A social science critique on the Looking Glass foundation’s campaign to raise awareness of anorexia - Ilyana Sori

Many public health interventions are created to correct an unhealthy behavior. There are many approaches that can be used to address different reasons as to why people decide to take part in a certain behavior. In the case of one specific public health campaign that helps adolescents fight anorexia, an intervention was created with the slogan “not every suicide note looks like a suicide note”. This campaign was created by the Looking glass foundation, founded in 2002, which is “a Vancouver-based, non-profit organization, whose goal is to develop Canada's first residential centre in British Columbia for the professional treatment of adolescents with eating disorders” (1). This specific public health campaign does not mean to offend or do harm to anyone who battles with anorexia, instead these advertisements where created to raise awareness of this mental and physical illness. While I do agree that awareness is important, I believe that the foundations campaign is flawed in a few ways. First, the advertisements fail to address the fact that people behave irrationally. Second, each advertisement uses techniques from theories that are out dated, such as the Health belief model and finally, large minority groups and males are excluded from the advertisements.
These flaws are especially important to correct because it is critical that more people be able to relate to this campaign. The more people who can relate the more successful the campaign and center will be and the larger the scope of awareness will be. Additionally, the delivery of the campaign should be as powerful as the slogan “Not every suicide note looks like a suicide note”, as well as the idea that “Small signs add up to reveal that girls are suffering from eating disorders.” (2) This critique shows that by using group level models we can strengthen the awareness campaign to fight this deadly disease. The arguments that follow make clear that there are other important factors to consider when creating a public health campaign not just the individual’s behavior or the facts of why the behavior is harmful.

