behavior is influenced by social systems (Plowden et al, 2002). In a study looking at prostate cancer knowledge, attitudes, and screening behavior among African-Americans in central Harlem, black men were more likely to seek care when a supportive environment existed along with significant encouragement (Ashford et al, 2001). To understand individuals’ behaviors, it is necessary to understand the social structure. Within this structure are networks that hold individuals together and create values and norms. Based on this viewpoint, health beliefs (negative and positive) are transferred within the group and affect behavior. In the black community, fatalism is a barrier to seeking healthcare. Black men are less likely to believe that they can control the outcome of prostate cancer (Ashford et al, 2001). These beliefs have been passed from generation to generation and are a result of the social structure.

This distrustful perspective of the medical profession, heavily influences the decisions to be screened for early cancer detection. In a study conducted by Woods et al., descriptive quantitative findings of a mixed–method longitudinal assessment explored prostate cancer screening behaviors among 277 black men. The participants in the study viewed cultural competence as a sign of acceptance of black values and an openness of having blacks connected to the health system in a meaningful and respectful manner (Bhopal, 1998).

I believe there is a growing sense that health care providers do not take the time to meaningfully discuss the implications of prostate cancer. Lack of qualitative discussion by the physician about prostate cancer implies the cancer is not an important issue among black men or that there is a strong cultural barrier that precludes quality of care. Research has shown that this is particularly true in discordant patient/physician relationships. For example in a study conducted by Woods et al. (2004) focusing on culture, black men, and prostate cancer, participants were asked about their consult visits with non-black physicians at various sites in the United States. The participants believed that non-black physicians felt intimidated when asked questions about prostate cancer and individual prognosis. The participants felt this reaction was indicative of a negative global view of the black man. The historical dominant stereotype of black men in American society as the “thug,” “bad guy,” limits the chances of having a successful physician/patient relationship that reinforces black male understanding of prostate cancer (Woods et al, 2004).

The categorization theory further elucidates the idea that stereotypes are perpetuated when certain characteristics in a person belonging to a specific group are used to make generalizations of all members of that group. For example, if a black man is observed as being unreliable, and always late, a person may then generalize this to be true of all black men. This paradigm presents a conflict such that the profession of medicine possesses the ultimate authority in health related matters (Plowden et al, 2002). Health and illness may be viewed as professional constructs because organized medicine determines what constitutes disease, and practicing physician legitimize sickness claims through diagnostic process as well as access to treatment and screening tests. Thus, the medical profession not only defines disease in theory and identifies it in practice; it also supervises those who are sick. Plowden et al. (2002) have focused on black men and prostate cancer screening methods emphasizing that a caring, trusting, environment leads to an increased interest by black men and offers the potential to engage them in respectful relationships with their physicians. Public Health interventions have failed to encourage physicians to cultivate a positive relationship with their patients; especially black males who are know to mistrust the healthcare system. These efforts would help to strengthen the possibility of informed, and shared decision-making regarding prostate cancer early detection and screening.

Black American Male Perspective on Prostate Screening Methods
Studies have shown that black Americans’ distrust of invasive diagnostic and therapeutic procedures inhibits them from seeking or accepting this type of care (Clark-Tasker, 2002). Clark-Tasker (2002) conducted a study that included two focus groups of black men whose ages ranged from 38-80 years. The participants were asked to complete questionnaires based on a culturally appropriate video on prostate cancer. Results indicated that, on average, the men believed in the efficacy of prostate cancer early detection methods. Men between the ages of 40 and 50 years of age expressed concern about possible changes in their sex lives if diagnosed with prostate cancer. They also considered the digital rectal examination (DRE), one of the methods of screening, to be embarrassing and uncomfortable despite having limited knowledge of the disease.

In addition, Woods et al. (2004) used questionnaires to identify critical elements affecting black men and their screening for prostate cancer. The DRE was seen as threatening to sexuality. The participants were willing to take the DRE, but they found this procedure to be degrading, invasive, and felt it was associated with homosexual inclinations. Considering that many black men have historically be susceptible to deceptions of the medical profession and the ideology that the biomedical community is a white institution, the additional feature of an invasive exam is enough to keep black men from being screened, increasing the chances for advanced stage diagnosis. Depending on the level of distrust of the medical community, submitting to a digital rectal exam is not a routine procedure for black men. It involves rationalizing a culture specific mind-set and acquiescing to a screening method that could potentially save their lives. In particular in the Clark-Tasker (2002) study, black men perceived prostate cancer as a threat to their manhood because of the fear of impotence. The ability to perform sexually is regarded as a vital natural function of healthy men of all ages and is related to physical, emotional, and psychological well-being. Public Health has not addressed these critical barriers that plague the psyche of black male culture. Lack of understanding the social networks, which create values and norms that hold the black community together, are vital to successful interventions. Based on this perspective, health outcome is affected by the extent to which social integration allows appropriate health behavior norms to be created and supported. The prostate cancer screening disparity amongst black men is a result of a lack of social integration.

Conclusion:
Today, there remains a great need for intervention strategies, including culturally competent approaches to prostate cancer for which there is effective treatment and prevention. Understanding health from a social perspective is important if appropriate interventions and policies are to be developed to engage black men in prostate cancer screening. Socioeconomic status, demographics, education, and access to care have been the criteria used to understand the factors that deter black men from being screened. This paper argues that these disparities are not the primary reasons for black detachment from the health care system. It is imperative to understand the black cultural and historical perspective in order to properly understand the elements contributing to late stage diagnosis of prostate cancer. The Tuskegee Syphilis Study continues to “cast its shadow” over the lives of black people. It has come to represent the inherent racism that permeates the American medical profession. While racism provides valuable insight, it cannot be the only prism used to examine the relationship between black people and the medical and public health communities

Black men’s lack of engagement with the health care system in general and more specifically prostate cancer screening occurs within a larger social context. This level of disconnectedness of black men from general society and the medical profession has persisted for a long time. To effectively reach black men, acknowledgement of previous negative experiences with healthcare, and proficient personal quality orientated delivery of care is necessary. Fostering a relationship between provider and patient while somewhat time consuming, is a culturally sensitive approach that will earn the trust of black men and allow for positive shared decision-making. Consideration of black men who have a history of lack of respect shows the providers commitment to care and to treat. This will assist in gradually breaking down the armor of distrust that keeps black men from seeking medical care, particularly with regards to prostate cancer screening.

Bibliography

Woods, Diane et al. “Culture, Black Men, and Prostate Cancer: What Is Reality?” Cancer Control Nov-Dec. 2004: 388-395.

Gamble, Vanessa. “Under the Shadow of Tuskegee: African Americans and Health Care.” American Journal of Public Health Nov. 1997: 1773-1778.

Plowden, Keith et al. “Sociological Persepctives of Black American Health Disparity: Implications for Social Policy.” Policy, Politics, & Nursing Practice Nov. 2002: 325-332.

Ashford, Alfred et al. “Prostate Carcinoma Knowledge, Attitudes, and Screening Behavior among African American Men in Central Harlem, New York City.” The American Cancer Society Jan. 2001: 164-172.

Bhopal, Raj. “Spectre of Racism in Health and Health Care: Lessons From History and the United States.” British Medical Journal June. 1998: 1970-1973.

Chan, Evelyn C. et al. “Informed Consent for Cancer Screening With Prostate-Specific Anitgen: How Well Are Men Getting the Message?” American Journal of Public Health
May. 2003: 779-785.

Cowart, Luvenia. “Educating African American Men About Prostate Cancer: The Barbershop Program.” American Journal of Health Studies Sept. 2004: 1-12.

Clarke-Tasker, Veronica A. “What We Thought We Knew: African American Males’ Persceptions of Prostate Cancer and Screening Methods.” ABNF Jounral May-June. 2002: 1-10.

Corbie-Smith, Giselle. “Attitudes and Beliefs of African Amerians Towards Participation in Medical Resarch.” Journal of General Medicine Sept. 1999: 537-546.

Hoffman, Richard et al. “Racial and Ethnic Differences in Advanced-Stage Prostate Cancer: the Prostate Cancer Outcomes Study.” Journal of the National Cancer Institute March. 2001: 388-395.

Just Say No (to D.A.R.E.): The Nation’s Most Widespread Drug Prevention Program Fails to Incorporate Basic Social Science Theories - Laura Wulach

2006-12-17T11:26:00.000-08:00

D.A.R.E. (Drug Abuse Resistance Education) is the most widespread drug prevention program in the United States, reaching up to 26 million students nationally each year and being implemented in over 75% of the nation’s school districts [1]. The curriculum is based upon four core areas: providing knowledge about drugs and alcohol, teaching effective decision-making skills, offering children alternatives to substance use, and teaching children how to deal with overt and subtle peer pressures [1]. D.A.R.E. uses the same curriculum throughout the United States, which is taught by police officers who participate in an 80 to 120 hour training. D.A.R.E. is traditionally presented in fifth or sixth grade during 17 lessons. Its most popular slogan is “Just Say No,” which represents its most basic principal that refraining completely from using substances is the most effective way to prevent abuse.

Arguably, the greatest advantage of D.A.R.E. is the network it has created to disseminate information, since over three-fourths of the nation’s school districts receive the D.A.R.E. curriculum each year. D.A.R.E. also benefits from extensive community and school-based support, both of which give it the potential to be a powerful medium to reach students [2]. Unfortunately, there are many studies that show that D.A.R.E.’s curriculum is ineffective [3, 4, 5], and in some cases, that it has increased the use of various drugs among certain groups of students [6]. In fact, the United States General Accounting Office wrote a report on the conclusive evidence that D.A.R.E. is ineffective in preventing drug and alcohol use [7].

While almost all studies have shown that D.A.R.E. is ineffective, virtually none have examined central social science theories that could help explain some basic flaws in the program. Once these social science theories are identified and incorporated into the program, D.A.R.E. could become extremely effective, offering widespread dissemination, community support, and a practical social science curriculum that would make D.A.R.E. a success and help reduce drug and alcohol use among adolescents. This paper will critique D.A.R.E.’s understanding of the ability to resist peer pressure, the effectiveness of police officers as teachers of the D.A.R.E. curriculum, and the “Just Say No” slogan. It will do so by examining theories from the social sciences that demonstrate why these aspects of D.A.R.E. are ineffective, and it will suggest that if these theories were incorporated into the D.A.R.E. program, D.A.R.E. would be considerably more effective.

One of D.A.R.E.’s primary aims is to teach students how to recognize and resist peer pressure, and thus avoid the pressures that often lead to experimenting with drugs and alcohol. While there exists a lot of research that shows that peer pressure is a significant factor in an adolescent’s experimentation with drugs and alcohol [8], there are many variables that contribute to one’s ability to resist peer pressure. D.A.R.E. believes that students can be taught to resist it; however, D.A.R.E. ignores the larger forces that play into the ability to resist peer pressure, such as the family. According to psychological evidence, “Research has shown that most young people who abuse alcohol or other drugs were first encouraged to do so by their peers and that the ability to resist such peer pressure is directly related to the strength and cohesiveness of family ties” [9]. Thus, D.A.R.E. is ineffective because it does not deal with the most important factors in determining whether a student will resist peer pressure.

Moreover, a family’s strength and cohesiveness is influenced by many larger societal forces, such as neighborhood safety, socioeconomic status, discrimination, and racial residential segregation [10, 11, 12, 13]. Since family cohesiveness can greatly impact the ability to which a child is able to resist peer pressure, it follows that increasing family cohesiveness would improve a child’s ability to resist peer pressure. Unfortunately, D.A.R.E. does not address this central issue at all, rather focusing solely on different refusal strategies for resisting various types of peer pressure [6]. While this strategy might be important, and peer pressure can lead to drug and alcohol use, ignoring the deeper factors that affect the ability to resist peer pressure results in an intervention that deals with peer pressure only on its most superficial level. Until D.A.R.E. attempts an intervention to improve family strength and cohesiveness, and thus increase the ability of children to resist peer pressure, D.A.R.E. will remain ineffective.

Furthermore, as D.A.R.E. strives to teach students how to resist peer pressure, it fails to ask the people who understand this issue the best: students themselves. Students face peer pressure on a daily basis, and while they struggle with it, most find ways to deal with it and get by. Students who use drugs and alcohol could provide invaluable information as to why they chose to use these substances and how they reacted to peer pressure, and students who do not use substances could explain their reasons for not using them and could explain how they reacted to peer pressure. By ignoring the first hand experiences and opinions of the people to whom the intervention is aimed, D.A.R.E. is not effective, as it does not create an intervention that incorporates the perspective of adolescents. While different in many ways, Siegel demonstrates how the failure of public health practitioners to incorporate the views of gay men into campaigns to prevent HIV has lead to a crisis among this population. Regarding the HIV prevention campaigns geared towards gay men, Siegel states, “… Our current efforts to understand the target audience are woefully inadequate and often lead to prevention programs that conflict with the audience’s core values” [14]. D.A.R.E.’s curriculum might not conflict with its audience’s core values, but it does fail to incorporate them into its prevention efforts. D.A.R.E. will remain ineffective until it asks students their opinions and experiences and incorporates them into the D.A.R.E. curriculum.

Another reason why D.A.R.E. is ineffective is because of its firm belief that police officers are the most effective teachers of drug resistance methods. D.A.R.E. is an initiative that originates from the Los Angeles Police Department, and thus is a program that is created by and for police officers. However, D.A.R.E. ignores one of the most basic psychological theories: that most adolescents rebel against their parents and parental figures. As children enter adolescence, they tend to rely on peers for clues as to how to behave and for emotional support. At the same time, adolescents rebel against the immediate controls of their parents [15]. Adolescents are more likely to view police officers as parental figures than as peers, and thus are more likely to rebel against what police officers teach. While D.A.R.E. views police officers teaching as its finest point, it might be exactly this fact that causes D.A.R.E. to be ineffective.

A third reason why D.A.R.E. is ineffective is because of its core method of teaching resistance: “Just Say No.” This message is ineffective because it is negative, unrealistic, and inconsistent with teens’ experiences. D.A.R.E. tells students to “say no” to all types and quantities of substances. However, adolescents quickly learn that it is possible to enjoy certain substances in small quantities, as they see their parents, relatives, and peers responsibly enjoying one beer or a glass of wine, and not experiencing any adverse effects. While it is true that drinking alcohol is as illegal for teens as is using drugs, it is still important that adolescents are taught the truth about how to responsibly drink alcohol, so that when they are legally able to drink it, they can do so responsibly.

It is essential that adolescents are taught in school the same messages that they see in other parts of their lives. When adolescents are taught that any use of any substance is bad, and then see in their lives that this is not true, they are more likely to reject the entire message. According to a communications theory, consistent messages need to come from a variety of sources and over a long period of time in order for adolescents to truly learn the message [16]. Austin argues that the media, family, and peers need to reliably offer the same message about substances for many years so that what adolescents learn in a classroom or on TV, they also experience in their day-to-day lives [16]. Thus, in order for D.A.R.E. to be effective, it would have to teach the complicated truth about substances, in a manner that is consistent with children’s reality.

Another problem with “Just Say No” is that it is an unrealistic goal. It implies that a person must never try any substance, which is not realistic or socially normal. Additionally, since it is a negative message, using the strong word “no,” it associates only negative feelings with substances. When some adolescents do decide to experiment with a substance, and feel the initial positive effects, they might be more likely to reject the message, as it once again is not consistent with the world in which they live. Thus, D.A.R.E. is ineffective because its central message is not consistent with a communication theory that emphasizes teaching adolescents the complicated truth.