Failure to address irrational behavior
The series of advertisements featured in this campaign range from a poster with a diary entry from a young girl about how she felt that day, to a commercial with a young girl weighing herself in a locker room and marking down the weight she has lost. Every advertisement is dark, gray, shows the extreme side of the disease, and every young girl is alone. These initial reactions to the campaign are negative ones that do not raise awareness for the issue. By using extreme images the advertisements illicit the response of fear in may viewers, which is not a value many people appreciate. This campaign as a whole does not consider certain core values that are important to adolescent girls. Each advertisement also assumes a fundamental attribution error, and labels the girls that are associated with the disease in a negative light. These missing ideas in the campaign account for the fact that people behave irrationally.
Core values are an important factor when considering why people believe what they do, and why they engage in many behaviors. A few core values include beauty, control, youth, happiness, and strength. When a person views a commercial where these values are held high, there is a positive response for that commercial and people will want to be like those featured in the commercial. Commercials that make people question their physical appearance target core values, which is another reason why campaigns like this one should also target positive core values because people with anorexia have trouble mentally dealing with the value of beauty specifically. In the commercials for this campaign none of these values are being portrayed. The extreme aspects of the disease are the only things beings portrayed. Whether this campaign is directed towards those who live with anorexia or their loved ones, positive core values will make both groups of individuals interested in learning more about the organization and getting involved.
The assumption of the fundamental attribution error is the idea that “…people are often quick to draw conclusions about the attitudes and personalities of others- even when plausible external or situational causes for behavior exist…” (8) These conclusions often lead to incorrect representations of the people who engage in a certain behavior. A lot of the stigma that is associated with anorexia is partly because the general public believes that people choose to starve themselves, but a lot of research has already been conducted that proves those stigmas are wrong (2). There is no need to continue showing images and words such as suicide that contribute to the cycle of that stigma.
Similar to the idea of core values is the idea of labeling. These commercials only portray extreme situations and not those instances where the disease is just starting. There is no indication of prevention in any of these commercials or poster advertisements. If these are the only images the public is exposed to, the early signs of the disease that many girls exhibit may not be noticed because there are no images of that stage of the illness. There is a negative portrayal in these commercials of those who have anorexia, which beings the process of labeling. Each story in the commercials shows the girls alone and exposed, images that illicit a strong emotional response from the viewers. These emotional responses may not be productive when they have already labeled girls who have anorexia the way they see these girls in the commercial. People may not see the disease in their loved ones because it may not be this extreme yet.
Use of outdated and incomplete public health methods
Each advertisement focuses on the individual, with the exception of the slogan. The health belief model and the theory of reasoned action are two ideas that are used to create these announcements. These are the most common and most used individual based models in public health. They suggest that the certain behavior a person is engaging in is planned, reasoned and then acted out. As I have previously argued, people’s actions are irrational, therefore the way these models assume people plan and reason before acting is false. This is not to say that these theories should be disregarded completely, they are a good starting point, but they also should not be the only models an intervention is based off of.
The health belief model is based on the idea that perceived severity, perceived benefits, perceived barriers (6) measure the likely hood a person will engage in a health behavior. If the perceived benefits, which are positive outcomes of the behavior, outweigh the perceived severity, which are the negative outcomes of engaging in this health behavior, and there are none or little perceived barriers, then a person will engage in a certain behavior. This is the traditional and most common way of explaining why people have negative health habits. “Over the past four decades, the Health belief model (HBM) has been one of the most widely used psychosocial approaches to explaining health-related behaviors. Initially developed in an effort to explain the widespread failure of people to participate in programmers to prevent to detect disease.” (6) If after forty years, this approach has not been very successful there is no reason to continue using it as the main model for intervention. These advertisements attempt to raise awareness that this is a dangerous disease, but of course the general public already knows that if you do not eat you will suffer health complications and eventually die. This generation is so different from past generations. Issues that were once taboo are now controversial issues that are being debated and discussed to find a resolution, which is another indication that changing times need new and improved models that take into consideration the development of a changing society.
Another theory that presents itself in this campaign is the theory of reasoned action. This theory “…is based on the proposition that an individual’s behavior is determined by the individual’s behavioral intention (BI) to perform that behavior, which provides the most accurate prediction of behavior (Fishbein and Ajzen, 1975). Behavioral intention is a function of two factors: one’s Attitude toward the behavior (A) and Subjective Norm (SN)”. (10) Attitude is generally defined as the positive or negative feelings towards a behavior, while subjective norm is the perceived attitudes other people have of you if you engage in a certain behavior. These two factors of the model are important especially for these commercials because this is a representation of young girls with the disease from the perspective of an organization, which may or may not have expert advice, but as a whole these representations may not be accurate and resonate with everyone who has anorexia. When someone with anorexia views this commercial they may be reluctant to look for help or talk about their problem because it may not be as extreme as the cases shown in these advertisements. If both attitude and subjective norms are positive then the person will consider stopping the unhealthy behavior. The negative images these commercials portray may have an adverse affect for those who have anorexia. They may believe that the general public only sees them as disfigured and dangerously skinny. It is important to label someone that is already sensitive about labels in a positive light, not in a negative one that these girls are portrayed as in these commercials and poster advertisements.
Exclusion of males and minority groups
In this particular intervention the advertisements do their best to portray the way an adolescent teen girl with anorexia would look and act. Throughout the series of advertisements there is no representation of males or a member of a minority group with anorexia. Along with acting irrationally people respond to those that are more similar to them, or situations they can relate to as stated in the idea called principle of communication theory. If the goal of the campaign is to raise awareness that this is a deadly mental illness, why should they leave out parts of the population that are also affected? There seems to be an institutional racism, and as stated in the first argument, an additional labeling problem that should be addressed in order to make this campaign more effective.
None of the advertisements featured include men or people from minority groups, therefore it is not a complete representation of the people that are effect. This exclusion brings the assumption that members of those groups do not suffer from anorexia. Research has been done that shows that people with anorexia come from all different groups in different communities. “Anorexia nervosa,[…], has one of the highest mortality rates among psychiatric disorders” (4) which means that there should be an all inclusive campaign that raises awareness of the debilitating disease. Additionally there should be a representation of the foundations mission in the campaign that it releases to the public. It is also proven that “[…] for thousands of young women and men, the mirror has a darker side. Rather than a true reflection, theirs is a distorted reality.” (9) It is the reality of how the people with anorexia feel that should be addressed in these advertisements because people already know the adverse effects and complications of not eating.
The problems of institutional racism are subconscious but apparent when the campaign is analyzed. “The Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, illustrates how the social hierarchy that exists in society plays an important role in explaining differences in the quality of care provided to People of Color in the United States.” (3) By not acknowledging that people with anorexia can also be found in communities of color perpetuates that idea that there are different diseases that affect the white community and communities of color. This idea leads to doctors and other health professionals incorrectly diagnosing or treating children who show signs of anorexia, who are not white young girls from a middle class family. They may see the acting out the result of behavioral problems or rebellion, when that is not the case.
The “We Beat Anorexia” Campaign
In order to correct these flaws I believe there should be one commercial that goes along with these current commercials which addresses all the flaws and details that were left out previously. This commercial will feature a large group of kids who have battled with the disease and won. The adolescents will represent each racial and ethnic group, as well as a range of ages and males and females. It will take place on a field where all the adolescents will be standing behind a banner that says “We Beat Anorexia and So can you”. They will also be wearing t-shirts that have a single word on them. Each word will represent a core value that each participant finds significant for them. The song Secrets by One republic will play as the camera scans the crowd showing the words written on the shirts. This is a popular song that many people can relate to along with the ability to relate to the crowd of kids. The words featured will be words such as beauty, security, happiness, family etc. After the camera is done scanning the crowd, it will focus on one of the individuals who will say “Be a part of the crowd, stand up for your right to feel comfortable in your own skin.” Each adolescent will then turn around and show the looking glass foundation logo that is located on the back of each shirt. The shirts will also be red because it is a unisex color that stands out in a crowd and makes an impression if a large group of people are also wearing the same color. A narrator will then have a similar message of hope just like the original campaign at the end of this commercial, with the music fading out. By using the ideas behind the advertising theory, the branding model, principle of commitment, and the principle of communication theory, the flaws the previous advertisements have will be closer to being eliminated.
These models focus on the effects of group behavior and the influence groups and society have on the individual, instead of focusing on the just the individual. With these flaws eliminated it will create a stronger, more effective campaign to raise awareness and increase treatment. There are many reasons why people want to be included in a group, and there are also many reasons why pointing out specific core values are an important way to get people’s attention to raise that awareness and change attitudes.
Advertising Theory to support the cause of awareness
The idea of the advertisement theory is to sell an idea not a health behavior. When a person is told repeatedly that their behavior is not healthy, not normal, they will not respond positively towards the health initiative. When they are instead told to buy into a product or an ideal that is positive and others also agree with, it will be easier to inform the consumer what the initiative is really about. By promising the consumer an ideal, supporting it with positive images and appealing to core values, people will be more receptive and listen to the message behind the flash of the advertisement. It is important to have the right support for the large promise because it is easy to send out the wrong message. In a book called Confessions of an advertising man, the author Ogilvy “[…] argues […] that advertising set within rules can be creative, and also more effective than those without rules. The rules to build a great campaign are as follows. 1. What you say is more important than how you say it: the information you give is more important to the consumer than the way you present it. 2. Unless your campaign is built around a great idea, it will flop: in order for people to be affected by the advertising, it has to be something new original.” (11) Ogilvy’s ideas further support the idea that having advertisements that just state why the health behavior is wrong will not change the bad habits of people.
In the new intervention I proposed previously the advertising theory is used by promising viewers and those with anorexia that there is a way to get help and if they do they will be able to accept themselves physically and mentally. This promise is supported by the adolescents portrayed in a serious manner, where they are not seen in an extreme light because not everyone that has anorexia is at a dangerous weight. The students also have t-shirts that have words that are core values which further. The fact that these teens have all battled anorexia and gained their confidence and health back is another positive support for the promise that others with anorexia can get help and treatment too to continue with their lives in a positive, healthy manner. This theory is the starting point in creating an effective, positive, and powerful campaign to raise awareness of the seriousness of the disease.
In addition to the promise being supported by the group, use of a popular song is also included in this advertisement. Recently One Republic was feature on the Top 40 list of popular music. This association with popular culture also creates a sense of familiarity. It is a catchy song that ties in the message of the campaign and the aesthetically pleasing image of the commercial. Instead of the gloomy, dark, and lonely portrayal of those with anorexia in the current advertisements of the Looking glass foundation, this commercial will have more light because it will be outside and that light will help embody the message of hope.
Core Values Exposed By Using the Branding Model
The second model that is featured in this new intervention campaign is called the Branding Model. In this theory the campaign and advertisements are used to create a set of associations people remember when they think of a specific campaign. “Public health brands have traditionally focused on increasing target audiences’ awareness of various health issues (agenda setting) and increasing awareness and encouraging adoption of preventive behaviours to reduce disease and injury. Following lessons from commercial marketing, public health campaigns can be even more successful by developing brand positionings that go beyond being simply informative, and begin to establish relationships with their target audiences. ” (13) There are many examples of this branding method in anti-smoking campaigns. The association could be a group, a t-shirt, a button, a slogan, or a word. People are usually interested in participating in something that is well known and respected. Core values are also involved in this theory. If the association is coupled with core values it makes the message even stronger. The goal for the branding model is to create something that people will feel they are a part of.
The “Be a part of the crowd” campaign is a brand that advertises awareness and the looking glass foundation itself. The general public will be able to associate this campaign with the slogan and the t-shirts that have the core values written on them. If people with anorexia receive treatment at the clinic they will also be able to receive one of the t-shirts. Being a part of the crowd creates a sense of belonging that patients with anorexia may struggle with. The slogan in itself includes words that hold as core values for many people. People will often associate the word “Right” with the idea of freedom, which is a very strong core value because without freedom there is no control. The positive portrayal of this side of the initiative to bring awareness to the general public will resonate more with people to want to change and create change more than just the harsh images in the original campaign and advertisements.
The general public will in turn associate the initiative towards awareness and treatment for anorexia with the core values depicted in this advertisement. Extreme images will no longer be needed to stress the fact that this is a one of the most deadly mental illnesses that adolescents face today. The brand that will now be associated with treating adolescents with anorexia will be a positive group initiative that stresses the importance of intervention and understanding of the causes and development of this mental illness. Branding this campaign will also take away some of the negative and misinformed stigma that is present when talking about anorexia. People will be more comfortable talking about treating the disease. When attacking the individual behavior, as many times is done when using the health belief model or other individual based models, we are missing a huge part of the social context that is involved in the development.
Two Additional Principles used to support Group behavior
To further support the idea that a group model is more effective than an individual based model is shown with the principle of commitment or the dissonance theory, as well as by the principle of communication. Both principles deal with the fundamental idea that people will act and keep an opinion if they feel that they are a part of a group. Even though there are specific aspects of each principle that distinguishes it from the other they work together to create a strong argument for group models. When used along with other models and theories, such as the advertising theory, the intervention is able to change the ideas of the general public without explicitly telling them to change. This advertisement does not lecture the general public to be aware of the seriousness of the disease; it is an advertisement that creates an association with the initiative, which in turn creates awareness in a positive light.
The idea behind the principle of commitment or dissonance is based on “one of the most fundamental states of conflict in human behavior which can be heightened by decision making is that between the need for openness and flexibility, on the one hand, and structure and consistency on the other. […] as one becomes personally involved in an issue or sees a direct relationship between his self concept and an object or person, the exact nature of this compromise may change. He may wish to interpret such objects, issues, and events in a manner consistent with important beliefs, especially following decisions in which psychological commitment and observable behavior combine to increase personal involvement.” (12) Simply put, if a person decides to engage in a certain behavior, and it turns out that that behavior is harmful, they will change their opinion and view of the situation to support their behavior because the idea of being wrong is more harmful to them than the behavior is.
Another point of the principle that is important to address is “to what extent does one approach a situation less than openly, guided by experience and expectations and recognizing, identifying and evaluating stimuli according to what one “knows” is there?” (12) People are less likely to enter a situation with an open mind when they already have preconceived notions of a situation. They stick to what they know. Along with this principle and the idea that people agree with what they think they know and understand is the principle of communication. The idea behind this principle especially in the case of making a persuasive argument, or when the need arises for awareness, people will relate to situations, if they have a similar experience or a similarity to the person that is presenting the information. It is important to note that people will not respond simply because of the way the message is portrayed, the message must also be important and powerful in itself.
These two principles are specifically used in the “Be a part of a crowd” campaign because there are so many different people involved in the campaign. The children range from different ages and they are all from different ethnic and racial backgrounds. There are many people that are now able to associate with this campaign. Males will also now be included which will raise awareness that males also have anorexia. Once the idea that there are a range of people who have anorexia the mind of a large population in the general public will change because there is now visual evidence in a campaign that the disease affects a wide range of people from different ages. The general public will now be more willing to understand the initiative and be more aware of the campaign because the can relate to a less extreme depiction of anorexia.
Conclusion
When considering in creating a public health campaign, it is important to consider the audience the campaign is being created for, can the act be explained using a group level model in a more effective way, is the advertisement and initiative inadvertently leaving out any members of the population that are also affected, and is message being conveyed the right one, are all important aspects of the campaign to think about. Core values are also an important aspect of gaining the audience’s attention. When people are able to associate, understand and feel comfortable with an initiative there will be a larger educational gain of the problem. That is when it is possible to gain followers and change the ideas of a population.
The looking glass foundation is an initiative that means has positive intentions with the means to change the ideas of a population. It is difficult to have a campaign that is not as effective as the foundation would like it to be. The idea of awareness is already there for the intervention but the flawed aspects of the campaign do not allow it to be a strong and effective message. They do strike an emotional cord because the images portrayed are devastating and concerning. They do not, however, appeal to a positive and hopeful message. These flaws make the campaign incomplete and therefore this campaign does not succeed in its ultimate goal of greater awareness and eventually treatment for those living with anorexia.



