Based on the social science theories discussed above, it is clear that D.A.R.E. needs to change its methods in order to become effective. First of all, in order to truly impact a student’s ability to resist peer pressure, and thus drugs and alcohol, D.A.R.E. needs to address the deeper social causes that play into resisting peer pressure. Since family cohesiveness affects the ability to resist peer pressure, D.A.R.E. needs to improve family strength and cohesiveness within each community. It could do so by involving parents in the entire process of drug resistance education. D.A.R.E. could create programs where police officers and teachers educate parents, from pregnancy onwards, teaching good parenting skills, with role playing, resources for further ideas and help, anger management techniques, and eventually information about how to teach children the truth about drugs. In order for this method to work, D.A.R.E. officers would need to include active community members in the process, so that the community accepts the D.A.R.E. officers and the messages they teach about parenting. D.A.R.E. would need to ensure that it was reaching all parents, and not just those who are more likely to be involved in their children’s lives. D.A.R.E. would also need to be willing to alter its parents program slightly depending on the specific community it is working with, in order to include cultural and social differences. By teaching good parenting skills from before a child is born, and using community members as fellow teachers, there is a chance that more children will be brought up in families that are more emotionally cohesive. These families would thus be more likely to have strong family ties, providing the skills and emotional environment that improve a child’s ability to resist peer pressure, and thus drugs and alcohol.

Unfortunately, in order to ensure that all children are raised in such families, changes would need to be made on a much larger scale, and would potentially reach beyond the capabilities of D.A.R.E. However, D.A.R.E., being organized and run by police officers, could take a stand on some of the larger issues at hand. For example, D.A.R.E. could actively support government policy changes that would improve neighborhoods, increase minimum wage, improve all school systems, decrease racial residential segregation, and create free job preparation courses. D.A.R.E. would need to be careful to advocate for positive policy changes without supporting a particular political party, as one of the beneficial aspects of D.A.R.E. is its wide-based support group, and supporting a particular political party could isolate people who have different political ideas. However, as long as D.A.R.E. was aware of this and was careful to not support a particular party line, D.A.R.E. could avoid losing its wide support base. As Williams and Collins suggest, interventions need to happen in geographic contexts, which D.A.R.E. could help establish by supporting changes on a larger, governmental level [13]. Since the police force is so crucial to the functioning of the United States, if they organized and focused in part on supporting policy change, they could have a huge impact on some of the structural barriers to improving family strength. Once some of these structural barriers are eliminated or at least diminished, the strength and cohesiveness of many families would improve, and they would be able to provide an environment in which children would be more likely to resist peer pressure, and not experiment with drugs and alcohol.

Another suggestion to improve D.A.R.E. is to ask the target audience what they want and need, as Siegel suggests be done for public health campaigns aimed towards preventing the spread of HIV among gay men [14]. D.A.R.E. could administer peer-lead focus groups and questionnaires where students who have participated in D.A.R.E. could express their comments, concerns, and suggestions. D.A.R.E. could ask students why they chose to use or to not use substances, and what factors they consider to be important in their ability to resist peer pressure. D.A.R.E. might be surprised how much it could learn from the adolescents who are facing peer pressure and who decide, despite what D.A.R.E. teaches them, to experiment with drugs. D.A.R.E. could learn equally as much from the students who choose not to use drugs, as they could help identify what skills, family influences, and decisions aid in staying away from drugs. After all, learning why adolescents decide to experiment or not with drugs could lead to important lessons that D.A.R.E. could incorporate in its program. Understanding peer pressure from the adolescent’s perspective and including this in its curriculum could result in a much more effective D.A.R.E. program.

Furthermore, in order to engage adolescents and improve the likelihood that they will listen to the messages being taught, D.A.R.E. needs to change who is teaching the message. As shown earlier, adolescents tend to rely on peers for cues as to how to act, and tend to rebel against parents and parental figures. Thus, if D.A.R.E. officers taught some students the D.A.R.E. messages, so that these students could then go into classrooms and teach their peers, it is likely that more students would pay attention to the messages, as they would be coming from peers. While this might be seen as risky, adolescents are likely to act more maturely when given responsibility. In fact, Kassebaum has shown that “Inviting at-risk teenagers to help another, such as a younger sibling, rather than just portraying them as victims or problems, can instill purpose, hope, and self-confidence” [17]. Thus, training as many youths as possible, and not just the best students or student leaders, to teach other students these important ideas could not only be more effective for the students who are learning, but also for the students who are teaching. Clearly, D.A.R.E. would not initially support this idea, as it would significantly limit the amount of D.A.R.E. officers in classrooms. However, D.A.R.E. officers would still be needed in order to teach the peer teachers the lessons. Additionally, the D.A.R.E. officers could then spend time in other areas of the community, such as D.A.R.E. sponsored after school programs, policy advocacy, and parental education. This approach would make D.A.R.E. much more effective, as students would be more likely to listen to and follow the messages that D.A.R.E. wants to teach.

Finally, in order to ensure that the message that the peer teachers are sharing is effective, D.A.R.E. would need to change the message from “Just Say No” to something more positive and honest. D.A.R.E. would need to take the time to create a curriculum that included a more in-depth look at the differences between substances, and how some can potentially be used in a responsible manner. In fact, STAR (Students Taught Awareness and Resistance), one of the most effective drug prevention programs, encourages students to discuss both the seemingly positive and negative effects of substances [18]. In this way, students are able to address and deal with their curiosity, and learn that while substances may have some positive initial effects, the negative effects outweigh them. Students would thus be taught a more complex, truthful message, and be more likely to see this same message over and over again in their daily lives. This is consistent with communication theories, which emphasize the importance of teaching adolescents consistent messages in all aspects of their lives, and in ensuring that the messages they hear are the same as what they experience in their lives. Thus, D.A.R.E. would be more effective, as the message it would teach would be more positive, realistic, and consistent.

Interestingly, D.A.R.E. recently updated its curriculum based on social science theories. The University of Akron, sponsored by the Robert Wood Johnson Foundation, is in its fourth year of a five year evaluating of the new D.A.R.E. program. It appears that they are making some positive changes by incorporating some ideas from the social sciences [19]. However, there is much criticism from many social scientists, who attended a meeting with D.A.R.E. officials to give their advice on how to make D.A.R.E. more effective, but were not included in the process of creating the new D.A.R.E. program [4].

One change that D.A.R.E. has made is to include a parental education component. This is a step in the right direction, as it involves parents in the process of preventing substance use. As shown above, one key way that D.A.R.E. could become more effective is by improving family cohesiveness among the families in each community, and this is one small way to begin to do that. Involving parents directly in their children’s education and teaching parents additional skills related to helping their children resist peer pressure is important. Unfortunately, parents that are already very involved in their children’s lives might be more likely to attend these D.A.R.E. sessions, and thus these programs will miss part of the target audience. Moreover, while these sessions might help a few parents improve their relationships with their children and thus potentially improve their family’s cohesiveness, there needs to be more research done to see whether a short term intervention that is offered when the child is in middle school could actually improve the strength of a family. It is likely that a much larger, societal level intervention would be necessary to improve family cohesiveness on a large scale basis by generally improving the socioeconomic levels of neighborhoods. If such a change were to happen, then these parental sessions could be useful in reinforcing certain ideas and in engaging the parents more in their children’s education. However, without changing the socioeconomic disparities that currently exist, it is difficult to imagine that these new parental sessions will improve family cohesiveness enough to impact the ability of children to resist peer pressure and thus not use drugs and alcohol. The addition of these sessions, while acknowledging that parents do play a key role in helping children resist drugs and alcohol, fail to really include social science theory and thus will not make D.A.R.E. more effective.

Another change that D.A.R.E. has made is to alter their core message from “Just Say No” to “Take Charge of Your Life,” which is a much more encouraging message that gives adolescents more of a sense of control in their lives. Contrary to its previous message, this message is positive, realistic, and consistent with what adolescents experience in their daily lives. “Take Charge of Your Life” gives adolescents more control over what choices they make and is more consistent with the reality they experience is, as this message implies that there are choices in life. Adolescents are less likely to reject this message outright, as it does not associate only negative feelings with substances, and as it does not indicate that avoiding substances is as easy as saying “No”. In fact, Zili Sloboda, who is the head of the research study about the new D.A.R.E. at the University of Akron, states that, “Students today are very sophisticated, and we have to be current with how we approach them… Obviously, they can't ‘just say no.’ We need to give them skills they can use, and then reinforce those skills” [20]. This is a constructive change that D.A.R.E. has made, and one that is based on communication theories. In this sense, D.A.R.E. has a chance at becoming more effective, as it is basing its central message on sound social science theory.

Another change that D.A.R.E. has made is to create a Youth Advisory Board (YAB). The YAB was created in 2000, and is composed of 50 students, one from each state who has graduated the D.A.R.E. program. According to the official D.A.R.E. website, “The YAB gives D.A.R.E. graduates an opportunity to speak to issues impacting the national and worldwide D.A.R.E. program and to advise D.A.R.E. America and local D.A.R.E. programs, government and community leaders on drug and violence prevention strategies beneficial to our youth” [21]. While this is an excellent idea, and supports social science theory that indicates how crucial it is to ask the target audience for their opinions and experiences, this is a very limited effort. Asking 50 students nation-wide for their ideas is helpful; however, when D.A.R.E. reaches over 75% of school districts in the nation, these 50 chosen students are not very representative. These children, as part of the YAB Mission Statement, must promise to remain drug and alcohol free [21]. Thus, D.A.R.E. is only including the perspectives of students who choose not to use substances, rather than getting a broader understanding of the complex issues of peer pressure by also including students who experiment with substances and students who abuse substances. By creating the YAB, D.A.R.E. is moving in the right direction by listening to social science theory, but is not going far enough to really get a broad sample of adolescents’ ideas and opinions regarding peer pressure and substance use.

D.A.R.E. is ineffective because it fails to base its program on social science theories. The new D.A.R.E. has incorporated psychology and communication theories into its curriculum, giving it the potential to be slightly more effective. However, the influence of D.A.R.E. will remain minimal until significant changes are made on a societal level that effect neighborhood safety, socioeconomic status, discrimination, and racial residential segregation. Until these issues are dealt with, many children will continue to be brought up in families that lack cohesiveness. The economic, emotional, and physical stresses that these issues place on families and communities jeopardize many efforts to reduce substance use among adolescents, as it is extremely difficult for families dealing with these issues to create strong family ties. All families need the opportunity to live in areas that are safe, that are not plagued by massive unemployment and poverty, and that offer good school systems and job opportunities. Economic and social policies need to be made on the national level that would address these issues and hopefully provide the opportunity for families to live in safer neighborhoods, improve their socioeconomic status, and not have to deal with discrimination or racial residential segregation. Realistically, it is not feasible that D.A.R.E. alone would be able to bring about these large scale changes, as they would require massive efforts by youth, parents, teachers, police officers, and politicians. However, once these policies are created and enforced, and once D.A.R.E. relies more heavily on social science theories, D.A.R.E. will be in a much better position to effectively influence adolescents. In the meantime, D.A.R.E. must incorporate more social science theories to improve its program so that it can become more effective and disseminate valuable messages that will impact adolescents and reduce drug and alcohol use.

References

1. About D.A.R.E.: New D.A.R.E.. (n.d.). Retrieved September 30, 2006, from http://www.dare.org/home/about_dare.asp
2. Perry, C. L., Komro, K. A., Veblen-Mortenson, S., Bosma, L., Munson, K., Stigler, M., Lytle, L. A., Forster, J. L., & Welles, S.L. (2000, March). The Minnesota DARE PLUS project: creating community partnerships to prevent drug use and violence. Journal of School Health, 70(3), 84-88. Retrieved November 5, 2006, from Health Reference Center Academic database (A61822581).
3. Drug education programs fail in Houston. (1999, January-February). Society, 36(2), 3-5. Retrieved November 5, 2006, from Expanded Academic ASAP database (A61822581).
4. Miller, D. W. (2001, October). DARE Reinvents Itself—With Help From Its Social-Scientist Critics. The Chronicle of Higher Education, 48(8), NA. Retrieved November 5, 2006 from Health Reference Center Academic database (A146948720).
5. Perry, C.L. (2003, February). A randomized controlled trial of the middle and junior high school D.A.R.E. and D.A.R.E. Plus programs. Archives of Pediatrics & Adolescent Medicine, 157, 178-84. Retrieved November 5, 2006 from Health Reference Center Academic database (A105929633).
6. Rosenbaum, D. (1998, November). Assessing the effects of school-based drug education: a six-year multilevel analysis of project D.A.R.E. Journal of Research in Crime and Delinquency, 35(4), 381-412. Retrieved November 5, 2006, from Expanded Academic ASAP database (A21255328).
7. U.S. General Accounting Office. (2003, January). Youth illicit drug use prevention: DARE long-term evaluations and federal efforts to identify effective programs. GAO-03-172R. Retrieved November 1, 2006 from http://www.gao.gov/new.items/d03172r.pdf
8. U.S. Department of Health and Human Services: National Institute on Drug Abuse. (2003, October). Preventing drug use among children and adolescents: a research-based guide for parents, educators, and community leaders (2nd ed.). 04-4212(B). Retrieved October 12, 2006 from http://www.drugabuse.gov/pdf/prevention/InBrief.pdf
9. Gray, P. (1999). Psychology (3rd ed.), (p. 627). New York: Worth Publishers.
10. Haan, M., Kaplan, G., & Camacho, T. (1987). Poverty and health: prospective evidence from the Alameda County Study. American Journal of Epidemiology, 125, 989-998.
11. Lu, N., Samuels, M., & Wilson, R. (2004). Socioeconomic differences in health: how much do health behaviors and health insurance coverage account for? Journal of Health Care for the Poor and Underserved, 15, 618-630.
12. Krieger, N. & Sidney, S. (1996). Racial discrimination and blood pressure: the CARDIA study of young black and white adults. American Journal of Public Health, 86, 1370-1378.
13. Williams, D. R. & Collins, C. (2001). Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports, 116, 404-416.
14. Siegel, M. (2004). The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A, pp. 66-69). In Siegel, M., Doner, L., Marketing public health: strategies to promote social change. Sudbury, MA: Jones and Bartlett Publishers.
15. Gray, P. (1999). Psychology (3rd ed.), (p. 468). New York: Worth Publishers.
16. Austin, E. W. (1995). Reaching young audiences: developmental considerations in designing health messages. In Mailbach, E., & Parrot, R. L. (Eds.), Designing health messages: approaches from communication theory and public health practice (p. 124). Thousand Oaks, CA: Sage Publications.
17. Austin, E. W. (1995). Reaching young audiences: developmental considerations in designing health messages. In Mailbach, E., & Parrot, R. L. (Eds.), Designing health messages: approaches from communication theory and public health practice (p. 131). Thousand Oaks, CA: Sage Publications.
18. Austin, E. W. (1995). Reaching young audiences: developmental considerations in designing health messages. In Mailbach, E., & Parrot, R. L. (Eds.), Designing health messages: approaches from communication theory and public health practice (p. 116). Thousand Oaks, CA: Sage Publications.
19. A longitudinal evaluation of the new curricula for the D.A.R.E. middle (7th grade) and high school (9th grade) programs: take charge of your life—year four progress report. (2006, March). Retrieved September 30, 2006, from http://www.dare.org/home/Resources/documents/DAREMarch06ProgressReport.pdf
20. Maltin, L. J. (2001, February). D.A.R.E. program will test new approach. Retrieved October 12, 2006 from http://www.dare.com/new_site/curriculum/DARE_program_test.htm
21. D.A.R.E. America Youth Advisory Board (n.d.). Retrieved October 12, 2006 from http://www.dare.com/youthadvisoryboardmission.asp

The Singular Focus on Trans-fats Obscures the Important Role of Balanced Nutrition in Managing the Obesity Epidemic – Ellen Klein

2006-12-17T10:16:00.000-08:00

The singular public health focus on the elimination of trans-fats has obscured the importance of other food related problems such as poor nutrition and vitamin intake. Interventions that concentrate solely on removing trans-fats from food overlook the problem of nutritional deficiencies. The obesity epidemic would be more effectively managed if a more comprehensive public health approach was to be implemented which includes overall nutritional awareness building and vitamin screenings.