REFERENCES
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To Wait Or Not To Wait: A Critique Of Why Abstinence-Only Sex Education in the United States Does Not Work- Keerthi Chandrasekaran

Teenage sexual behavior has always been an issue of major concern. According to recent data from the Guttmacher Institute, nearly 46% of US teens between the ages of 15-19 have had sex at least once (1). In addition, nearly 800,000 women of the same age range become pregnant each year and of the 18.1 million cases of sexually transmitted infections (STI’s), roughly 48% of them belong to men and women between the ages of 15-24 (2). Even in comparison to other developed nations, the US leads with a teenage birth rate of 52.1 per 1,000 births, which is almost four times higher than the average teenage birth rate of the entire European Union (3). In addition, 60% of teenage girls who gave birth before age 18 drop out of high school and those who do not receive their high school diploma or GED by the age of 20 are more likely to live at the poverty level for the rest of their lives (4). These shocking statistics show that there is a need for a better public health intervention in order to reduce the instance of unsafe teenage sexual behaviors including teenage pregnancies and STI’s.
Current public health interventions are based around sex education programs in middle schools and high schools, with nearly 89% of 7th-12th graders receiving sex education at least once during their schooling (5). Sex education programs generally follow one of two paths: comprehensive education or abstinence only education (6). Comprehensive sex education programs focus on the benefits of abstinence and contraception as well as how to avoid STI’s and teen pregnancies. These types of programs are supported by national organizations such as the Society for Adolescent Medicine (7), and the American Public Health Association (8), who recognize that teens will have sex regardless of what an authoritative figure (or anyone for that matter) tells them. Therefore, these programs aim to educate teenagers on safe sex methods, while teaching them how to deal with difficult or uncomfortable situations when it comes to sex (9). On the other hand, abstinence-only programs focus solely on abstinence and exclude any other types of sexual and/ or reproductive health education such as contraceptive use including birth control or condoms. Abstinence only education teaches teenagers that abstinence is the only 100% foolproof way of preventing unwanted pregnancies and sexual transmitted infections. It also focuses on the “social, psychological, and health benefits” of abstaining from any sort of sexual behavior. Abstinence only education programs receive support from a wide variety of sources ranging from religious groups/ organizations to the US Federal Government (5).
Despite this wide range of support, abstinence only education programs fail on several levels. Abstinence works in theory, but in practice is extremely difficult for teenagers to do, especially when peer pressured by their significant other and/ or friends to have sex. In addition, abstinence only education does not provide teenagers with any sort of education for when they encounter an uncomfortable sexual situation (10). In addition, research has shown that abstinence only programs are ineffective at reducing teenage pregnancy and the incidence of STI’s. In fact, teens exposed to abstinence only education programs were just as likely to have sex and were more likely to engage in unsafe sex practice such as not using a condom, having sex at a young age, having multiple partners, etc (11).
Since these current methods are ineffective, one can look to the social and behavioral sciences as well as the field of developmental psychology in order to find a more creative and practical solution to this growing problem. Through an in-depth analysis of current abstinence only education programs, one can see how truly ineffective and unappealing such programs are to teenagers. In order to get teenagers to change their unsafe sex behaviors, new interventions need to focus on what teenagers value and use those core values to convince teens to not engage in sex at such a young age. Additionally, we need to implement the successes of current comprehensive sex education programs into abstinence only programs, so that adolescents can make well-informed decisions about their sexual behavior.
How Do Teens Perceive Risky Sexual Behaviors?
Most of the sex education programs available to teens utilize the Health Belief Model. The model works on an individual level and states that in order for a person to make a behavior related change, the individual must be able to perceive the susceptibility and severity of their negative health behavior. If the person weighs the perceived benefits of a behavior change with the perceived barriers of implementing such a change, then they can make an informed decision that will dictate the appropriate behavior (12). Although the model allows for the individual to make a completely rational and calculated decision, it fails to take into account social, cultural, and/or environmental influences (13). In addition, the model relies heavily on an individual’s “perception” of the situation, which varies dramatically from person to person.
Abstinence only education follows the Health Belief Model, since the programs assume that teens perceive their susceptibility and severity of unsafe sex consequences in the same way that adults do. In other words, abstinence only education assumes that teens believe that they are at a high risk of contracting STI’s and having unwanted pregnancies and would therefore avoid having sex at all. However research suggests the opposite; teens often underestimate the risk of unsafe behaviors, especially when it comes to sex (14). From a developmental standpoint, adolescence is characterized by a heightened sense of egocentrism. Teens often believe that they are invincible and unsusceptible to any sort of harm, which is why they engage in risky behaviors (15). In addition, abstinence only education presumes that teens will easily overcome the perceived barriers to abstaining from sex, such as not caving to peer pressure and ignoring the influence of the media in its portrayal of sex.
From this psychological standpoint, one can see that abstinence only education fails to take into account the perspective of the individual teenager. The Health Belief Model makes too any false assumptions regarding the decisions and subsequent behaviors that teens will make. Also, the model assumes a sort of “vacuum” where teens are free from societal and cultural influences. Abstinence only educational programs need to revamp the psychological approach they are based on, in order to create a more effective intervention.
Why the Lecture?
Another critique of abstinence only education is the “authoritative” voice it uses. These programs often deliver their message by lecturing adolescents on why they should abstain from sex. The programs do not offer any other options and assume that teens will follow their message through intimidation and fear of contracting STI’s or becoming pregnant. Contraceptive use is rarely mentioned and if it is, then it is usually mentioned as an ineffective method (6). Also, these lectures are often delivered by parents, teachers, leaders of a religious organization, and/ or other adult figures who may not be easily relatable to teenagers (10).
The problem with this authoritative voice is that teenagers hate being told what to do. Their rebellious nature causes them to turn against anyone who impedes their freedom. From a developmental point of view, teens are at a stage in their life when they are trying to develop their own independence and prove that they can take care of themselves (15). Since abstinence only education programs lecture teens on exactly what to do, teens look at these programs as a threat to their freedom and ability to make their own decisions. In additions, teens develop extremely close relationships with their peers who they share common interests with and who are more likely to understand their emotional state. They are less likely to listen or connect with their parents or educators who they have far less in common with (16).
In order to correct this problem, advocates of abstinence only education programs need to deliver their message in such a way to captivate a teenage audience. It would also be of use to employ a messenger that is relatable to teens, so that teenagers would be more likely to listen to the message. The last thing a teenager wants is a lecture about health risks that they barely perceive or think they are susceptible for from a person who they cannot relate to.
The Assumption of Morality
Several abstinence only education programs are supported by a wide range of religious organizations for their emphasis on purity and morality. Many religions find abstinence to be the only type of sex education that agrees with their religious beliefs, especially that of no sex before marriage. There is also a strong belief that morality alone will prevent teenagers from engaging in any type of behavior that would taint their purity (6). These beliefs have gone beyond places of worship to national organizations such as True Love Waits (http://www.lifeway.com/tlw/), which uses a written pledge (17) and the Silver Ring Thing (http://www.silverringthing.com/home.asp), which uses a silver finger ring inscribed with Biblical verses (18), to serve as a vow to remain celibate until marriage.
With no disrespect to any religious beliefs, one may argue that morals alone cannot prevent risky teenage sexual behaviors. Research shows that several of these pledges have been proven to be inefficient. Teens who commit to an abstinence pledge or oath end up delaying their first sexual initiation by a mere 3 years (9). In addition these same teens are also more likely to engage in unsafe sex practices (ex. not using a condom or using birth control) and are more likely to contract STI’s and HIV/AIDS, most likely to their lack of knowledge and education on the topic (19).
In addition, the period of adolescence is characterized by a period of continuous identity and personality development. Lawrence Kohlberg, a prominent developmental psychologist, classifies adolescence as a stage of “Conventional Reasoning,” where teenagers abide to certain moral standards; however they are the standards of others, such as their parents or family members (20). Teenagers are still struggling to develop their own personal and moral codes and may blindly take the view of their parents or family members simply to please them. In terms of abstinence pledges or receiving abstinence-only education, teens may not fully agree with the ideas being presented, but may go through such pledges to satisfy their parents or other important figures in their lives. This lack of true commitment actually makes it harder for teenagers to stay motivated and follow through with their intended promise.
From these examples, we can see that abstinence pledges may end up doing more harm than good. Therefore there is a strong need to revamp the current approach to abstinence only education in order to get teenagers motivated enough to change their negative behaviors and unsafe sex practices. Rather than using morality alone, public health interventions should perhaps take a holistic approach and use other values in tandem with morality to appeal to adolescents.