The problem with the current approach to eliminate trans-fats as the singular solution to the obesity has been twofold. Firstly, by exclusively concentrating on the removal of trans-fats, the public receives the erroneous message that weight issues can be solved by simply eliminating trans-fats from our diets. Foods that are high in trans-fats are often unhealthy for other reasons, so the public can get a false sense of security that the removal of the trans-fats now renders this food healthy. Weight loss cannot be maintained if proper nutrition is neglected. Secondly, public health awareness of the benefits of maintaining adequate vitamin intake and nutritional balance is not achieved. Public health providers need to include the message of adequate nutrition in the campaign to decrease obesity.

What are trans-fats? Trans unsaturated fatty acids, (“trans fats”), are solid fats produced artificially by heating liquid vegetable oils in the presence of metal catalysts and hydrogen. (1) This process, partial hydrogenation, causes carbon atoms to bond in a straight configuration and remain in a solid state at room temperature. Naturally-occurring unsaturated fatty acids have carbon atoms that line up in a bent shape, resulting in a liquid state at room temperature. Trans fats are produced commercially in large quantities to harden vegetable oils into shortening and margarine. The oils used to cook French fries and other fast foods are usually this kind of partially hydrogenated oil, containing trans fats. Commercial baked goods frequently include trans fats to protect against spoilage and to add crispness to foods. They raise both total cholesterol and LDL, the "bad" cholesterol, levels while lowering levels of beneficial, HDL cholesterol in the body.

Commercial production of partially hydrogenated fats began in the early 20th century and increased steadily until about the 1960s as processed vegetable fats displaced animal fats in the diets of the U.S. and other Western countries. Lower cost was the initial motivation, but health benefits were later claimed for margarine as a replacement for butter. (2)

So, what changes are needed to improve the current public health approach to the obesity epidemic? First, the epidemic could be better managed if it were integrated with nutrition education. Overall nutritional education is a vital part of the message. A balanced diet of adequate nutrients and caloric needs must be maintained to ensure proper health. The USDA’s 2005 Dietary Guidelines for Americans recommends “a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.” (3)

Second, obesity screening interventions could be combined with vitamin blood level screenings. In almost every public health setting, combined screenings are often more effective than screenings of one disease alone. Many people have deficient levels of vitamin in their blood, but are not aware of it. The efficacy of individual public health screening interventions is often improved when integrated with another screening intervention program. For example, safe sex campaigns integrated with STD and HIV screenings improve the success rate of both projects. A site that provides flu shot vaccines could benefit from being combined with tuberculosis screenings. Mammograms could be done on female partners accompanying men undergoing prostate screenings. Hearing & eye tests could be done at the same time as depression screenings. These are just a few examples of how public health goals can be met more easily through synergistic integration. This same approach could be made with obesity interventions and vitamin level screenings.

In the United Kingdom, an integrated approach has already begun. Encouraging are recent requests for dieticians to “take on a wider role in health promotion” A survey of readers subscribed to Network Health Dietitians magazine revealed that professional dieticians in the UK wish to more actively participate in other public health issues. Eighty one percent of the dieticians surveyed expressed desire to expand their roles into a “holistic approach, increasing media presence and offering exercise and smoking cessation advice.” The dieticians also expressed frustration of their profession’s lack of visibility. They believe their skills and training could be utilized in a more interdisciplinary manner to promote other public health issues. (4)

Vitamin screenings could become a “Standard of Care” for patients being treated for obesity. Results from the screenings would have two useful purposes. First, the screening results would provide important health information to both the patient and care provider. Patients would discover information about their own vitamin levels and be able to take action to correct these deficiencies. Vitamin deficiencies are the main reason for many health problems, as discussed further in this paper.

Second, if providers were required to submit results of vitamin serum level screenings, a database could be formed that would reveal trends in vitamin deficiencies for a particular community or region. These screenings could be enforced by Department of Public Health, the same way they mandate the reporting of certain infectious diseases.

Obese adults are chronically vitamin deficient of the fat soluble vitamins: A, D, E and K. Excess layers of adipose tissue position fat soluble vitamins out of reach from blood vessels which would ordinarily resorb the vitamins from fat storage. An observational clinical trial revealed that obese subjects had significantly lower basal vitamin D concentrations and higher parathyroid hormone concentrations.

Cancer, rickets, poor eyesight, and immune disorders are caused by deficient levels of fat soluble vitamins. (5) “PubMed database search yielded 63 observational studies of vitamin D status in relation to cancer risk, including 30 of colon, 13 of breast, 26 of prostate, and 7 of ovarian cancer, and several that assessed the association of vitamin D receptor genotype with cancer risk.” (6) Much research is being done now to find the link between Prostate cancer and vitamin D deficiency. A biological link has been discovered, and epidemiologic data need to be researched to support this link. (7)

A problematic result of the current public health approach, which solely focuses on trans-fats elimination, is the escalation of lawsuits against fast food companies and food manufacturers. “…there are public health groups that are trying to pursue such an approach. For example, the Public Health Advocacy Institute states that: "Tobacco litigation focused on the tobacco industry's behaviors that interfered with the consumer's ability to make a free and informed choice. As in tobacco, there is a similar concern with the food industry." (8)

These legal claims serve to reinforce the erroneous idea that trans-fats are the sole culprit of obesity. The group BansTransFats.com sued Kraft Foods, Inc. in 2003 to eliminate trans-fat in Oreo cookies. Kraft eliminated trans-fat from Oreos and reduced or eliminated it in about 650 other products. Also, in 2003, BanTransFats.com prevailed in a lawsuit against McDonald’s. McDonald’s agreed to pay $7 million to the American Heart Association to fund a trans-fat program. It is important to note that even though these foods are trans fat free they are still very unhealthy. A single serving of Oreos (34g or roughly three Oreos) contains 7 grams of fat, which represents 11% of the USDA daily recommended intake of fat based on a 2,000 calorie diet, while being totally devoid of vitamins. (9) A large order of McDonald’s French fries contains 30g of fat, or 47% of the recommended daily intake based on the same guidelines. (10) It is clear that even without trans fats, the over consumption of these foods can still lead to obesity. The success of these two suits against Kraft and McDonald’s reinforces the message that trans-fats are the holy grail of obesity and serves to eclipse importance of balanced nutritional intake. (11)

A hyperbolized focus on trans-fats communicates fear and negativity, which is an ineffective and often maladaptive mode of communication. Guided by the Extended Parallel Process Model (EPPM) investigators Cho and Witte discuss fear and health risks: “ …if an audience is already frightened by a threat and feel hopeless, further heightening of threat perceptions may promote self-defeating actions, instead of self-protective actions.” When people feel they have some control, ‘high self efficacy’ over a solution, they are more likely to engage in steps toward the solution. Alternatively, when they perceive the solution has ‘low self efficacy’, they engage in defensive denial and avoidance. (12) After all why should we worry about things we have no control over? Furthermore, by creating an inordinate fear of a small part of a much larger problem can lead people to feel that the danger has past once the small piece is removed. People are so frightened of trans fat in particular that they either give up on trying to eat healthy, since trans fats are in many convenience foods, or they work to have it removed by legal or legislative action. In either case, once the trans fat is gone the public believes that the risk is gone with it. They then shift their attention to other matters and can lose sight of the big picture. By focusing on the tree that is trans fat, the public can miss the forest.

This week, the Board of Health of New York City passed the first citywide ban on trans-fats in restaurant cooking. Some believe that a new standard has been set in Public Health. While it is definitely a step in the right direction, the long-term beneficial effect toward managing the obesity epidemic will be realized only if the messages for balanced nutritional diets are also emphasized. Banning trans-fats is an excellent and important intervention, though it will not be successful without additional interventions such as nutritional education and vitamin screenings.
Focusing solely on the elimination of trans-fats as the ultimate solution to reducing obesity is a strategy, which provides a misleading public health message, while doing nothing to reduce the obesity epidemic. The use of fear and legal action reduces self-efficacy and reinforces the message that no other intervention is necessary for weight loss. An integrated approach including nutrition education, vitamin screening, and overall nutritional balance would improve the management of the obesity epidemic.

Bibliography
1.) Katan MB, Mensink RP, Zock PL. Trans fatty acids and their effect on lipoproteins in humans. Annu Rev Nutr 1995; 15:473-493.
2.) Herman, R. (Nov 15, 1999) Transfatty acids and Coronary Heart Disease. Retrieved Nov 22, 2006. http://www.hsph.harvard.edu/reviews/transfats.html
3.) USDA Dept of Health and Human Services (Jan 12, 2005) New Dietary Guidelines will Help Americans Make Better Food Choices and Live Healthier Lives Retrieved Nov 20, 2006 http://www.hhs.gov/news/press/2005pres/20050112.html
4.) No author cited. (Nov 10, 2006) 98% Of UK Dietitians Want Wider Role In Public Health. Medical News Today. http://www.medicalnewstoday.com/medicalnews.php?newsid=56109
5.) American Journal of Clinical Nutrition, Vol. 72, No. 3, 690-693, September 2000.
6.) Holick,MF.Am Journal Public Health Am J Public Health. 2006 Feb;96(2):252-61. Epub 2005 Dec 27.
7.) Schwartz, GG. Cancer Causes Control. 2005 Mar;16(2):83-95.
8.) Siegel, M (July 11, 2005) Obesity Lawsuits Tryiing to Follow Tabacoo Model . Retrieved June 13, 2006. http://tobaccoanalysis.blogspot.com/2005/07/obesity-lawsuits-trying-to-follow.html
9.) Kraftfoods.com (2006) Oreo Sandwich Cookie Nutritional Info, Retrieved December 6, 2006. http://www.kraftfoods.com/main.aspx?s=product&m=product/Product_display&Site=1&Product=4400000820
10.) Mcdonalds.com (Nov 12, 2006) McDonald’s USA Nutritional Facts for Popular Menu Items. Retrieved Dec 6, 2006. http://www.mcdonalds.com/app_controller.nutrition.index1.html.
11.) Bantransfat.com (Feb 11, 2005) The Campaign to Ban Partially Hydrogenated Oils. Retrieved Nov 15, 2006. http://www.bantrasfats.com/mcdonalds.html.
12.) Cho, H. & Witte, K. (Oct 2005) Managing Fear in Public Health Campaigns: A Theory-Based Formative Evaluation Process. Health Promot Practice 6(6(4):482-90.

Beyond Tipping the 1992 Food Pyramid: A social science critique of MyPyramid.gov - Tara Naylor

2006-12-17T10:09:00.000-08:00

The release of the new food pyramid, MyPyramid, (http://www.mypyramid.gov/) in January 2005 was a step forward in the fight against obesity because it combines both healthy eating and exercise. The United States Department of Agriculture (USDA) describes MyPyramid as an interactive food guidance system. To this end, they have tipped the 1992 food pyramid onto its side, stripped away all pictures of foods, and added a stick figure climbing up stairs on the side of the pyramid. Internet users can log in to the MyPyramid website where they enter their age, gender, and activity level to create a personalized pyramid. They also get a personalized eating plan that outlines not only which foods to eat, but also the quantities of these foods in cups or ounces. The plan also encourages at least 30 minutes of exercise each day. This is a great improvement from the one-size fits all approach of the 1992 food pyramid that measured portions using the cryptic term of “servings”, and ignored the importance of exercise in maintaining a healthy weight

Even so, there are dissenters that feel the pyramid is still inadequate. An article on food pyramids published by Harvard School of Public Health says, “The bad news is that the new pyramid doesn’t convey enough information to help you make informed choices about your diet and long-term health.” (1) They go on to say that there is no distinction made between fat types (trans, saturated, unsaturated), the grain information can be misleading (make half your grains whole) and there are no specific foods that should be avoided in MyPyramid. The article goes on to promote other pyramids, including their own Healthy Eating Pyramid, which they claim is based on more current research and not influenced by lobbying efforts by the food industry.
For those without internet access, MyPyramid is little more than a picture of a stick figure climbing stairs on a pyramid that has colorful bands of various widths that taper at the top of the pyramid. Without the internet to decode the colorful bands, the food groups they represent and how much should be consumed remains a mystery. Many people who need this information do not have access to the internet. In the United States 71% of the population uses the Internet, but there is a socioeconomic divide. About 90% of the most affluent quarter of Americans use the internet compared with only 43% of the poorest quarter of Americans. (2) In an article titled Uncle Sam’s diet sensation: MyPyramid—an overview and commentary, Johnston says, “[MyPyramid.gov is] not likely to be accessed by the populations that need it most: the underprivileged.” (3) In a population studied from birth to 36 years of age, later onset of obesity was more common in the lower occupational groups and those with lower educational achievements. (4) A highly significant association was found between level of education (a primary measure of socioeconomic status) and risk factors for disease, with the lowest education level being at the highest risk for disease. (5)

Furthermore, even those who can get access to the internet may have a difficult time assimilating the information if they have a low literacy level. A study has shown that many health websites are written at a reading level that prohibits optimal access and interpretation by some low literacy adults. (6) In the United States, illiteracy and poor health status are independently associated, even after adjusting for confounding sociodemographic factors. (7) The Stanford Nutrition Action Program (SNAP) was developed as a dietary fat intervention specifically for low-literacy adults. (8) This program focused on goal-setting through classroom based teaching with an interactive learning style, and used only a few written materials. The curriculum included food tastings, demonstrations, interactive discussions and group activities to achieve the nutrition objectives. By tailoring the intervention to the needs of this low-literacy population, the SNAP curriculum was significantly more effective in achieving dietary changes than the general nutrition curriculum.

The USDA has added the slogan “Steps to a Healthier You” to the bottom of the food pyramid which makes the message more positive and indicates that these changes will not happen overnight. On the MyPyramid.gov website, the USDA says of their slogan, “It suggests that individuals can benefit from taking small steps to improve their diet and lifestyle each day.” The problem for most overweight Americans is that following the food pyramid is not a small step; it requires a concerted life change. While the superficial changes are headed in the right direction, the USDA is still missing the importance of the way people think about food, and how these factors influence what they ultimately decide to eat. Even people who are committed to eating healthy will have to seek out the MyPyramid website, answer the questions and then print out the personalized pyramid. Then they have translate the personalized serving recommendations for each food category into a grocery list and finally into meals.

There are successful interventions that use small steps that can be implemented more easily to gradually change the eating behavior of Americans. It has been shown that cutting out or burning as few as 100 calories each day through reduced food intake and increased physical activity, could prevent weight gain in many people. This can be accomplished by leaving behind the last few bites of each meal or walking for 15 minutes each day. (9)

For so long public health messages have focused on the negative effects of a poor diet (higher risks of heart disease and cancer) that people have become afraid of food. The diet message has reached saturation level in the minds of most Americans. At this point it makes more sense to shift to a more positive campaign that promotes the benefits of exercise. A stick figure walking up MyPyramid, and an anecdotal comment about 30 minutes of moderate to vigorous exercise does not encourage sedentary people to get started in an exercise routine. A specific exercise program that is quick and easy to fit into a busy schedule that people can just follow without thinking too much about it would increase their level of physical activity. The feeling of accomplishment encourages people to continue the exercise program and over time people would buy in to the concept of food as fuel for the body. Participants in a study of obese women in a nutrition-exercise program expressed concerns they had during the program; including child care, transportation to a safe place to walk/jog, alternatives during inclement weather, rewards for reaching milestones, etc. (10) We should keep these concerns in mind when developing an intervention to promote physical activity.

The USDA has failed to incorporate social and behavioral sciences in designing this intervention. All of the focus is on the individual in MyPyramid. Overeating can be considered an eating disorder, and it is an addiction on the individual level. In a study comparing Weight Watchers and Overeaters Anonymous from a developmental and sociological perspective, Weiner showed that both interventions are valuable as they are group/community based approaches. (11) A solid understanding of the psychology behind people’s eating habits and the community in which they live is critical to the development of a successful intervention to change someone’s diet. It is at the essence of the problem to contextualize the factors that are going through someone’s head when they are deciding what to eat.

The Diffusion of Innovations theory describes the pattern of how new behaviors are adopted by society. It provides a conceptual paradigm for understanding the process of diffusion and social change. There are early adopters that pioneer the change and then others seeing their success quickly follow suit. This more closely emulates the way the American public embraces fad diets, so it makes sense to use a similar theory as the basis for designing an intervention to promote healthy eating. Rogers proposed a five-stage model for the diffusion of innovations. (12) To make this model work, the innovation must first be communicated effectively so that people know that the innovation exists and how it works (its function). Once the message is communicated, people must be convinced of the value of the innovation through persuasion. The MyPyramid.gov campaign was not well publicized. In fact, not very many people are aware that the food pyramid has changed.

A public health intervention designed to implement small changes in portion size and a simple defined exercise program would be the innovation, and then strategic campaigns would promote early adopters within communities. These people would be social leaders that are popular, and they would then spread the message of healthy eating and exercise. Others, seeing the success of the early adopters, would try these small steps to reduce portion size and start exercising and this early majority would share their stories of success with friends and colleagues. Those who are skeptical, or from a lower socioeconomic status may take longer to receive the message. And there will always be some people (laggards) who will be resistant to implementing this intervention at all.

A successful example of an intervention that puts the Diffusion of Innovations theory into practice was described by Wiist and Flack. (13) They used a church-based program to educate a minority group about reducing cholesterol. Leaders of the church were asked to identify “natural helpers” in their community, and these people were trained to test cholesterol levels and provide structured education to those with high cholesterol levels. The church leaders were among the first to be screened, and encouraged the community to do so from the pulpit during sermons, through the church service bulletins, on the church bulletin boards, on local radio and in newspapers. This intervention was successful in lowering cholesterol levels because it was designed with social and behavior principles in mind. People who may not go to the doctor otherwise were screened and became informed of their cholesterol level. The intervention was done in the context of a community in which the members were comfortable, and people they trusted taught the education classes. The community aspect is very important, because this created a support network of people who were working together towards a similar goal.
America is experiencing an obesity crisis and the public health effort is going to need to take a more proactive and productive stance to improve the eating habits than MyPyramid.gov. This campaign is complicated, poorly communicated and unpersuasive, and it is not accessible to those without Internet access. In his critique of MyPyramid.gov, Johnston says, “…Obesity prevention programs structured only to educate and inform have generally been unsuccessful.” (3) To create a successful public health intervention for the obesity problem in America, we need to leverage social support networks in communities. We need to identify the people in these communities to whom others naturally turn for advice and build on these relationships to influence others to modify their health behavior. By focusing on their perceptions and understanding the barriers that keep them from eating healthy and being more active, public health interventions would be more successful. When interventions are geared to wants and needs of the population in which we want to affect change people will be more responsive and motivated to implement these changes in their own lives.

References:
Harvard School of Public Health. Food Pyramids. 2006 http://www.hsph.harvard.edu/nutritionsource/pyramids.html
Evans L. UCLA World Internet Project Finds Gaps between Rich and Poor, Young and Old, Men and Women. 2004. http://www.international.ucla.edu/article.asp?parentid=7488
Johnston, CS. Uncle Sam’s diet sensation: MyPyramid—an overview and commentary. 2005 MedGenMed 7:78.
Braddon FE, Rodgers B, Wadsworth ME, Davies JM. Onset of obesity in a 36 year birth cohort study. Br Med J (Clin Res Ed). 1986. 293: 299-303.
Winkleby MA, Fortmann SP, Barrett DC. Social class disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med. 1990. 19:1–12.
Birru MS, Monaco V, Charles L, Drew H, Njie V, Bierria T, Detlefsen, and Steinman RA. Internet Usage by Low-Literacy Adults Seeking Health Information: An Observational Analysis. J Med Internet Res. 2004. 6: e25.
Weiss BD, Hart G, McGee DL, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1992. 5:257-64
Howard-Pitney B, Winkleby MA, Albright CL, Bruce B, Fortmann SP. The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults. Am J Public Health. 1997. 87: 1971-1976
Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the Environment: Where Do We Go from Here? Science 2003. 299:853 -855.
Lasco RA, Curry RH, Dickson VJ, Powers J, Menes S, and Merritt RK. Participation rates, weight loss, and blood pressure changes among obese women in a nutrition-exercise program. Public Health Rep. 1989; 104: 640–646.
Weiner S. The addiction of overeating: self-help groups as treatment models. J Clin Psychol. 1998 54:163-7.
Rogers E. Diffusion of Innovations. 1962.
Wiist WH, Flack JM. A church-based cholesterol education program. Public Health Rep. 1990. 105: 381-388.

The Failure of the Dietary Guidelines to Promote the Health of a Culturally Diverse America: An Abandonment of Social Science Principles-Rebecca Bokat

2006-12-17T09:52:00.000-08:00

The Dietary Guidelines for Americans were first published in 1980 following the Senate Select Committee on Nutrition and Human Needs Dietary Goals, in order to combat the increased incidence of overweight, obesity, and chronic diseases that were the result of a poor diet and sedentary lifestyle (1). Despite the establishment and periodic revision of the Dietary Guidelines for Americans, the prevalence of obesity has doubled over the past three decades and continues to increase in the United States (2). Obesity is costly to society because it is associated with chronic diseases including cardiovascular disease, type II diabetes, hypertension, stroke, dyslipidemia, osteoarthritis, selected cancers, gallbladder disease, sleep-breathing disorders, musculoskeletal disorders, and all-cause mortality (3). The rate of obesity in the United States follows a socioeconomic gradient, such that the burden of disease falls disproportionately on people with limited resources, racial and ethnic minorities, and the poor (3). The goals of the Dietary Guidelines to promote the health of Americans and to reduce their risk for major chronic diseases has not been realized because the Guidelines rely solely on scientific evidence and fail to take into account basic behavioral and social science principals. In order to design an effective strategy to combat the obesity epidemic and meet the needs of a multicultural and dynamic population, the cultural, economic, and social differences among Americans must be taken into account.

The homogenous approach to nutrition recommendations reflected by the Dietary Guidelines for Americans fails to take into account the increasingly heterogeneous US population. Census data demonstrate an increase in diverse racial and ethnic groups in the United States from approximately one-fourth to one-third of the population, and this trend is expected to continue, such that by the year 2030, minority groups will account for forty percent of the total population (3). Given that African Americans are the second largest ethnic minority group in the country and that this population has a higher prevalence of obesity and weight-related diseases than the general US population, extensive research has been conducted on the eating practices of African Americans. Research has indicated that the dietary habits, food choices, and cooking methods unique to African Americans evolved from a long history of slavery, persecution, and segregation (5). The slaves who were brought to the US combined their West African cooking methods with those of the British, Spanish, and Native American techniques to produce a distinctive African American cuisine known as ‘soul food’ (5). Soul food emphasizes fried, roasted, and boiled food dishes using primarily chicken with the skin left intact, pork, pork fat, organ meats, sweet potatoes, corn, and green leafy vegetables (4). As a result of the high intake of deep fried foods, eating chicken with the skin, not trimming fats from meat, seasoning vegetables with fat and meat, and reusing oils, fats and grease to flavor foods, the traditional African American diet tends to be low in fiber, high in sodium, nitrates, sugar, fat and/or cholesterol (5). These dietary practices continue to persist despite their health implications because long-term beliefs, attitudes, and behaviors among the African American community have been handed down across generations. Subsequently, healthful eating is viewed as an abandonment of tradition and culture and is perceived as conforming to the dominant culture. Mexican Americans are a second minority group that is becoming a fast growing segment of the American population, and like African Americans, dietary practices and nutrition related behaviors are culturally defined and established early in life. A collaborative research study conducted by the CDC’s Division of Nutrition and Physical Activity found that the dietary practices typical of Mexican American families included eating traditional Mexican food that is high in fat and starch and low in vegetables (6). This study also discovered that young African Americans and Mexican Americans have different perceptions about healthy and unhealthy weight compared with whites (6). Specifically, a person who is overweight is considered to be well-nourished or “full figured” in the African American and Mexican American cultures. The Dietary Guidelines for Americans are not culturally relevant or sensitive to the dietary practices and food-related behaviors of the diversity of ethnic and racial minorities that represent large segments of the American population. The Dietary Guidelines, which are based on the medical model and view food as being therapeutically valuable, isolate food from the cultural context of eating and therefore has limited effectiveness with many minority groups.

The Dietary Guidelines for Americans 2005 recommends nine servings per day of a variety fruits and vegetables and three cups of reduced fat or fat-free milk or other dairy products for the reference 2,000 calorie level (7). However, the Guidelines do not take into account the limited availability and high cost of fruits, vegetables, and reduced fat dairy products and the greater availability and lower costs of high-fat foods in impoverished urban neighborhoods. These low income neighborhoods have a disproportionately higher number of racial and ethnic minority populations, particularly Hispanic and non-Hispanic blacks (8). The limited access and higher cost of healthier foods in poorer urban neighborhoods is a direct result of the migration of supermarkets to the suburbs, leaving low-income shoppers who do not have access to private transportation at the mercy of high priced convenience stores and local grocery stores (5). Convenience stores, also known as bodegas, and local grocery stores that serve poorer inner city neighborhoods have limited inventories and usually do not stock large amounts of perishable foods (5). In the Bedford-Stuyvesant neighborhood of Brooklyn, only 21 percent of the bodegas offered apples, oranges and bananas; leafy green vegetables were found in only 6 percent of the bodegas; and only one in three bodegas sold reduced-fat milk (9). A study that tracked the availability of diet soda, low-fat or fat-free milk, high-fiber bread, fresh fruit and fresh vegetables in food stores in East Harlem and the Upper East Side found that stores on the Upper East Side were more than three times as likely than the stores in East Harlem to stock all five of the aforementioned items, despite the fact that East Harlem had more than twice as many food stores per capita as the Upper East Side (10). East Harlem is around 90 percent Hispanic and black (10). Even if healthy food is available in these types of neighborhoods, local convenience and grocery stores often charge more for it than supermarkets (9). In the Bedford-Stuyvesant neighborhood of Brooklyn, the average cost of a gallon of milk was 79 cents higher in the Bodega than in a supermarket (9). Although there is limited access to healthier food options in most of these low-income neighborhoods, there is a greater availability of inexpensive, high-fat foods. A recent geographical analysis determined that predominantly black neighborhoods have 2.4 fast-food restaurants per square mile, compared to 1.5 such restaurants in predominantly white neighborhoods (3). On Third Avenue in East Harlem, a banner outside McDonald’s advertises a $1 menu, while down the street a KFC sign boasts that you can “Feed Your Family for Under $4 each (10)”. Foods that are energy-dense and highly palatable, like fast-food and potato chips, sodas, and doughnuts available at bodegas, are associated with diminished feelings of satiety and the over consumption of fats and sweets, leading to increased energy intakes (3). Research focusing on the availability and cost of foods in impoverished urban neighborhoods has concluded that neighborhood differences may account in part for health disparities that have a dietary component (5).

The Dietary Guidelines for Americans blindly assumes that provided with nutrition information, consumers will make the appropriate changes in their eating habits and lifestyles. The DGAs view individual level behavior change separate from the social context of eating, which research has shown influences all aspects of eating patterns. Social connections satisfy one of the fundamental human needs of belonging identified by psychologist Abraham Maslow in his Hierarchy of Needs (11). Humans need to feel belonging and acceptance whether it comes from large social groups or small social connections (11). Individuals have a need to belong to a social group and eating certain foods from one’s cultural group is a way of staying connected to that group. Research through focus group interviews has shown that minority groups, particularly African-American and Hispanic populations, report that eating healthfully is perceived as giving up part of their cultural heritage and trying to conform to the dominant culture (5). Individuals may consciously or unconsciously participate in culturally defined eating patterns in order to maintain group identity (5). A resident of Spanish Harlem was quoted as saying that people in his neighborhood “associate diet as unhealthy. If you’re dieting, then you’re sick. You look at people on the streets, they’re heavy. That’s the way we grow up here (10)”. Despite the resident’s family history of diabetes, he added that people in his community “love eating trash…we grew up eating McDonald’s and I still find myself eating candy and chocolate cake (10).” He also added that the members of his community have “cultural differences…for a guy to eat a salad, he’s a wimp. The women can’t be chumps either. A woman can eat a salad but has to eat it on the low. She has to do it quiet. They make fun of you: What are you, a rabbit (10)?”

It is evident from the obesity epidemic that is currently plaguing the nation that the Dietary Guidelines for Americans are an ineffective public health intervention. Not only are the Guidelines not reaching large segments of the American population, particularly low income ethnic minorities, but the Guidelines are not applicable and practical in the real-life setting of these people’s lives. The biomedical orientation of the Guidelines limit their effectiveness with lower-income minority groups because they isolate eating behaviors from the cultural, economic, and social context in which eating patterns are developed, maintained, and passed down. The individual-level nutrition recommendations made by the Guidelines developed for the general population are not culturally relevant or specific to many minority groups residing in poor inner city neighborhoods. The Guidelines expect these population groups to practice dietary patterns that are contrary to the foods available and the dietary practices followed in their environment. An effective public health intervention to reduce obesity and the risk of chronic diseases must take these cultural, economic, and social differences into consideration; otherwise the impact of the obesity epidemic will continue to disproportionately affect people with limited resources, racial and ethnic minorities, and the poor.

References

1. Mahan, L.K., & Escott-Stump, S. (2004). Krause’s Food, Nutrition, & Diet Therapy (11th ed.). Philadelphia: Saunders.
2. Zhang, Q. & Wang, Y. (2004). Trends in the Association between Obesity and Socioeconomic Status in U.S. Adults: 1971 to 2000. Obesity Research, 12(10), 1622-1632.
3. Boyle, M.A., & Holben, D.H. (2006). Community Nutrition in Action (4th ed.) Belmont: Thomson Wadsworth.
4. Airhihenbuwa, C.O., & Kumanyika, S. (1996). Cultural Aspects of African American Eating Patterns. Ethnicity & Health, 1(3), 245-263.
5. James, D. (2004). Factors Influencing Food Choices, Dietary Intake, and Nutrition-Related Attitudes among African Americans: Application of a Culturally Sensitive Model. Ethnicity & Health, 9(4), 349-367.
6. Centers for Disease Control (2000). Executive Summary: Healthy Weight, Physical Activity, and Nutrition: Focus Group Research with African American, Mexican American, and White Youth. DNPA Physical Activity and Nutrition Adolescent Initiative.
7. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Office, January 2005.
8. Townsend, M.S. (2006). Obesity in Low-Income Communities: Prevalence, Effects, a Place to Begin. Journal of the American Dietetic Association, 106(1), 34-36.
9. Santora, M. (2006, January 20). New York Pushing Better Diet in Poorer Neighborhoods. New York Times.
10. Kleinfield, NR (2006, January 10). Living at the Epicenter of Diabetes, Defiance, and Despair. New York Times.
11. Maslow’s Hierarchy of Needs. Wikipedia: The Free Encyclopedia. Retrieved November 11, 2006, from http://en.wikipedia.org/wiki/maslow’s_hierarchy_of_needs

Social Sciences Help Reveal Three Major Flaws in Public Health Intervention “Take a Loved One for a Check Up Day”- Laura Mottola

2006-12-17T09:23:00.000-08:00

“Take a Loved One for a Check Up Day” is a national campaign with the intent of motivating those who usually do not go to the doctor other than in a moment of emergency to get a periodic screen at the end of September of each year. Those people are then encouraged to help their family members or close friends do the same. Even though the campaign is directed to everyone, it focuses on decreasing the healthcare gap between minorities and the rest of the American population. The idea is that “Take a Loved One for a Check Up Day” will help minorities have better health outcomes and a decreased mortality rate by increasing their access to healthcare.