A New Approach to Sex Education
As one can see, current sex education programs that revolve around abstinence-only education are failing. In order to fix this problem, I propose a new intervention that will help adolescents realize the consequences of their risky sexual behaviors. This new intervention will utilize peer groups where teenagers can talk to each other about sex and its consequences. These groups will create a forum for discussion where teens can safely confide in their peers about the pressures of having or not having sex. Each peer group will have a peer leader who is responsible for facilitating discussions and creating a safe environment for teens to speak to each other. The peer leader should also integrate information such as how to use contraceptives and how to say no to having sex into these discussions. In addition, the peer groups can add a personal touch by bringing in “guest speakers” such as teen moms or teens who contracted STI’s to talk to teens about their experiences with unsafe sex practices.
The idea behind this new intervention is that instead of having parents or educators lecture teens on what to do, let teens decide for themselves. By laying out the facts and engaging in conversation with their peers, adolescents will learn how to make appropriate decisions regarding sex. The discussions will help them learn from each other’s success and mistakes and will also help them realize that the consequences of practicing unsafe sex have an immediate impact on them. Teenagers would be more willing to undergo this sort of sex education program since they are working with their peers who they easily relate to. In addition, peer groups will help give teenagers an identity since they have committed to the groups through their own will. Finally, peer groups will help teenagers look at the options that they have if they find themselves in an uncomfortable sexual situation.
How Do You Get Teens To Listen?
Instead of relying on the Health Belief Model, the new intervention is based around the Theory of Psychological Reactance. This theory is based on the idea that people have adverse emotional reactions when their sense of freedom is being taken away (21). This is the reasoning behind why people hate to be told exactly what to do; they want the ability to freely make their own decisions without being manipulated in any way. In order to decrease reactance and make it work in public health, we need to stop telling people what to do and restore that sense of freedom that was previously taken away. The simplest way to deflect reactance is to develop a line of communication that does not tell the audience exactly what to do. This can be accomplished by delivering the message from multiple sources and from messengers that are extremely similar to the recipient. The more the recipient of the message can relate to the messenger, the more likely they will agree with the message being presented and the less reactance they will have against the message (22).
Contrary to the Health Belief Model, the Theory of Psychological Reactance does not make any assumptions about perceived susceptibility or severity of disease. It recognizes that teenagers may succumb to peer pressure and uses that fact to its advantage. The proposed intervention uses the Theory of Psychological Reactance by changing the source of the message. Instead of relying on educators or parents, the use of peer groups and leaders relies on teens themselves to spread safe sex practices to this specific population. By diffusing the message through similar messengers, such as peer leaders, teenagers are more likely to listen to the proposed message since they relate to the messenger, thus decreasing reactance. In addition, since current approaches take away teenager’s freedom and subsequent ability to make their own decisions, the use of psychological reactance will help restore that freedom. Instead of making teens feel like their being manipulated, peer groups will allow for discussion which will help adolescents feel like they are in control of the situation. The more they feel manipulated, the less likely teens will listen to the message and the more likely they will rebel against it. However, if you offer teenagers more options, then they are less likely to feel like their personal freedoms are being threatened (15).
Stop The Lectures
The proposed intervention is unique in that it essentially turns the table on teens; instead of lecturing teens and threatening their sense of freedom, it shows them how the consequences of their unsafe sex behaviors will ultimately lead to the loss of their own freedom by removing the authoritative voice. Peer groups could bring in “guest speakers,” such as teen moms and teens who have been infected with STI’s or HIV/AIDS to share their experience with others. Teens would be able to interact with these speakers and could see first-hand what the consequences of unsafe sex are. In essence, adolescents can see how taking care of a baby or managing a chronic STI or even HIV/AIDS will impose on their freedom to live life on their own terms. This approach may work better with teenagers since it allows them to make their own decisions based on the information presented. It puts the individual teenager back in control of the situation since they are not necessarily being told what to do.
A perfect example of this type of intervention is being done by the Candies Foundation (http://www.candiesfoundation.org/us.html). The goal of this foundation is educate the public about the consequences of teenage pregnancies. Through various media campaigns and celebrity sponsors, the foundation has been successful in reaching millions of teens all across the United States. In particular their television and print ads literally focus on how the consequences of teen pregnancy take away one’s freedom to live life. One particular ad features a picture of a baby stroller underneath a slogan that reads “Not what you had in mind for your first set of wheels, huh?” (http://www.candiesfoundation.org/print.html). The ads are generally endorsed by celebrities who teenagers have deemed as “cool” such as Fergie, Usher, Hayden Panettiere, Fall Out Boy, Ciara, and Hilary Duff among others (22).
The success of the Candies Foundation is attributed to its smart advertising and use of the Theory of Psychological Reactance to show teens how their freedom is being taken away. Although this particular ad campaign uses fear, it does so in an extremely subtle way. By getting rid of the authoritative voice and showing teens the consequences of unsafe sex practices, these new interventions can teach teenagers that the decision of whether or not to practice unsafe sex is ultimately theirs. In addition, the Candies ad campaign and other similar types of ads that appeal to teenagers diffuse the voice of authority and make it possible for teenagers to make informed decisions that they will commit to.
Teens Will Listen To Each Other
Abstinence pledges and oaths often do not give teens the opportunity to talk about any questions they may have regarding sex and sexual behaviors. In addition, studies have shown that teens are more likely to talk to their peers then their parents or teachers about sex (24). Keeping this in mind, the proposed intervention employs the use of peer groups or peer leaders to carry its message. Open discussions will allow teens to freely voice their opinion and ask questions without having to worry about being reprimanded. Teens can discuss issues such as how to deal with the pressure to have sex and ways to say no to sex. This new approach may work better than previous approaches since teens are more likely to talk to each other since they are more comfortable with each other. Also this approach works in terms of the Theory of Psychological Reactance since the messenger (peer leaders) are similar to the recipients (other teenagers), thus decreasing the amount of reactance. Teens are more likely to listen to each other then they are to parents, teachers, and/ or other adults since they share common interests, values, and goals with their peers (16).
In addition, the use of peer leaders and peer groups will allow teenagers to commit to a group. In essence this is a form of branding which helps teenagers form an identity. Branding is a common marketing technique that uses a set of associations to sell a product. In public health, branding can be used positively to define a healthy behavior, thus allowing adolescents to feel like they are a part of something (25). In terms of sex education programs, peer groups will allow teenagers to commit to a cause and self-identify with a group. Since teens are so easily influenced by their peers, if they see that one of their own friends is part of a cause, they are more likely to support and take part in that same cause (16).
The Future of Abstinence-Only Education
Despite being the only foolproof way to avoid unwanted pregnancies and the contraction of STI’s and HIV/AIDS, abstinence-only education has proven to be extremely ineffective among the teenage population. Current abstinence-only education programs are modeled around the Health Belief Model which assumes that teenagers have perceived the severity as well as their own personal susceptibility to unsafe sex practices as a serious threat to their future. In addition, abstinence-only education uses an authoritative voice such as a parent, educator or other significant adults in a teen’s life, to lecture adolescents on the benefits of abstaining from sex. Lastly, several of these programs assume that teenagers will blindly take and follow through with abstinence pledges and oaths. These current methods do not take into account the teenager’s perspective on sexual behavior nor do they allow for adolescents to express their own opinions on the matter.
In order to make abstinence-only education more effective, public health campaigns need to restructure their approach. The previously outlined new intervention, improves upon the fallacy of past sex education programs by utilizing peer groups to promote its message. Instead of using the Health Belief Model, the new intervention is developed around the Theory of Psychological Reactance and Branding. Both are powerful marketing techniques that target the core values and beliefs of teenagers. These theories allow for teenagers to make their own decisions without being forced to comply with anyone else’s ideas. In addition, since adolescents are more likely to listen to each other rather than their parents or educators, both theories allow for the implementation of peer groups where teens can talk to each other about the pressures of having or not having sex. These peer groups also allow adolescents to make a commitment and become part of a group thus giving teens an identity and voice for expression.
As one can see, there are several options that are readily available to the public in order for communities to improve the effectiveness of sex education. If directors and educators of sex education programs learn to target the core values and ideas that are important to adolescents, then they will be remarkably successful in getting this specific population to change their unhealthy behaviors. Also, by employing the help of organizations like the Candies Foundation as well as the use of popular celebrities, it is possible to get teenagers to change their behavior, which at the very least entails practicing safer sex methods if not abstinence. The more effective these programs are in motivating and capturing the attention of adolescents, the more likely they will have success in making a difference in their lives.