From a Social Sciences perspective, there are six flaws that make this campaign a potential failure. First, the campaign seems to ignore the fact that health insurance coverage does not necessarily guarantee better health. The study done by C.E. Ross and J. Mirowsky has shown, in fact, that people with high SES have better health, not because of their medical coverage, but because of other factors. (A) Secondly, it does not take into consideration the fact that health access does not always equal care as one may encounter non-financial obstacles on his path. Regarding this matter, Kevin A. Schulman and others have proved that people of certain gender and race may receive less care than others with the same health insurance status. (B) Thirdly, the constant focus on individual factors, such as access leads to undermining the importance of social factors in influencing behavior, as discussed by Theodore Pincus and others. (C) Furthermore, this public health intervention fails at putting emphasis on behavior and its dependence on self-efficacy. Albert Bandura’s Social Cognitive Theory underscores the strong association between the two. (D) An additional flaw of the campaign consists in the lack of providing consistent support to patients in terms of providing care during the rest of the year. As a result, there is no possibility of creating strong self-efficacy as shown by Jim Grizzell. (E) Last, but not least, “Take a Loved One for a Check Up Day” gives an unintended message by communicating the idea that to improve one’s health it is sufficient to go to the doctor once a year and that the adoption of a healthy lifestyle does not require much effort. Wakefield M. et al. and Hart GJ et al. help clarify the effects of unintended message applied to other fields of public health. (F)

A. Health access does not guarantee better health outcome. The first flaw of the campaign is the idea that reduction of health access disparities between minorities and the rest of the American population will result in better health outcome for all. However, in their article, C.E. Ross and J. Mirowsky made the strong claim that medical insurance has no impact on health. (1) In their study, they found that people with a high SES tend to have better health compared to poor subjects. Then, they examined whether the finding resulted from ownership of medical insurance by high SES individuals. The shocking result was that access to care was slightly if not at all responsible for the association between high SES and good health. In fact, when doing a comparison with the uninsured, individuals who had public coverage reported worse health while health conditions of privately insured people were not significantly different from the uninsured. The final conclusion reached was that: “Insurance is not associated with better health outcomes in any case.” (1) On the other hand, economic hardship revealed a significant association with worse health in poor people. Specifically, the economic strain of having difficulty paying bills was strongly related to chronic health problems and physical disabilities. (1) This reveals the idea that there are other factors to be considered other than health access when trying to improve the public’s health. The Canadian healthcare system gives an additional example of the absence of association between better health outcome and universal access. In regard to the topic, Daniel Drezner says: “As many as 24,000 patients die in Canadian hospitals each year, while tens of thousands more are crippled, injured or poisoned in association with medical errors that could have been prevented”. (2) The high number of deaths and injuries reported above shows once again that access to all does not necessarily equal better health to all.

B. Health access does not equal care. A second flaw of the campaign is the assumption that health access always equals receipt of care. There is no consideration of the fact that even if one is offered access to care through insurance coverage, he may face other impediments to obtaining medical assistance. These are called non-financial barriers. As Thomas Bodenheimer and Kevin Grumbach assert: “Non-financial barriers include long distances between patients and healthcare facilities, language, literacy, cultural differences between patients and healthcare givers, and factors of gender and race.” (3) For example, even if one has good healthcare coverage, he may receive limited care due to his belonging to a specific race or gender. In regard to this matter, Kevin A. Schulman and others did a study concerning the differences in treatment of patients affected by cardiovascular disease based on race and sex. Actors used for the trials represented patients with equal medical conditions. The result was that doctor’s recommendations to undergo cardiac catheterization varied significantly with gender and race. The lowest rates of cardiovascular procedures were in fact seen among African-American women in support of the authors’ idea that: “Subconscious bias occurs when a patient’s membership in a target group…activates a cultural stereotype in the physician’s memory regardless of the level of prejudice the physician has.”(4) Furthermore, in support of the idea that racial discrimination may affect the provision of care, a recent study has proved that: “Despite similar insurance coverage and clinical status, white Medicare patients were 30%-50% more likely than African-American patients to undergo procedures, such as coronary angiography, bypass surgery, and angioplasty.” (5) This matter is of critical importance in this campaign, which is specifically oriented toward minorities.

C. Social Factors. A third flaw of the campaign is the lack of attention to social factors that affect the people in question. Social factors include environment, social economic status, and race. In the case of “Take a Loved One for a Check Up Day,” social factors may be particularly useful since the campaign focuses on a specific group of people, which belongs to a specific environment, has a specific income, and represents a specific race, mostly African-American. As Theodore Pincus and others say: “Focus on access to healthcare professionals ignores the most important determinant of health: the patient himself or herself in a sociocultural context.” (6) This concentration on health access in fact leads to ignorance of important variables, social factors, which are responsible to shape one’s behavior. Most times, it is possible to understand one’s actions better by looking at the environment in which he lives rather than his genetic make-up. Grenard JL and others show how the influence of social factors on behavior is a reality by examining the cause of smoking behavior in Chinese teenagers. During the study, these were in fact found to begin smoking due to peer smoking, cultural influences, and inter- and intra-personal influences. (7)

D. Behavior and its Dependence on Self-Efficacy. The campaign also fails to address behavior and its dependence on self-efficacy. Behavior is a better determinant of long-term health and self-efficacy is the driving force that leads to certain behaviors. As Michael McGinnis and William H. Foege say: “The three leading causes of death-tobacco, diet and activity patterns and alcohol-are all rooted in behavioral choices.” (8) The role of self-efficacy consists in influencing those choices through motivation, perseverance, thought patterns, and vulnerability. (8) Self-efficacy is defined as the belief that one has the capabilities to execute the courses of actions required to managing prospective situations. This has a very strong association with human behavior and behavioral change especially. In fact, where there is strong self-efficacy, behavior is more likely to change. This idea is confirmed by E. Meland and others who have shown in their study, in which they compared two interventions advising cardiovascular high-risk men of lifestyle changes in Norway, that: “Self-efficacy was a statistical significant predictor of smoking cessation success”. (9) Albert Bandura was the first to introduce the concept of self-efficacy, through his Social Cognitive Theory. This theory explains that: “Behavior change is affected by environmental influences, personal factors, and attributes of the behavior itself.” (10) Specifically, self-efficacy becomes the “single most important characteristic” (10), which leads to behavioral change because as Jim Grizzell says: “People’s behavior lead to certain outcomes… and their expected outcomes are filtered through a person’s expectations or perceptions of being able to perform the behavior in the first place.” (10)

E. One Day Only. Another flaw of “Take a Loved One for a Check Up Day” campaign is that it aims to give screening to minorities once a year. It wants to encourage these people to do prevention on one day, hoping then that they will suddenly become enlightened and take charge of their health without receiving consistent medical support throughout the year. However, even if one is aware of the risks, he may not necessarily perform the actual behavior. Even if one is aware that he has to begin exercising and quit smoking if he wants to lower his chance of having a heart attack, he may not do it. We now know how important strong self-efficacy is in changing one’s behavior from unhealthy to healthy. Thus, we can say that one day of screening is not of much help to those who have medical conditions related to smoking, physical inactivity, and eating fats because it completely misses the criticality of behavior and self-efficacy. As Jim Grizzell says: “One of the ways to increase self-efficacy is offering the opportunity for skill development and modeling the desired behavior.” (10) Doing a check up once a year will not likely result in strong self-efficacy.

F. Unintended Message. The sixth and final flaw of “Take a Loved One for a Check Up Day” is the unintended message presented to the audience. Unintended messages often result in a misunderstanding of the idea expressed by an ad or campaign. In the case of this intervention, which has minorities as its target, one may think that if he goes to the doctor once a year, his health will automatically improve as he will be screened and given medications in case those are needed. There are many examples of influence of unintended messages from other fields of public health. Two studies examine specifically the resulting optimism toward smoking cessation through nicotine replacement theory (11) and the effects of Anti-retroviral Therapy for treatment of AIDS (12). Both studies show how unintended message could increase a detrimental behavior, such as smoking in teenagers and sexual risky behavior among homosexuals. On that same path, “Take a Loved One for Check Up Day” may establish a level of optimism in those who adhere to it. In their minds, they may think that they can keep eating unhealthy, smoking, and not exercising as long as they go see the doctor once a year.

In conclusion, the six flaws of “Take a Loved One for a Check Up Day” show how this campaign will not succeed in the long run. In fact, it concentrates exclusively on the access factor without going to the root of the problem, behavior. It is obvious that behavior is the motor of people’s actions. Therefore if one could influence behavior, there would at least be a greater chance for minorities of having better health. To do that, first, “Take a Loved One for a Check Up Day” should have its name changed to “Take a Loved One to a Prevention Day.” Then, the event should take place once every other month rather than once a year so that those who adhere to it feel supported throughout the process. It would consist of education programs to stimulate people’s self-efficacy to eat right, exercise, and quit smoking by showing the advantages of a healthy behavior. Furthermore, participants would be required to at least eat healthy and not to smoke on the same day of the event. As a result, these would become aware that even though it takes effort to behave healthy, it is doable. Those people who have succeeded in the program should then talk about it with their friends and family and show its benefits. The reason behind it is that if healthy behavior becomes the social norm, most risk factors will be eliminated and more people will be healthy.

Bibliography:

1) Ross CE, Mirowsky J. Does medical insurance contribute to socioeconomic differentials in health? Milbank Memorial Fund Quarterly/ Health and Society 2000; 78: 291-321
2) Thomas Bodenheimer, Kevin Grumbach, Understanding Health Policy, 2002; 22
3) Daniel W. Drezner. Wow, my second healthcare post in less than a year. Home Page. Sat, May, 22,2004.
4) Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. New England Journal of Medicine 1999; 340: 618-626.
5) Thomas Bodenheimer, Kevin Grumbach. Understanding Health Policy, 2002; 24
6) Pincus T, Esther R, DeWalt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Annals of Internal Medicine 1998; 129:406-411.
7) Grenard JL et al. Influences affecting adolescent smoking behavior in China. Nicotine and Tobacco Research. 8(2): 245-55. Apr. 2006
8) McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-2212.
9) E. Meland, JG Maeland,E. Laerum. The Importance of self-efficacy in cardiovascular risk factor change. Scandinavian Journal of Public Health. 1999 March; 279(1): 11-7
10) Grizzell Jim, Behavior Change Theory and Models. 30 Sept. 2003
11) Wakefield M. Durrant R. Effects of exposure of youths at risk for smoking to television advertising for nicotine replacement therapy and Zyban: an experimental study. Health Communication. 19(3):253-8, 2006.
12) Hart GJ, Williamson LM. Increase in HIV sexual risk behaviour in homosexual men in Scotland, 1996-2002: prevention failure? Sexually Transmitted Infections 2005; 81:367-372.

Academic Curiosity in a Real World: A Criticism of the Methods Used by Funding Agencies to Evaluate Deserving Research Proposals- Karl Stasko

2006-12-17T09:12:00.000-08:00

Why does common sense often take a secondary role in public health research? Gary G. Bennett, a PhD from the Harvard school of Public Health, recently published a surprising study in the American Journal of Public Health. His research utilized a pedometer to show the effects of television viewing on the physical activity of multiethnic low income families. The results revealed that each hour of watching television corresponded to fewer steps taken, and ultimately decreased the chances that individuals will meet the proposed health goal of taking 10,000 steps a day (2006). Dr. Bennett should be commended for his good intentions; however, the surprising part of this study is that it was funded by grants and published in a respected journal. Shouldn’t it be clear that watching television correlates to less activity, especially to public health practitioners the main audience of the American Journal of Public Health? Common sense reveals that most people aren’t running 5 miles on the treadmill while they watch television, regardless of income and ethnic background. Yet, studies such as these continue to be published and awarded grants by funding agencies. There is something wrong with the system.

Public Health is dependent upon academic research and actual real world interventions. Resources are often scarce for public health departments who must compete with other services, such as fire and police departments for funding. It can be argued that public health researchers might often use grant monies for academic curiosity rather then for direct intervention. Funding agencies must change their grant evaluation policies in order to encourage researchers to solve problems, rather then to merely point them out in redundant variations. Arguments can be made that: (1)Public Health researchers often feel pressure to obtain grants
and publish from their particular institutions and peers, which doesn’t always lead to truly novel research proposals; (2)Current criteria used by funding agencies may exclude more deserving research proposals due to grant requirements; and (3)Grants are allocated to researchers for studies which are too similar to existing research; therefore, they provide no new insight to the current body of knowledge in the their respective fields.

Research is important for developing directed and successful intervention. Therefore, the quality of studies and subsequent publications are paramount to the future direction of public health.

Pressure to Publish
The pressure to publish is very real in the world of academia. The term “publish or perish” is an all too familiar cliché proving this very point. Professors must often publish works in order to obtain tenure at their academic institutions. Even graduate students in certain fields may be urged to publish in order to be competitive in the job market. This is a problem because this pressure may lead to hastily done, mediocre research, which isn’t relevant to real world interventions (Fox, 1983). In order to address this all too prevalent situation it is necessary to find out what might be driving this behavior.

Alfred Adler believed that a sense of inferiority, or more precisely, avoiding a sense of inferiority, drives many people in their life’s goals and aspirations. This drives individuals to act unrealistically and manifests itself as a desire for power and dominance. In this case, researchers might retreat from real world problems and develop self centered attitudes (Boyd, 2005). The current environment at academic institutions may very well promote this type of innate behavior. The pressure to perform and obtain tenure is surely a source of competition among professors, with publications becoming a way to keep score, and obtain a sense of prestige. The price of this game is a separation from real world issues, and a decline in useful and thoughtful research. The truth is that funding agencies are inundated with study proposals which are fueled with this underlying motivation. It is unfair to say that principal investigators have deviant intentions when it comes to being funded and published. However, it may be more realistic to say that there is a sense of malaise when it comes to pursing breakthrough proposals. Why is this encouraged by funding agencies, by awarding funding for such proposals?

Exclusion
The current criteria and characteristics of successful grant candidates reveals a
system which tends to fund a traditional group of researchers. A study in the Annals of Epidemiology states that the NIH budget has not kept up with inflation in the past three years, even though it has doubled its budget from 1998 to 2003 to 27 billion dollars (Bonetta, 2006). Researchers are still finding it difficult to obtain grants for their work. The NIH criteria includes meeting standards of significance, approach, innovation, investigators, and environment (http://grants.nih.gov/grants/guide/notice-files/NOT-OD-05-002.html). These standards seem to encourage novel ideas and responsible research; however, a closer look at the allocation of grants reveals a striking pattern.

A 2005 study in the American Journal of Medicine found that R01 grants were
disproportionately allocated to universities ranked in the top ten by US News and World Report, most often with principal investigators who were full professors. Competing renewal applications for previously funded studies were also more often funded then new proposals. According to Druss of the American Journal of Medicine, the problem which arises from this concentration of funding is a limited scope of education and expertise which decreases the social benefits of the research undertaken (2005). There are underlying roots and consequences to this selection process.

In many situations confidence is key. Albert Bandura’s theory of self efficacy corresponds to a person’s sense of ability to effectively deal with the environment. This tends to effect the motivation and behavior of individuals (Boyd, 2005). Therefore, it can be easy to see why there might be a stigma in the grant allocation process. Researchers who aren’t in top tier institutions or full professors, may develop an attitude which lessens their confidence, causing them to believe their proposals aren’t important or fundable. In contrast to this phenomenon, professors from more prestigious universities might find more value in their own work which might be mediocre, due to their higher sense of self efficacy. How does this affect those people who make funding decisions? The answer is that self efficacy can create a bias. Decision makers might feel more confident in choosing historically prestigious candidates because it increases their own sense of self efficacy. The end result is a similar population of researchers with similar ideas. This does not question that there are great minds at these top institutions, only that there is an increase in the chance of redundancy where great minds think alike.

Redundancy
Repetition is too acceptable in research. Grants are allocated to researchers for studies that are often too alike, and provide no real useful insight. Skepticism, or a desire to extend the findings of previous research often fuels this redundancy (Mullen, 2006). The grant review process is often an arduous task, and committee members may not have the time to pick out unoriginal works, or the exposure to the thousands of other works which might bring this type of situation to light. In some cases reviewers might be experts in the field who are accustomed to certain methods of research, and are therefore less receptive to novel theories.
It is also noted in the Journal of Medical Ethics that journals are not doing enough
to criticize and exempt unoriginal repetitive works (Barnes, 2003). The consequence of this issue is a terrible waste of funds. Grants average in the hundreds of thousands of dollars. This is a travesty when unoriginal studies have no real impact, or return on investment. There is such a lack of funding that too often important research interventions are lost over time because there isn’t an adequate budget to implement the project. Clearly there would be a benefit in being more selective in allocating funds for research proposals. Certainly the funds left over from choosing only high impact novel proposals, could be used to actually push those proposals into real life interventions. There is also something to be said about grants that are specified for underprivileged or underrepresented populations. The example in the beginning of this criticism about television and physical activity conveys the idea that we should use common sense in this area. Underprivileged people are not a different species. In some cases, cultural differences may require different methods of intervention, but in others we can use existing knowledge to deal with the issues at hand. Conditioned behavior may be a reason for this repetition.

B.F. Skinner’s model of operant behavior states that behavior which is reinforced will often reoccur (Boyd, 2005). This is truly the core of redundancy. The current system rewards unoriginal work through grants, publications, prestige, and tenure. There must be a new paradigm where quality is truly celebrated over quantity. Reinforcing this ideal will hopefully change the behavior of researchers, and this reinforcement can start with a more selective grant allocation process.

Conclusion
Public health goals are focused on improving the overall health of society. In a sense society must believe in public health practitioners in order to reap the benefits of health programs and recommendations. Trust is important. However, many people might picture public health professionals as a group of academics sitting around a table, out of touch with the true public’s needs and concerns. The current grant system of funding unoriginal research only solidifies the perception of the out of touch academic elitist. Research forms the support structure of intervention. Novel high impact research creates the best foundation for action. Funding agencies should support quality, and utilize grants for real world problem solving, thus supporting the fact that academic curiosity can exist in the real world.

References
American Public Health Association. “Watching Television May Drain Time That Could
Be Spent Exercising.” Retrieved November 5, 2006 from http://www.apha.org/news/press/ajph_current.htm.

Barnes, D., and V. Yank. 2003. “Concensus and Contention Regarding Redundant
Publications in Clinical Research: Cross-Sectional Survey of Editors and
Authors.” Journal of Medical Ethics 29: 109-114.

Bonetta, L. 2006. “Growing Pains for NIH Grant Review.” Cell 125 (5) 823-825.

Boyd, M. A. 2005. Psychiatric Nursing Contemporary Practice Philadelphia PA,
Lippincott Williams & Wilkins.

Druss, B.G. “Tracking Publication Outcomes of National Institutes of Health Grants.”
The American Journal of Medicine 118 (6): 658-663.

Fox, R.D. 1983. “The Pressure to Publish: A Graduate Student’s Personal Plea.”
Teaching of Psychology 10: 177-178 Retrieved November 2, 2006
www.dennisfox.net/papers/pressure-plea.html.

Mullen, P.D. and G. Ramirez. 2006. “The Promise and Pitfalls of Systematic Reviews.” Annual Review of Public Health 27: 81-102.

“NIH Announces Updated Criteria for Evaluating Research Grant Applications.”
Retrieved November 5, 2006 from http://grants.nih.gov/grants/guide/notice-files/NOT-OD-05-002.html.

Abstinence is best? How this country’s ignorance to basic social science principles is ultimately endangering sexual health of youth - Melanie Steeves

2006-12-17T08:57:00.000-08:00

Swedish teens are having sex. French and English teens are having sex. Canadian teens are having sex and not so far away… American teens are having sex! This is something we know and something we study, but not something, it would seem, that we, as a nation, are willing to accept. Instead of having open and honest discussions with the adolescents in the country around sex and reproductive care, as most other nations do, the policy in the United States has increasingly been to preach abstinence and pretend the phenomena does not exist. In fact, while there are 3 federal programs dedicated to funding abstinence-only education, there is not one program funded federally that promotes comprehensive sex education policies. (Dailard, 2002)
In terms of statistics, the United States performs poorly on all measures of adolescent sexual health when compared to other developed countries around the world. Teens are disproportionately affected by sexually transmitted infections (STIs). While adolescents aged 15-24 account for 25% of the sexually active population in the United States, nearly half of new STIs occur among this same age group. Teen pregnancy and abortion rates in this country are far higher than those in other nations as well. (Alan Guttmacher Institute fact sheet, http://www.guttmacher.org/pubs/fb_ATSRH.html).

Research has shown that teens are having sex regardless of the type of sex education they receive and that they greatly benefit from having the necessary information to negotiate a healthy and safe sexual relationship. (Kirby, 2001) This essay accepts and supports that view, and moreover, intends to review specific social science principles to illustrate why an abstinence-only approach, when combined with adolescence, may be a recipe for disaster.

Rebellion and establishing a sense of self

Adolescence is a period of physical and mental growth. It is a time when teenagers must navigate their way through the mastery of many developmental tasks. According to the Psychological Basis of Psychiatry, these tasks include establishing a defined sense of self, developing peer groups, cultivating autonomy and separation from family, and preparing for intimate relationships. (Thambirajah, 2005) In fact, Erik Erikson’s theory of psychosocial development postulates that the central goal of adolescence is to establish a defined ego identity. (Thambirajah, 2005) Rebellion is a natural part of this development. Teens push against authority and their parents as a way of establishing their autonomy and their own sense of self. Smoking, ignoring curfews and parental rules, and acting out in school are all ways that teenagers assert their independence.

By teaching abstinence-only sex education and discouraging adolescents from having sex, we may be creating an area where teens can rebel against authority and assert their independence. Adolescents may come to see sex as a forbidden fruit and therefore be more likely to engage in sex acts. If instead, we had frank conversations about sex, they may be less likely to see out sex as a form of rebellion. If sex were normalized in the home and in schools, teens would have no means to push against authority in this area. Instead, they would be able to partake in intimate relationship when they were ready, with the tools and self-efficacy needed to engage in a healthy sexual interaction.

Creating cognitive dissonance

Cognitive dissonance is simply defined as the inner tension one feels when one holds two conflicting viewpoints, or when one’s behavior does not match one’s inner morals or beliefs. The theory suggests that an individual will alter their beliefs or behavior to relieve this inner tension, sometimes by irrational means. (Thambirarajah, 2005)

As an example, in a Florida study concerning the impacts of cognitive dissonance, adolescents were put into two groups and read preventative, public health messages that either totally opposed consuming an alcohol-like substance or recommended using moderation in consumption. Half of the subjects then tried the product while the other half performed a random task. The two messages had the same effect amongst the teens who had not tried the product. Interestingly though, participants receiving the abstinence message who also tried the product expressed stronger intentions to use the product than did those who had received the message urging moderation, perhaps to alleviate some of their feelings of inner tension over the conflicting message and their subsequent behavior. (Albarracin, 2003)

Keeping this study in mind, students involved in abstinence-only sex education classes who already have sex may forgo barrier methods such as condoms, to help relieve the cognitive dissonance they feel. That is, because they have been taught they should not have sex, they may deny to themselves that what they are engaging in is a sexual act and they may believe that they, therefore, do not need protection. Comprehensive sex education, on the other hand, acknowledges that teens may be having sex and aims to provide the tools necessary to engage in healthy and safe sexual relationships thus alleviating any threat for cognitive dissonance.

Influence of peer groups

Adolescence is a time when young people are forming their self-concepts largely through their peer groups and experiences. They tend to define themselves in relation to the company they keep, their clique, gang, sports team, etc. Peers operate as guides through an individual’s social world; peers provide the information, rules, and emotional support teens need to separate from their families and move toward independence. (Thambirajah, 2005) As we continue to push abstinence on teens we must realize that we may be alienating many groups of teens and hence, countless numbers of the teenagers we are trying to protect.
As we increase the number of programs geared towards abstinence-only sex education, we need to understand that this message essentially excludes a huge number of adolescents and peer groups. Most teenagers will have sex before they leave high school, an estimated 7 in 10 teens to be exact. (Guttmacher, 2006) Those adolescents who have already had sex will not see how an abstinence-only message applies to them. Additionally, those teens who have not had sex, but who belong to a peer group where sexual experience is normalized will most likely tune out the teachings. Also, the gay and lesbian community may not identify with the wait-until-marriage message, as they are not permitted to marry in nearly all states, and therefore believe that the idea to abstain does not apply to them.

By teaching such a black and white form of sexuality education we are alienating an estimated 70% adolescents. The message of abstinence-only sex education competes with the standards and expectations of many peer groups. In disregarding the influence that peer groups have on adolescents, we are ignoring a huge segment of the teen population and thusly not providing them with the appropriate information about their sexual health. Perhaps if we geared our safe sex messages around the standards and goals of peer groups we would have an easier time reaching out to all adolescents. By engaging student groups in their health rather than dictating appropriate forms of behavior, we could better involve all teens in their reproductive well being.

Conclusion

We know from international research that abstinence-only education may not be the best way to equip the adolescents of this country with the tools they need to protect themselves and negotiate intimate relationships. Rarely, however, do we consider why this approach may not succeed in terms of social science theories and principles. This paper was intended to illustrate how and why our reliance on abstinence has failed to improve the reproductive health of out nation’s adolescent population. The author used basic psychological principles-- cognitive dissonance, adolescents’ reliance on peer groups and adolescent development of self concept-- to highlight the potential shortcomings of our current approach and to suggest methods we could employ to work more effectively with adolescents regarding their sexual health.

References

Dailard C, Abstinence promotion and teen family planning: the misguided drive for equal funding, The Guttmacher Report on Public Policy, 2002, 5(1):1-3.

Guttmacher. Facts on American teens’ sexual and reproductive health. Alan Guttmacher Institute Website, 2006. Retrieved 11/6/06. http://www.guttmacher.org/pubs/fb_ATSRH.html

Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.

Thambirajah MS. Psychological Basis of Psychiatry. Elsevier Limited. 2005, 222-224, 305-311.

Albarracin D, Cohen JB, Kumkale GT. When communications collide with recipients’ actions: effects of post-message behavior on intentions to follow the message recommendations. Personality & Social Psychology Bulletin, 2003, 29(7):834-45.

Too Posh to Push? A Critique of the Role of Public Health in the Increasing Cesarean Section Rate- Cynthia Johnson

2006-12-17T08:41:00.000-08:00

The cesarean section (C-section) rate in the US rose to an all-time high of 29.1% in 2004. This represents a dramatic increase from 4-6% in the 1930’s that tripled to 15.2% between 1968 and 1978. In 1981 a National Institutes of Health commissioned report brought the concern about the rising rate to the public and strongly supported vaginal birth after cesarean (VBAC). Ten years later, in 1991, the Healthy People 2000 initiative advocated for a cesarean rate of 15%. (1) A small percentage of the current cesareans are due to demand C-sections, but the health policies regarding demand C-sections have undoubtedly contributed to the increasing rate. I will define demand C-section and the scope of its impact on the C-section rate. I will make three arguments to support my thesis that the approach to demand C-sections has unwittingly reinforced the high C-section rate. The first argument is that, based on framing theory, public health has framed demand C-sections such that benefits are exaggerated and costs are minimized. The second argument, based on the dissonance theory, is that physicians and patients, at an individual level, have been complicit in the crisis of the rising C-section rate. The third argument, based on the theory of reasoned action, is that public health has been unable to present a clear message for society. Finally I will propose strategies for reframing the issue of demand C-sections.

There are many types and definitions of C-sections. A primary, or first C-section is done for a medical indication such as serious bleeding. A demand C-section is done for a first time mother with no medical indication. An elective repeat C-section is done for a patient who declines a vaginal birth after cesarean (VBAC). If there is a medical indication for repeat C-section then it is simply called a repeat C-section. The primary C-section rate clearly can drive up the repeat C-section rate since many women are not candidates for, or decline, a VBAC.

A demand C-section is also called cesarean delivery on maternal request. The National Institutes of Health (NIH) convened a conference in March 2006 to look at the issue of Cesarean Delivery on Maternal Request. The conference conclusions highlighted the medical complications of C-sections and determined that the decision to have maternal request C-sections should be individualized. Another conclusion was that the magnitude of the problem could not be determined. (2) In fact, there are some data to show the magnitude of the problem. Dr Declercq from the BU School of Public Health is one of the researchers involved in a national survey of women’s birth experiences called “Listening to Mothers.” This 2005 study of 1573 participants showed one in 252 women had requested their first C-section with no medical indication. (3)

Framing theory suggests that a behavior is determined by the way that behavior is framed by society. This supports my first argument that benefits of demand C-sections are exaggerated and costs are minimized. How the issue of elective C-section is framed becomes a public health problem because there are diametrically opposed perspectives regarding the benefits and risks of C-sections. I present two opposing views of C-sections. It is confusing for women to decide which authority to believe, and furthermore, there are clear risks that are not publicized as broadly.

Some articles emphasize the potential benefit of C-sections. In the American College of Obstetrics and Gynecology Clinical Review of March-April 2005 the editors list the maternal and fetal risks of both C-sections and vaginal deliveries. They write, “Vaginal birth may be nature’s way, but nature’s way has always been hazardous and still is in nations where cesarean delivery is not a readily available option.” Furthermore, they point out that there is no evidence to show that C-section is detrimental. There are studies that conclude elective C-section is safe and psychologically well tolerated with comparable results to an uncomplicated vaginal delivery. (4)

Other articles present C-sections from a critical point of view. The November 16, 2005 Boston Globe article describing the record high number of cesarean sections highlighted the quote “Many (women)…have to submit to major surgery in order to get medical care.” In a world where independence and taking charge are considered survival tactics of the fittest, submitting to major surgery is not considered a benefit. Many women use the book Our Bodies Ourselves as a guide for woman care. In a chapter about cesarean sections in the 2005-2006 edition, the statement is made that “Surgical deliveries have increased alarmingly over the past thirty years.” Should we be alarmed? In the December 15, 2005 issue of Ob.Gyn. News, a newspaper for obstetricians and gynecologists, Bruce L. Flamm, MD suggests that the all-time high C-section rate in 2004 is a “perfect storm” of medical, legal, and personal choice issues. A “perfect storm” is not what we aim for in medicine or in life.

It is difficult to study the risks of C-sections since the risk for each individual woman and her baby is small. To comprehend the risks of C-sections we need to look at world literature on large populations of women. First let’s look at the problems for the babies. In a recent ecological study, Villar et al looked at the WHO global survey on maternal and perinatal health in Latin America and found a threshold rate of C-section associated with negative outcomes. The risk of preterm delivery and neonatal death rose at C-section rates of between 10% and 20%. An increase in fetal death was associated with cesarean delivery, especially elective cesarean delivery. (5) The New York Times published an article on September 5, 2006 with the headline “Voluntary C-sections Result in More Baby Deaths,” based on an article by MacDorman, Declercq, Menacker, and Malloy from a national linked birth and infant death database. (6) Both international and national data show an increased risk of death for babies after C-section.