References
1. Abma JC et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002, Vital and Health Statistics, 2004, Series 23, No. 24.
2. “Facts on American Teen’s Sexual and Reproductive Health.” Guttmacher Institute: Home Page. Jan. 2010. http://www.guttmacher.org/pubs/FB-ATSRH.html#1
3. A League Table of Teenage Births in Rich Nations. United Nations Children’s Fund, 2001. http://www.unicef-irc.org/publications/pdf/repcard3e.pdf
4. National Campaign to Prevent Teen Pregnancy Why it matters: Teen pregnancy and education. (2007). http://www.teenpregnancy.org/
5. Sex Education in the U.S.: Policy and Politics. Kaiser Family Foundation, Oct. 2002. http://www.kff.org/youthhivstds/upload/Sex-Education-in-the-U-S-Policy-and-Politics.pdf
6. Kohler, Pamela K. et al. "Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy." Journal of Adolescent Health 42 (2008): 344-51. http://www.planetwire.org/files.fcgi/7689_Ab_Only_Ed_Kohler_.pdf
7. "Society of Adolescent Health and Medicine." SAHM | Home. http://www.adolescenthealth.org/Overview/2264.htm
8. APHA: American Public Health Association. 03 Dec. 2010. http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1334
9. Harris, Mary Beth, and Jane G. Allgood. "Adolescent Pregnancy Prevention: Choosing an Effective Program That Fits." Children and Youth Services Review 31 (2009): 1314-320.
10. Santelli, J., M. Ott, M. Lyon, J. Rogers, D. Summers, and R. Schleifer. "Abstinence and Abstinence-only Education: A Review of U.S. Policies and Programs." Journal of Adolescent Health38.1 (2006): 72-81.
11. Trenholm, Christopher, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs. Publication. Mathematica Policy Research, Apr. 2007. http://www.mathematica-mpr.com/publications/PDFs/impactabstinence.
12. Rosenstock, Irwin M. "Why People Use Health Services." The Milbank Quarterly 44.3 (1965): 94-127.
13. Thomas, L. "A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education." Journal of Professional Nursing 11.4 (1995): 246-52.
14. Cohn, Lawrence D., Susan Macfarlane, Claudia Yanez, Walter K. Imai, and Et Al. "Risk-perception: Differences between Adolescents and Adults." Health Psychology 14.3 (1995): 217-22.
15. Santrock, John W. "Physical and Cognitive Development in Adolescence." Life-span Development. Boston, MA: McGraw-Hill Higher Education, 2009.
16. Maxwell, Kimberley A. "Friends: The Role of Peer Influence Across Adolescent Risk Behaviors."Journal of Youth and Adolescence 31.4 (2002): 267-77
17. "LifeWay: True Love Waits®." LifeWay | Biblical Solutions for Life. LifeWay Christian Resources of the Southern Baptist Convention, 2001. http://www.lifeway.com/tlw/
18. The Silver Ring Thing. 1995. http://www.silverringthing.com/home.asp
19. DiCenso, Alba. "Interventions to Reduce Unintended Pregnancies among Adolescents: Systematic Review of Randomized Controlled Trials.” Child: Care, Health and Development 28.6 (2002): 533. British Medical Journal. http://www.bmj.com/content/324/7351/1426.full
20. Kohlberg, Lawrence. "The Claim to Moral Adequacy of a Highest Stage of Moral Judgment." The Journal of Philosophy 70.18 (1973): 630-646. http://www.jstor.org/stable/pdfplus/2025030.pdf
21. Hammock, Thomas, and Jack W. Brehm. "The Attractiveness of Choice Alternatives When Freedom to Choose Is Eliminated by a Social Agent1." Journal of Personality 34.4 (1966): 546-54.
22. Dillard, J. P., & Shen, L.. On the nature of reactance and its role in persuasive health communication. Communication Monographs, 72 (2005): 144–168.
23. The Candie's Foundation, 2001. http://www.candiesfoundation.org/index.html
24. Whitaker, D. J., and K. S. Miller. "Parent-Adolescent Discussions about Sex and Condoms: Impact on Peer Influences of Sexual Risk Behavior." Journal of Adolescent Research 15.2 (2000): 251-73.
25. Grier, Sonya, and Carol A. Bryant. "Social Marketing In Public Health." Annual Review of Public Health 26.1 (2005): 319-39. http://www.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.26.021304.144610