Now let’s look at the risk of death for the mothers. Deneux-Tharaux et al from France showed that cesarean delivery is associated with a three-fold increase in the risk of postpartum maternal death as compared with vaginal delivery. (7) US women have a 1 in 3500 chance of a pregnancy-related death. However, maternal mortality in developed countries has not significantly decreased in the last 20 years. The American College of Obstetrics and Gynecology (ACOG) News Release in August 2006 suggests that choosing vaginal delivery over demand C-section could help lower maternal mortality rates. ( 8) A study by Silver et al showed serious maternal problems with an increasing number of C-sections. Most of the problems are from the placenta growing into the uterine muscle causing significant bleeding and often leading to hysterectomy. (9)

On the one hand there are clear risks to demand C-sections. There are, on the other hand, medical journals that frame demand C-sections as safe and appealing. The power of the public health establishment represented in the major medical journals has led to a situation where the debate is framed in a manner that is deleterious to women’s health.

The dissonance theory suggests that individuals selectively attend to information that matches their position while systematically filtering out contradictory information. This theory supports my second argument that physicians and patients have been complicit in promoting the crisis of the increasing C-section rate. Both physicians and patients, based on their self-interest, screen out contradictory information. As we noted with framing, there is conflicting evidence in both the popular press and the medical literature regarding the benefits and risks of C-section.

Most physicians find it easier to schedule C-sections rather than wait for a woman to come to the hospital in spontaneous labor because it makes life more predictable and can be scheduled during the day. Whereas C-sections generally take about one hour, spontaneous labor can take hours to days. Since there is no consensus from NIH regarding the risks and advantages of demand C-section there is no limit to the number of C-sections that can be scheduled. Every physician can choose the body of literature that supports his/her view of what the C-section rate should be.

A woman can also selectively choose the information that supports her view of whether a demand C-section is appropriate for her. A paper by Lucas from Scotland, where the national rate of C-section is 30% (close to the US rate of 29%), discussed the role for repeat elective C-section in the rising rate of C-sections in Scotland. His questionnaire showed the majority of women made their decision to have a repeat C-section instead of a vaginal birth after cesarean based on non-clinical and personal issues. (10) The reasons that US women give for a maternal request C-section are also personal. It is the path of least resistance for many women and lends some control to an emotional experience over which they may feel they have very little control.

Here is a list of the personal issues that a woman could invoke to demand a C-section. Having a definite date and time for delivery is a compelling reason to schedule surgery, especially when there are other children for whom to find care. One can choose a “designer date”, such as the birthday of a family member or a special anniversary date. Scheduling a C-section is more convenient for the patient and the physician. Some patients feel it is safer to have surgery, especially if they buy into the lure of technology. After a C-section women may stay longer in the hospital where meals are provided on a regular basis. Some women are afraid of the pain of labor. Most are not thinking about the postoperative pain or they feel they can use more medication for pain after the baby is born. Some women are concerned about pelvic floor damage after a vaginal delivery and are worried about urinary or bowel problems or pain with intercourse in the future. Some women prefer to have a spinal anesthesia for surgery with a single dose of medication instead of an epidural catheter in their backs for labor. Women may know that disability claims usually cover 8 weeks of maternity leave after a cesarean and 6 weeks after a vaginal delivery so you get more covered time at home with your baby. Obstetrical practices are larger than in the past due to increased demands for hospital coverage and paperwork, so the chance of having your own doctor or midwife at the birth is less frequent. With a planned C-section you know who will deliver the baby. Any one or combination of these reasons could be enough to demand a C-section and ignore any risks associated with major surgery.

The perceived self-interest of woman to choose C-section is influenced by the framing of C-sections by society. They are getting incomplete information. Physicians also screen out the risks in the self-interest of convenience and financial gain. The end result is that women and doctors choose C-section more frequently than is warranted by an objective consideration of the risks.

The theory of reasoned action suggests that attitudes toward a behavior and perceived expectations regarding a behavior determine a person’s intention to perform that behavior. Intentions then cause the actual behavior. This theory includes both social and individual factors. Framing theory describes behavior of society and dissonance theory describes behavior of individuals. These are the roots for this third theory and for my third argument that public health has been unable to present a clear message for society. Organizations like medical groups and hospitals are biased toward C-sections because C-sections give them more control and profit. Hospitals get more money for C-section deliveries that keep their beds filled more frequently. Society has made C-sections not only accepted, but also expected and even preferred. Women perceive C-sections as safe and normal. They may not even realize that it is major abdominal surgery.

Public health has not taken a strong stance in dispelling myths about C-sections. Some professionals believe Hollywood celebrities and super models have spawned the current trend for C-section on demand. (11) There is an implicit understanding that you will look like a model after a C-section. The literature shows that women in higher socioeconomic strata find it easier to choose to have a C-section. C-section rates are higher for women who have medical insurance, who are older, more educated, and wealthier. These are factors that may be related to having more control. The women who have C-sections tend to be private and not public clinic patients. (12) Some classes of women may have access to hospitals and doctors who perform more C-sections. A study of female obstetricians in England showed that one third of them would opt for a C-section for their first delivery if given the choice. In Latin America too, it has been noted that the rates of elective C-section in private hospitals reflect a complex social process. Victora and Barros report that women from poor families in Brazil were inspired by trends in the rich families and subsequently demanded C-sections. (13) Brazil now has the second highest C-section rate in the world.

Public health policy has at times attempted to determine the ideal C-section rate and imposed guidelines to reach or maintain those goals. One of the methods in the past was to require obstetricians to have a second opinion from another obstetrician before doing a C-section. That policy no longer exists. Insurance companies in the past would not pay for a repeat cesarean until a woman had attempted a vaginal birth after cesarean (VBAC). Large studies then showed the risk of a VBAC delivery and now some insurance companies will not cover a VBAC. It is pointed out in an article by Cyr, titled “Myth of the ideal cesarean section rate: Commentary and historic perspective”, that the US lags behind other developed countries in every measure of health care quality. (1) Better perinatal outcomes are achieved with lower cesarean rates and less spending on health care in Europe. So public health in the US not only has no recommendation for C-section rate, but also gets poor grades on the world health report card in this regard.

Is the C-section rate spiraling up because of a backlash to policies in the past? Is it because people, and women in particular, want to have a modicum of control over the complexity of life in the US? Is it because some in the generation of women in the childbearing age are used to getting what they want and/or are fearful of the pain of childbirth? Is it because medical groups and hospitals are getting financial rewards?

How can we get the message of the risks of surgery out to women and reframe the issue of demand C-section? According to Aiken consumers will devalue the credibility of sources of health recommendation that are at variance with their own practice. (14) What source would women trust to get more information regarding demand C-sections?

The diffusion theory might help with the task of reframing demand C-section. It focuses on social networks, opinion leaders, and change agents. I suggest six strategies that fit this model.

One strategy is to assemble opinion leaders to look at the issue of demand C-section. Although that is what NIH did in 2006, they seem to have raised more questions than arriving at a consensus regarding solutions. An editorial from Ireland recommended that the NIH consensus conference be reconvened because “American obstetricians overreacted to publications that were alarmist and limited.” (15)

A second strategy is to publish a strong editorial about the risks of demand C-section. There are several examples of dramatic trends noted in response to an editorial in a prominent journal. For example, the VBAC rate dropped precipitously after articles about uterine rupture and an editorial were published in the New England Journal of Medicine in 2001. A similar trend was noted in the number of articles about counting fetal kicks to evaluate fetal health after an editorial in The Lancet in 1987. I think we need a high profile champion to write an editorial about the risks of C-section to the mother and the baby. The importance of MD attitude in making decisions has been studied in other areas and cannot be overemphasized for the decision about delivery mode.

A third strategy is to collect timely data. We need US data similar to the WHO global data from Latin America to determine the risk of C-section in the US. We need to have population studies that fairly compare the risks and benefits of demand C-sections and C-sections with medical indications. The studies should look at which classes of women are getting C-sections. It is beyond the scope of this paper, but the change model used in international health and in corporate circles could be used to bring the data and ideas into mainstream thought and practice.

A fourth strategy is to use the media. Presenting the issue of demand C-section on Oprah or 20/20 or a show like Grey’s Anatomy, House, or ER could be an additional way to get the message out into the realm of public awareness.

Some opinion leaders have suggested a fifth strategy. They suggest that we should let the C-section rate float and self adjust. I am skeptical about a system that is the path of least resistance for both physicians and patients. For all of the reasons that I have pointed out in this paper, there is reason to believe the C-section rate would keep increasing. It is difficult to take away a covered benefit and people react to a forced specific C-section rate because it means cost control to them. Women do not want to hear about the risks that are meaningless to one individual.

My sixth and final strategy relates to delivery support. Throughout history it has been midwives who delivered babies and made birth a woman-centered event. They were well known in their communities and respected for their medical knowledge and skills. Birth became “medicalized” as the numbers of physicians increased and the field of Obstetrics and Gynecology came into its own as it evolved out of the surgical field and focused on women. There is no question that giving birth is safer in hospitals, but midwives are well suited for doing normal deliveries. Since one of the reasons for demanding a C-section is to have your own doctor at the delivery, there might be a place for certified nurse midwives to do more than the 9-11% of deliveries in the US that they do today. Women want to have emotional support in labor. Obstetricians by training do not spend as much time with women as women might like and need. Obstetricians would be involved for high risk pregnancies and to do C-sections for patients who cannot have a vaginal delivery, but midwives could give women the emotional support they need at an important time in their lives, just as they have throughout history. Reversing the trend toward more C-sections would decrease the risk of women dying from the complications of placental problems that are inevitable after multiple C-sections.

Society and individuals have the same goal of healthy mothers and healthy babies. Public health has contributed to the highest C-section rate in US history by, first, exaggerating benefits and minimizing cost with a lack of clear framing; second, presenting conflicting information to individuals; and, third, making C-sections seem a reasonable option for delivery in our society. Demand C-sections are a relatively small percentage of the C-sections done, but the philosophy of surgery with no medical indication pervades the mindset for both society and individuals. The costs are minimized and the benefits are exaggerated. Women and their babies are experiencing unnecessary risk.

Cyr R. Myth of the ideal cesarean section rate: Commentary and historic perspective. American Journal of Obstetrics and Gynecology 2006 June;194(4):932-936.

National Institutes of Health State-of-the-Science Conference Statement. Obstetrics and Gynecology, 2006 June;107(6):1386-1397.

Declercq E, Sakala C, Corry M, Applebaum S. Listening to Mothers II Executive Summary. October 2006.

Schindl M, Birner P, Reingrabner M, Joura E, Husslein P, Langer M. Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience. Acta Obstet Gynecol Scand, 2003 Sep;82(9):834-40.

Villar J, Valladares E, Wojdyla D, Carroli G, Velazco A, Shah A, Campodonico L, Bataglia V, Faundes A, Langer A, Narvaez A, Donner A, Romero M, Reynoso S, Dimonia de Padua K, Giordano D, Kublickas M, Acosta A. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. The Lancet 2006 June;367:1819-1829.

MacDorman M, Declercq E, Menacker F, Malloy M. Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” United States, 1998-2001 Birth Cohorts. Birth 2006;33(3)175-182.

Deneux-Tharaux C, Carmona E, Bouvier-Colle M, Breart G. Postpartum Maternal Mortality and Cesarean Delivery. Obstetrics and Gynecology 2006;108:541-548.

ACOG News Release http://www.acog.org/from_home/publications/press_releases/nr08-31-06-2.cfm.

Silver R, Landon M, Rouse D, Leveno K, Spong G, Thom E, Moawad A, Caritis S, Harper M, Wapner R, Sorokin Y, Miodovnik M, Carpenter M, Peaceman A, O’Sullivan M, Sibai B, Langer O, Thorp J, Ramin S, Mercer B. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstetrics and Gynecology 2006;107:1226-1232.

Lucas A. Information for women after CS: are they getting enough? RCM Midwives, 2004 Nov;7(11): 472-5.

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Ailen L, Jackson K, Lapin A. Mammography screening for women under 50: Women’s response to medical controversy and changing practice guidelines. Wom Health 1998;4:169-197.

Agnew G and Turner M. Letter to the Editor. Can a 29% Cesarean Delivery Rate Possibly Be Justified? Obstetrics and Gynecology 2006;108:452.

Television campaign strategies ineffective in promoting breastfeeding due to failing to employ social and behavioral science principles - Ellen Kim

2006-12-17T08:34:00.000-08:00

Babies are born to be breastfed. Although extensive scientific research and pediatricians nationwide overwhelmingly agree over the benefits of breastfeeding, only 72 % of new mothers in the United States attempt to breastfeed and only 13.9% breastfeed exclusively for 6 months without supplemental foods and liquids (Figure 1, 1). The United States Breastfeeding Committee and the United States Department of Health and Human Services Office on Women’s Health share the responsibility of addressing the disparities in breastfeeding rates. Over the past year, these two vital organizations have developed television public service announcements that address the importance of breastfeeding by suggesting that not breastfeeding your baby is reckless. To illustrate, the “Ladies Night” spot opens with a middle class African-American pregnant woman vigorously riding a mechanical bull followed by text on the screen that reads: “You wouldn’t take risks before your baby’s born.” What ensues is the sound of a fall in the form of a clump and the final set of text that reads: “Why start after.” In another television public service announcement known as the “Log rolling” spot, similar recklessness prevails when two Caucasian middle class pregnant women participate in a log rolling contest. Once again, the shock value of the commercial leaves any audience speechless, for who would ever imagine any mother riding a mechanical bull, or much less participate in a log rolling event? Following both public service announcements is the tag line on the screen: “Babies are born to be breastfed.”
In an industrialized world where roughly 60% of the women form part of the working population (2), the practice of breastfeeding is invariably more complicated than what is portrayed in recent television ads. The campaign strategy of national breastfeeding awareness ads maybe ineffective because it conveys a guilt-ridden rhetorical message, sends misinformation, and fails to promote the importance of breastfeeding.
In the media there are effective and ineffective ways to employ fear. Media persuasion can facilitate in changing attitudes. However, inducing too much fear interferes with the information processing (3). In consequence, the audience ignores the relayed message (4). The inappropriate utilization of fear appeals may impede the importance of breastfeeding message delivered to the audience. In an event in which the fear seems highly unlikely, it deters the audience from processing the public health message and to focus more on the derisive ad and the hazardous scenario that evolves before their eyes. To a certain degree, using an unrealistic example of a pregnant woman riding a mechanical bull or log rolling to describe the dangers of not breastfeeding, produces an almost fatuous feeling to the issue at hand. Breastfeeding your child is a serious issue and one that should be addressed in the same fashion. Furthermore, research suggests that depicting the severity of health consequences fails to impact an individual’s intention to change the recommended behavior (5).

Studies have shown that the more similar the source (communicator) is to the audience (recipients) in terms of age, gender, and ethnic background, the greater the delivery of the message (4). Data from the 2005 National Immunization Survey regarding Breastfeeding Practices further reveals that non-Hispanic black or African American and socio-economically disadvantaged groups have the lowest breastfeeding rates (1). The television campaign appropriately used a non-Hispanic black woman in one of their ads, but in the other ad used two Caucasian women. Next, they used middle class women when data suggests it is the socio-economically disadvantaged groups who have the lowest breastfeeding rates. In order for public health officials to reach this target audience, they need to present actors who portray the target audience. In the development of public health messages, officials need to be aware that emphasizing the similarities between the communicator and audience increases the effectiveness and acceptance of the message (6).

Research also suggests that individuals are likely to resist the information if they are called to learn something that contradicts what they already know. Atherton asserts that cognitive dissonance occurs when “discomfort [is] felt at a discrepancy between what you already know or believe, and new information or interpretation” (7). The television ad uses an inappropriate and inapplicable analogy by equating a fictionally dangerous activity with failing to breastfeed an infant. The false implication relayed is that feeding an infant formula is as dangerous as bull riding or logrolling. Feeding misinformation is counterproductive in relaying the message to the audience; consequently, the audience is unlikely to accept the message and change their behavior. Instead, the campaigns should align with the American Academy of Pediatrics recommendation that the media should portray breastfeeding as positive and normative (8).

Maslow’s Hierarchy of Needs theory states that the basic physiological needs of an individual must be met before he or she self actualizes the need to attain one’s highest potential (4). The needs that need to be met include physiological, belongingness and love, safety, and esteem needs. When these needs are met, then the individual is ready to motivate him/herself to grow and find self-fulfillment (9). However, the underlying message from these television campaigns is that women who do not breastfeed are going against nature and what is deemed as healthy in the community. Guilt-ridden campaigns are counterproductive in making women feel accepted and possess self-esteem; in so doing, these ads may cause women to live unconstructive lives and engage in unhealthy behaviors. Guilt may sometimes serve as a catalyst to become proactive but, on the other hand, it can also lend itself to motivate the wrong action. Any manipulation of inducing feelings of guilt runs counter to the value of noninterference or liberty (10). Additionally, women need to develop high self-esteem so that they make positive health decisions. Research confirms that “individuals with high self-esteem exhibit well-integrated behavior…such individuals are assumed to make optimal use of the information given them concerning health matters, and to perceive the consequences of certain actions for their health” (11).

According to Chin and Benne, there are three basic strategies for effecting change and they include the rational-empirical, normative re-educative and power-coercive strategy (12). The television ad campaign used the normative re-educative approach to employ tools such as the fear tactic and guilt ridden messages. It is essential to provide all women basic information about the importance of breastfeeding, along with the power to make informed choices. In certain situations the normative re-educative approach is appropriate, but not in a situation where women are left with low self-esteem, guilt and fear.

Women who choose not to breastfeed and those, who cannot, for a variety of reasons, are left feeling ridiculed. Although research has suggested breastfeeding is superior to infant formula, there are also studies that reveal contraindications to breastfeeding, which include: medical disorders, viruses, and medications that a pregnant woman may currently be using (13). Women who are unable to breastfeed, due to economic reasons or other deficiencies, should not be left feeling ashamed or inadequate. Those feelings of inadequacy will not translate to accepting the recommendation that breastfeeding is best for their baby. These ads do not address the major barriers among poor women. Not many women are fortunate enough to afford the 12 weeks of unpaid vacation mandated by the Family and Medical Leave Act. It is imperative that the economic, social and cultural needs of a pregnant woman are met as well as ensuring that the proper avenues of support and involvement from society and health care professionals are made available to achieve an increase in breastfeeding rates in the US (8).

The success of any public health campaign depends on examining the broader picture. Television campaigns can effectively promote breastfeeding by incorporating the epidemiology of breastfeeding armored with the understanding of the cultural, medical, economic and emotional needs of mothers, and approaching interventions using social and behavioral sciences. Conversely, utilizing the fear tactic and conveying guilt-ridden messages are ineffective in meeting women’s self esteem; thereby, the ad fails to promote the importance of breastfeeding among the target audience. In general, breastfeeding is necessary for optimal infant and child health, growth and development, but cannot be achieved without the continued societal and government support, education, collaboration and positive enthusiasm from the environment (8).

References

http://www.cdc.gov/breastfeeding/data/NIS_data/data_2005.htm

U.S. Department of Labor: Women’s Bureau, Statistics and Data 2005. http://www.dol.gov/wb/stats/main.htm

Soames R.F., (1988). Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health. 78(2): 163-167.

Thambirajah, M. S. (2005). Psychological Basis of Psychology, 122-227

De Hoog, N., Stroebe, W., De Wit, J.B.F (2005). The impact of fear appeals on processing and acceptance of action recommendations. Society for Personality and Social Psychology. Vol. 31(1): 24-33.

Feldman, R.H. (1994). The influence of communicator characteristics on the nutrition attitudes and behavior of high school students. Journal of School Health Apr: 54(4):149-151

Atherton, J. S. (2005). Learning and Teaching: Cognitive Dissonance and learning. Retrieved November 15, 2006 at http://www.learningandteaching.info/learning/dissonance.htm

American Academy of Pediatrics Policy Statement: Breastfeeding and the use of human milk. Retrieved November 15, 2006 at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496#T1

Huitt, W. (2004). Maslow’s hierarcy of needs. Educational psychology interactive. Valdosta, GA: Valdosta State University. Retrieved November 14, 2006 at, http://chiron.valdosta.edu/whuitt/col/regsys/maslow.html

Neblett, W. (1974). The ethics of guilt. The Journal of Philosophy. Vol. 71(18): 652-663.

Torres, R., Fernandez, F., Maceira, D. (1995). Self-esteem and value of health as correlates of adolescent health behavior. Adolescence. Vol. 30: 403-412. Retrieved December 5, 2006 at, http:///vnweb.hwwilsonweb.com/hww/results/results_single_ftPES.jhtml

Chin, R. Benne KD. (1976). General strategies for effective change in human systems. In Bennis W et al. (eds): The Planning of Change (3rd edition), pp. 22-45.

Chandran, L., Gelfer, P. (2006). Breastfeeding: The Essential Principles. Pediatrics in Review. Vol. 27(11): 409-417.

Public Health’s Need to Reframe Nutrition from The Teenage Perspective: Switching from An Authoritative Voice to Empowering Adolescents – Asef Karim

2006-12-17T08:14:00.000-08:00

Public Health’s authoritative counseling on nutrition

Public health practitioners generally present nutrition as a way to prevent disease. They contend that poor nutrition can cause life-threatening diseases such as hypertension, congestive heart failure, diabetes, osteoporosis, and cancer (4,7,16,17). Teenagers are told to eat healthy to avoid the long-term ramifications of poor nutritional choices. They are encouraged to act on the belief that the food they eat today will impact their distant future. Although this encouragement is well-intentioned and scientifically plausible, its tone is unappealing, if not condescending, to a teenager. It is unrealistic to expect a teenager to make a preventive health choice, the consequence of which may only be evident decades down the road, based on such authoritative counseling.

To be effective, public health needs to address nutrition from the teenage perspective and ask: In what manner does nutrition impact the immediate world of a youngster? Public health also needs to look beyond the individual teen and evaluate the broader social context within which teenage life exists in order to determine the underlying forces that direct the selection of a teenager’s individual nutritional health choices. Teens themselves should be the active public health advocates and messengers of good nutrition rather than just the passive recipients of school- or hospital-based expert nutritional intervention programs. Only with this shift in understanding, acceptance, and involvement will the public health message of “you are what you eat” be embraced by teenagers.

The public health campaign for nutrition is a list of recommendations that includes: “make healthy snacks available at home, encourage portion control, look for whole grains, fruits, vegetables, and calcium rich foods, eat a variety of ethnic foods, learn how to evaluate the nutrient density of a food item, and go to fast food web sites and evaluate nutritional contents” (2,5). Alongside this dietary ‘to-do’ list, there is a constant warning that poor nutritional choices lead to debilitating future disease states (17). Overall, public health paints an image of food and health that is boring, non-engaging, negative, and hopeless if one does not adhere to the warnings.

There are a variety of reasons why teenagers make poor nutritional choices. They learn food choices within their family setting. Children emulate their parents by imitating their behavior. Thus, parents who make unhealthy nutritional decisions pass their dietary habits and traits to their children. Parents also may not have time to make healthy snacks and lunches or be able to afford expensive fruits and vegetables for their children’s meals. Instead, parents provide teenagers with basic lunch money to buy food. As a result, teenagers have limited resources and no choice but to purchase whatever is available to eat at school. The organizational structure in schools also affects a youngster’s food choices. A recent study reveals: “If there are lengthy queues at the school lunch room, teens will opt to buy their lunch at local shops, choosing fast food outlets that have the shortest or fastest moving queues in order to eat quickly and resume other non-food activities” (18). As such, hanging out with friends or participating in other activities such as sports may take precedence to eating a meal.

Focusing on immediate versus future health risks

A necessary precondition to advocating proper nutrition to youth is to first identify the level at which teenagers relate to nutrition. Do they contemplate long-term consequences of food choices or do they make decisions based on the immediacy of their teenage reality? This concept of a decision-maker’s temporal preference in health behavior is important because it can determine the relative receptiveness of a targeted nutritional message to a teenager (3). Intertemporal models of behavior change explain that engagement in health behaviors is partly determined by time preferences (3,13). These models assume that people, especially young people, are impatient, and that an immediate health outcome is usually preferred to a delayed outcome (13,14). Because young people are rebellious, like to be independent, and tend to live for the moment, they discount future health problems and do not consider themselves at risk for chronic illnesses like heart disease, high blood pressure, or diabetes (13). Consequently, their frame of reference does not link the food they eat to their future health condition.

Encouraging good nutritional behavior as a method to prevent future chronic illness is impractical to youth because the benefits seem of little value compared to the immediate cost. Teenagers’ actions reflect the immediate day-to-day concerns of their reality: they go to school and study for exams to advance to the next grade, participate in team sports to gain bragging rights as the current champs, engage in extra-curricular clubs to form social networks, and work part-time to acquire pocket money to spend on entertainment with friends. The consequences of an adolescent’s nutritional choices need to be framed within this reality and be presented with attention to immediate “real world” effects, not distant future health risks.

An immediate problem teenagers can identify with is poor appearance. Linking food to oral disease as reflected in one’s appearance is an approach adolescents would understand. Dental disease from poor nutrition can result in bad breath, discolored teeth, holes in teeth, pain, bleeding gums, missing teeth, and the impaired ability to chew (1). The accompanying social effects may include shame, embarrassment, low self-esteem, and even social isolation (1). These immediate debilitating effects are more convincing to teenagers than is the future potential for chronic illness. Teenagers can understand and visualize how these compromised oral health conditions could impact their appearance and change their lives (6). As such, they would consider proper nutrition if they associated it with preventing these conditions.

Recognizing social norms-the need to belong and the attraction of fast food

Teenage life is complicated. Teens are confronted with adult expectations, organizational systems within schools, and peer pressure. It is important to recognize that there are many prevailing social and cultural norms that contribute to a teen’s dietary behavioral choice.

The pressure of belonging to a peer group may force a teen to make an unhealthy dietary choice. For example, if a child brings a healthy lunch to school, but his or her friends choose to go to a fast food restaurant for lunch, the child will probably neglect his homemade meal for a chance to be with friends. The importance of being accepted as a member of the peer group by contributing to the activities within that group may supersede individual nutritional desires simply to avoid the stigmatization of being the ‘outsider’ (18).

Outside of home and school, fast food institutions have made food fun, easy to buy, and cheap. The convenience of resorting to a fast food meal among friends is a comforting reward and substitute to the lack of a family sit-down dinner. Moreover, fast food is glamorized by celebrities. By endorsing certain beverages and foods, sports heroes and fashion icons convey a social message of acceptance and coolness if these products are consumed. The 1990’s Pepsi campaign featuring supermodel Cindy Crawford in a tight white t-shirt and blue jeans sipping on her Pepsi can conveys to young girls that by drinking Pepsi, they too, can belong to an elite group of ‘cool beautiful people’. The 2006 National Children’s Bureau (NCB) Report on food and drink advertising states that “children are drawn towards [food] products that are heavily branded and marketed, which tend to be of little nutritional value” (8). Media savvy and trend setting, teens readily accept and imitate the media messages of popular television and movie stars into their culture of being; they declare that they want to belong to this cultural phenomenon.

Corporate marketing techniques using celebrities have made fast food and beverages, despite their inherent unhealthy content of high fat and high sugar, extremely attractive products to adolescents (12). To counter this, the NCB Report recommends that “Government should introduce measures to stop manufacturers from using celebrities to endorse unhealthy food and drink” (8).

The same type of visceral attraction that fast food campaigns solicit to youngsters cannot be attributed to healthy food campaigns. For the most part, these campaigns, such as the “5 a day” campaign, are static and boring. The “5 a day” television Public Service Announcement (PSA) consists of an adult voice imparting the wisdom of good nutrition accompanied by the image of a young girl doing arts and crafts followed by images of “good foods” (15). This message is not dynamic and does not actually show the young girl relating to good foods. Youngsters who are rebellious, independent, and subject to peer pressure will not identify with this message. They will reject the message because it denies them autonomy and personal choice. Rather than talking about how important good food is, the PSA may be more persuasive if it simply showed a group of confident enthused youngsters eating and sharing good foods on the go. Such an image would explicitly convey that good foods are part of the peer social norm and experience. By choosing to eat such foods, teens could fulfill their internal desires of belonging to their peer group.

To further effect, the NCB Report states that, “Government and food manufacturers need to be more sophisticated in how they promote healthy food and drink to children. Techniques used to sell unhealthy food should be introduced to make healthy food fashionable and exciting-such as branding, celebrity endorsements, and [the use of] creative packaging” (8). Ultimately, a corporate savvy and creative approach is needed to show that good foods are cool and kids are ‘lovin it’.

Public health needs to understand the social reality of teenagers. The greater social context of ‘belonging’, as exemplified in the allegiance to the peer group and by the effect of celebrity marketing techniques, is important. It reveals powerful underlying forces that direct a teenager’s health choices.

Delivering an empowering positive message

Delivering the message of proper nutrition needs to come from the proper advocate. Food choice messages from health experts, nutrition counselors, and medical practitioners, though sound scientifically, may not reach the hearts of teens to effect change. Such messages, often serious in tone, critical in judgment, and which incite fear as the ultimate motivator, are ineffective.

Fear appeal messages have been used in public health campaigns to attempt behavior change (9,10,11,19). The basic premise is that a fear message makes a health threat seem so serious and likely to happen that the individual is “motivated to control the danger and consciously think about ways to remove or lessen the threat” (19). However, as Witte and Allen contend, if an individual doubts that the recommended response will work or that he or she is incapable of performing the response, he or she will focus on eliminating the fear through denial (e.g., “I can’t get high blood pressure or heart disease from eating this, it won’t happen to me”), defensive avoidance (e.g., “This is terrifying, I need to forget about it”), or reactance (e.g., “They are just trying to control me, I’m going to ignore them”) (19). Negative messages may not work because they focus on controlling inadequacies and fixing deficiencies, rather than focusing on the potential for positive growth and change.

Instead, adolescents will be more likely to accept a message if it comes from someone who appears to be in their peer group. They are more likely to relate to a contemporary and believe the messenger’s words and actions. For example, the “5 a day” PSA would be more effective if the young girl speaks about how much she enjoys fruits and vegetables or if she is shown going about her daily activities enjoying her good food. Such peer role modeling is inspirational. It motivates teens to act independently, create, and pursue like opportunities to be happy and healthy. Furthermore, teens gain a sense of ownership and are empowered to control their health. Role modeling creates an environment for self realization and change, rather than enforcing change from punishment.

The Future

To effect nutritional behavioral change amongst teenagers, public health specialists need to convey that good food is fun to eat and that it makes you feel and look good. These good food messages should come from happy, healthy young people. The public health approach to dietary recommendations should start by exploring a young teenager’s dietary pattern in the context of his or her world. Examination of the range of social and cultural influences on food and eating within family, school, and the outside environment should be considered. Social issues surrounding eating patterns such as the parental lack of time to make good lunches or dinners or the unavailability to commit to a structured family meal need to be addressed. Furthermore, the content, manner, and tone in which messages are conveyed to young people to empower them to make proper nutritional choices need to be re-evaluated.

It is simple; public health should emulate the corporate sector and invest time, money, and creative approaches to attract teenagers to ‘better’ nutrition products.

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