Anti-Smoking Campaign Ads On Cigarette Packages And The Health Belief Model – Jenna Barry

The US Food and Drug Administration have a new public health intervention in the works for combating smoking. The decline in smoking has been stalling since 2004 and there is still about 20% of Americans who smoke. It is a large public health issue and even though most people are aware of the dangers of smoking the habit continues. There have been many different interventions put into action over the years and some have been more effective than others. Public health officials have spent years studying why some interventions work better than others but there are still new interventions being made that rely on old theories that aren’t very effective. The new anti-smoking campaign being made by the Food and Drug Administration is an example of a new intervention being based on an old theory. This intervention will most likely be flawed due to the model it is based on and other countries that have tried similar programs are beginning to move away from it.
The new anti-smoking campaign that is being initiated is aimed at current smokers. The Food and Drug Administration has come up with 36 different graphic images, 9 of which will be chosen to be displayed on all cigarette packages. The images range from a man in a coffin, dirty teeth, bald cancer patient, to smoke damaged lungs. There is a large range of images that are meant to hit smokers with a strong impact of what their smoking is doing to them and to others. The hope is that these images will be a stronger message than the current warning labels and be harder for people to ignore. The images are going to be larger than current warning labels and take up half of the front side of the cigarette package. Starting in October of 2012 the images will be mandatory for all cigarette packages. The United States is behind other countries in regards to this program. Many other countries have already enacted such programs and some say they used even more graphic images than what the United States has planned.
This new anti-smoking ad campaign is a public health intervention that is based on the social science theory called the Health Belief Model. The health belief model was created in 1966 by Irwin Rosenstock and it dominates about 98% of all public health interventions. The model was initially created to find out what lead people to obtain chest x-rays for the detection of tuberculosis in the 1950s (1). The basis of the model is that it is used to predict the likelihood that people will perform preventive health behaviors. A person’s motivation to perform a preventive health behavior is based on three categories. The categories are susceptibility to disease and or health condition, their perceived severity, and the importance of health to the individual. The model also takes into account the perceived barriers that individuals include in their decision making, such as, cost, inconvenience, and discomfort.
The strengths of the health belief model are that it calls attention to the fact that people need to be educated about their behavior. The model is concise and efficient and it’s fairly easy to establish an intervention. There is good generalizability with this model and it is good when it comes to simple decisions and behavior that is constant.
There are many limitations of the health belief model. When dealing with complicated, complex and fickle behavior it is hard to use the health belief model. People have a hard time abstaining from some behaviors even when they intend to follow healthier behaviors. There is an inner struggle between an individual’s intentions and the behaviors they end up performing. There are many things that the health belief model doesn’t account for that are strong influences on people’s behavior. The model doesn’t take into account the forces from social and environmental factors, which play a large role in day to day decision making. The model is an individual level model that only predicts the behavior of an individual and doesn’t look at society as a whole and how group dynamics play a large role. People’s behavior is often irrational and unplanned and the health belief model relies on the opposite thinking that their behavior will be rational and planned. The model predicts an individual’s behavior by assuming they will calculate rationally between the benefits of the health behavior and the barriers of performing the health behavior. This calculation will only work if the individual thinks rationally but people are irrational. Due to this the model is poor at predicting addiction, which is behavior without intention and is irrational.
There are far more limitations to this model than there are strengths. This doesn’t mean that the model is completely useless but relying on it alone is not very beneficial. If it was to be combined with other models then it could work better. The new anti-smoking campaign is following the health belief model only and thus is not likely to wield very good results. The campaign is organized on the assumption that people only need to be told about the negative consequences of their smoking and they will want to quit. However, as a society we have known for a while now the dangers and risks of smoking and yet 20% of people in the US are still smoking and new people are continuing to pick up the habit. The campaign being based on the health belief model makes it a flawed one and the benefits will probably be few.
One reason that the new anti-smoking campaign is flawed is because it doesn’t take into account social factors like socioeconomic status and previous experiences (2). It relies only on the individual’s health beliefs and that if they are told about the dangers then their health beliefs will change and so will their behavior. The campaign hopes that using such graphic images will shock smokers into seeing the extreme dangers that they are putting themselves at risk for by smoking. If the individual has had previous experiences where they have known many people who have smoked and none of them experienced any major consequences then the individual may feel their susceptibility to disease is low. If there is a low susceptibility due to social factors not being taken into account then the health belief model is likely not going to work as well for that individual (3).
Another big reason that this new anti-smoking campaign is flawed is because the health belief model is poor at predicting addictive behaviors. Cigarette smoking is influenced by many factors that are not health related so it is hard for the model to predict these factors and behaviors (4). These factors are psychological and physiological and very complex in nature. The campaign is only targeting the severity and susceptibility of the disease and the barriers involved are more complex so that won’t be enough. Smokers are already aware of the dangers and just showing them graphic images isn’t going to target the more complicated reasons behind why they smoke. There is a strong addiction with smoking and this is a large barrier to try to tackle. The inconvenience and discomfort they would go through by trying to quit is a strong deterrent so individuals have a hard time between intention and behavior.
One of the largest flaws of the new anti-smoking campaign is that it is based on the idea that individuals behave rationally when weighing the perceived benefits of the health behavior with the perceived barriers. People do not behave rationally but rather they are irrational (5). There are 5 major ways why people behave irrationally. The first is due to expectation and stereotypes and when people are labeled a certain way they are going to live up to that label. Smokers are often labeled by society with negative connotations and if the individual feels they are part of this stereotype then they will try to live up to it. The second is due to ownership and loss aversion. This deals with prospect theory and how decision making is based on emotions and experiences. People are attached to things they own and human behaviors, such as, smoking are part of a person. When a person is doing something unhealthy (i.e. Smoking) they own it and it’s a part of them. If they smoke then it’s a part of their identity and they don’t want to give it up or lose it. The third reason for irrationality is framing. People are greatly affected by the way something is framed and the way the campaign is framed is more likely to incite a negative response from people due to rebellion. The fourth reason is fundamental attribution error, which deals with not taking into consideration the context where behavior takes place. Most likely people that smoke are doing it around other smokers and in that context they are not apt to think about the consequences when they see other people doing the same thing. The fifth reason involves self-control and those lacking self-control are not going to behave rationally.
An intervention that would be better at combatting smoking would tackle all of these flaws that the new anti-smoking campaign has not addressed. The intervention that would be better would focus on using multiple theories that are based on a group level. Group level models are more effective than individual level models like the health belief model. If an intervention was to combine multiple group level models it could put together the strengths of them into one intervention. A better intervention would be similar to the Truth campaign that used advertising theory and combine this with a marketing paradigm. The new proposed intervention would be to create a mass production advertisement that didn’t say anything about health consequences due to smoking. The focus of the advertisement would be to target people’s rebellion by using the theory of psychological reactance. Some people are worried that the new anti-smoking campaign will cause people to feel that their freedom is being threatened so in rebellion due to the theory of psychological reactance they will instead smoke more. As public health officials we need to use these theories that evoke stronger emotions and reactions from people to our advantage to influence people to choose healthy behaviors on their own. The mass advertisement would be targeted at smokers and inform them of how the tobacco industry is the one that is threatening their freedom. At the same time the campaign could create an image of sexy, strong, and independent individuals that are talking back to the tobacco industry. The promise made by the campaign could be that if you rebel against the tobacco industry like them then you will obtain a core value that the actors appear to possess.
This new intervention would address the first flaw of the new anti-smoking campaign that there are no social factors taken into account with the plan to display graphic images on the cigarette packages. This new intervention specifically targets social factors by using the marketing theory and targeting a core value of society (6). Core values are usually universal and many people can relate to them so it would target a large audience at a time and not just on an individual basis. People don’t value health until they don’t have it. Only when you’re not healthy do you start to lose other core values. So people that are healthy and smoking don’t feel like there is any incentive because they don’t feel that they’ve lost any core values. However, if there was this new intervention that made a large promise about how if you’re like the people in the advertisement then you can also have the core values that they possess. The intervention would start off by targeting the deepest aspiration that was believed to be held by the target audience and giving the image that the actors had obtained this core value by their anti-smoking behaviors. This would be more effective than the new anti-smoking campaign because it takes into account social factors like the target audience’s wants and needs. People spend their whole lives trying to obtain core values and if they think there is a behavior that can help them achieve these it will be a strong influence.
The new intervention would address the second flaw in the new anti-smoking campaign by using advertising theory. The new anti-smoking campaign will not be strong enough to address the addictive behaviors behind smoking. The new proposed intervention would be more complex and use stronger models that can have a greater impact on fighting addictive behaviors. Advertising theory can create a dramatic emotional impact that defies your brain. It would target strong human emotions and once these emotions are engaged then the mind will follow the emotion. The way to motivate people is to make them a promise. The promise is the basic premise of the advertising theory. The larger the promise the more effective it will be, which is the opposite of what you would think. The truth of the promise has nothing to do with whether or not the advertisements are effective. If we can develop this new public health intervention and make sure every message has a strong promise we can influence more people. Currently public health interventions are not taking advantage of this theory and that is a detriment to the cause. The promise would be backed up with support but not factual support. Instead it would be supported through stories, and images of people like the target audience. Advertisement theory is very universal and can be used for many products so it would work well for anti-smoking (7). For example, the promise that could be made in the new intervention could be that if you don’t smoke then you will be cool and attractive and powerful.
The third flaw of the new anti-smoking campaign would be addressed in the new intervention by appealing to the irrationality of people instead of assuming they are rational, like in the health belief model. This would be addressed by using the theory of psychological reactance to our advantage, rather than having it work against our public health initiatives. The plan for the graphic images on cigarette packages is going to have the theory of psychological reactance working against it. Instead this theory should be implemented in a new intervention to work to get people to smoke less. The mass advertisement could educate people about how the tobacco industry is targeting them and taking away their freedom. The most common thing to cause people to rebel is when people have lost control or loss of freedom. People then react to this perceived threat of their freedom when they feel that they are being told they have to do something or not do something and they have no choice in the decision. Right now every public health message tells people what to do and this evokes psychological reactance. As a result they must resolve this threat and do the opposite of what they are being told to do. Reactance has been found to be the most important risk factor for smoking (8). Before the new intervention is put into effect it should be measured and tested for how much reactance it creates. Reactance can be decreased through three different factors. The first factor is explicitness or the degree to which the language is clear; how plain is the intent of the source. Sometimes explicitness increases reactance and sometimes it decreases reactance but generally it reduces reactance. People are less likely to feel manipulated if the intent of the message is clear. The second factor is dominance or the extent to which the source believes they have control; the degree of the authoritativeness of the message. The more dominance there is the more reactance there will be. The third factor is reason or the degree of support for the claim in the message. The more support that there is for the message the less reactance there will be. The support doesn’t have to be scientific. Scientific support is actually the least effective kind of support. The intervention would be more effective if it uses stories and images to target the audiences emotions instead. The most important factor is how similar the source is to the target audience. The more similar the source is to the audience the less amount of reactance there will be. The intervention should thus use peers of the target audience to express the anti-smoking message rather than government officials or doctors. An example of an advertisement where peers have been used to increase the influence of a message was the ad campaign that was supporting gay marriage and the source of the message was straight couples to help appeal to their peers. Another option is to make it so there’s no perceived source of the message so the audience can’t discern that they are being told to do something by an identifiable source.
The new intervention will also address the reasons for people’s irrationality and will appeal to them rather than ignore them. It will address the expectation and stereotype irrationality by labeling people who are in the advertisement as active and cool and those who are non-smokers will begin to adapt this as part of their identity like in the 84.org campaign. The second reason for irrationality (ownership and loss aversion) would be addressed by creating a group of people in the advertisements that appear to have accomplished strong core values and people will want to be part of this group. Interventions can’t entice people to do healthy behaviors by offering them health so if they are offered these core values it will be something for them to aspire to. To be a part of the group they will have to quit smoking and establish the group as part of themselves and own it. The third reason of framing would be addressed in the new intervention by framing things in a more positive and appealing way. Fundamental attribution error and self-control would be addressed in the intervention by making sure the context of the message is taken into account and individuals will overcome their lack of self-control if there is a strong motivator like clear core values. Irrationality affects people’s behavior greatly and if an intervention could account for all of these things and use them to the advantage of public health then it would be a very strong message.
There are many newer more advanced models of social behavior that can be very influential for public health. The fact that so many public health interventions are relying on single models or ineffective models is a detriment to our society. There are many negative health behaviors that lead to extremely negative health outcomes. Prevention could be a huge step in combatting these diseases and illnesses that affect millions of people. An impact can only be made if the interventions start to be more innovative. Currently the interventions rely too much on the idea that if only people are informed about their poor health habits then they will stop. This is much how the health belief model is based and the fact that new interventions are coming out and still only relying on this one model is unfortunate. Companies that are damaging the health of people in the United States like the tobacco industry and fast food restaurants are using these new group level models that are effective and getting people to behave the way they want them to. Public health needs to fight back by using these same models that the big companies are using and are working. The tobacco industry has long known that appealing to people’s emotions will get them more loyal customers every day. They have tried to seem like they are on the side of supporting public health by giving money to our interventions. However, they know are interventions aren’t working and some are even helping them so they gladly support the ones that don’t work and are quick to fight back against the ones that do. New interventions need to be made and they need to use these stronger models and hopefully if this becomes more typical there would be too many good interventions for the tobacco industry to fight all at once.

References

1. Baum, Andrew. Cambridge handbook of psychology, health, and medicine . s.l. : Cambridge University Press, 1997.
2. Ajau. Infosihat.gov. Infosihat.gov. [Online] [Cited: December 2, 2010.] http://www.infosihat.gov.my/media/BahanRujukan/bahan%20rujukan%20doc/HealthBeliefModel.pdf.
3. Compliance with a medical regimen for asthma: a test of the health belief model. Becker, M. 3, s.l. : Public Health Rep, 1978, Vol. 93.
4. A critical review of the health belief model in relation to cigarette smoking behaviour. Galvin, K.T. 2, s.l. : Journal of Clinical Nursing, 1992, Vol. 1.
5. Ariely, Dan. Predictably Irrational. NY : HarperCollins Publishing, 2008.
6. SOCIAL MARKETING IN PUBLIC HEALTH. Grier, Sonya. s.l. : Annual review of Public Health, 2005, Vol. 26.
7. Finnegan, John. Communication Theory and Health Behavior Change:. [book auth.] K Glanz. Health Behavior and Health Education: Theory, Research, and Practice. s.l. : Jossey-Bass, 2002.
8. Deflecting Reactance: The Role of Similiarity in Increasing Compliance and Reducing Resistance. Silvia, Paul. 3, s.l. : Basic and Applied Social Psychology, 2005, Vol. 27.

Texting and Driving: Public Health Campaigns Fail To Acknowledge and Adapt to Motivations Behind Human Behavior – Kate Johnson

Texting and driving is a relatively new phenomenon to enter the public health landscape. The world has seen a rapid evolution of interconnecting technologies over the past decade, but texting has only become mainstream in the United States over the past few years (1). The development of Personal Digital Assistants (PDA’s) and keyboard technologies for cell phones have helped facilitate and encourage a shift to communication via text. As with the emergence of any new cultural behavior, the implications for society going forward must be addressed. Texting, like cell phone use in general, has dangerous implications when it comes to public health.
A recent report from the National Safety Council finds that 28 percent of all traffic accidents, or 1.6 million crashes per year, are caused by cell phone use or texting while driving (2). While cell phone use is still a more dominant cause of traffic accidents because more people engage in cell phone use (calls) than text, texting has been found to the most dangerous activity when it comes to distracted driving (2). Additionally, findings show that teenagers are the most at-risk population group; individuals 20 years and under have the highest incidence of distraction-related fatal car crashes (3).
Currently, 19 States and the District of Columbia have established laws that ban texting while driving (4). These laws, while important in establishing authority, are inherently hard to enforce. Text messages are often sent below the dashboard of a vehicle, out of sight of an observing officer. While law enforcement may recognize faulty driving practices that are indeed a result of texting while driving, it is hard for them to prove it.
In addition to the enactment of laws against texting and driving, there has been a recent push to raise public awareness. Various outlets have released public service announcements (PSA’s), commercials, billboards and celebrity-endorsed warnings against texting and driving (5-6). Despite numerous organizations’ attention to the matter and increasing coverage by the national news media, the current efforts to prevent and combat texting while driving are very disjointed. The Federal Government has established its own campaign aimed at combating distracted driving, which centers around providing facts and statistics on a newly established website, but has made no real strategic effort to address the issue through media or programs (3).
The most noteworthy campaign to-date has been the ‘It Can Wait’ campaign, administered by AT&T (7). AT&T’s campaign has released a series of PSA’s, which show the image of an incomplete text message, accompanied by a tragic story of a car accident resulting in death or injury. The incomplete text is meant to represent that which was never sent or received because an accident occurred in the midst of writing or receiving a text message. The major message ‘It Can Wait’ aims to convey is that ‘not text is worth dying over,’ or that no text is so important that it can’t wait. (7)
The following critique will focus primarily on the ‘It Can Wait’ campaign, given its stature among current efforts, though the collective state of public health efforts will continue to be addressed.

Illusion of control and perceived risk are not accounted for.

The ‘It Can Wait’ campaign offers a simple and concise message. Everything from the black and white color scheme to the lack of imagery is intentionally devoted to communicating a clear and straightforward message (7). The advertisers want viewers to focus on the story being told by an invisible voice while simultaneously focusing on the visual of the incomplete text message. This type of communication is strictly looking to appealing to emotion. ‘It Can Wait’ advertisements are not informative beyond the singular experience of the story being told, which disregards key aspects of human behavior and serves as a major flaw in their campaign.
Individuals who engage in texting while driving are operating under an illusion of control based on a false sense of perceived risk, among other behaviors. This could also be viewed as an ‘it won’t happen to me’ mentality. Given the newness of attention being paid to texting while driving, there is little data with regard to actual perceived risk. But, as we have seen with other public health issues, public perception of the riskiness of behaviors, when it comes to them personally, is often misguided (8). A specific study targeted to cigarette smokers found that only 40 percent of smokers believed that they had a higher than average risk of cancer (9). Studies like this highlight the fact that despite knowledge of certain health risks associated with a behavior, as the dangers of smoking are widely known, individuals will still disassociate themselves from unfavorable outcomes.
Surveys conducted by the Pew Research Center have confirmed a low sense of perceived risk among teenagers and an illusion of control when it comes to texting and driving. In addition to cavalier attitudes, which expressed no perceived risk in texting and driving, those who acknowledged risk proceeded to rationalize ways in which they ‘control’ the situation to reduce perceived risk. Some teenagers felt holding the phone at eye-level while texting eliminated risk because they were able to see the road at the same time, while other expressed a sense that sending a text, versus reading a text, raised and lowered your risk levels, respectively. (1)
The views of control expressed by teenagers in the Pew surveys highlight human desire for control: “most social scientists agree that there is a motivation to master one’s environment, and a complete mastery would include the ability to ‘beat the odds,’ that is, the control chance events (10).” While individuals may know that there is some risk in texting while driving, a view of the act as a particular skill set, which can be mastered, contributes to the illusion of control and the desire to master that skill set and, thus, control the situation.
The ‘It Can Wait’ campaign fails to realize that, while the emotional content of their messages may play to human emotion, it does not encourage action. People will feel bad for the tragic stories of other, but account for low perceived risk and illusion of control tells us that they will not be convinced that it can happen to them.


Lessons from the ‘Truth’ campaign: ‘It Can Wait’ needs a message other than ‘don’t.’

The ‘It Can Wait’ campaign is centered on appealing to people’s emotions. They have framed the issue to be one focused on tragedy and death, essentially communicating: ‘if you text and drive, someone will die.’ As has been established through trial and error with other public health initiatives, this strategy of telling people what they should not do on the basis of doom and gloom does not work, particularly with teenagers.
An important campaign that showcases a successful way of advertising to youth by defining and overcoming the pitfalls of authoritative advertising methods of the past is the ‘Truth’ campaign. The key elements of the ‘Truth’ campaign that contributed to its success were involving youth/conducting research, using affirmed youth sentiment to establish tone and making ‘Truth’ a brand (11).
‘Truth’ committed itself to learning from and formulating its campaign around its target population. Youth sentiment, obtained through annual summits, review boards and qualitative research, was determined and used to guide campaign initiatives. A major point of interest established from this research was overwhelming youth consensus about judgmental advertising: they don’t like it. Individuals, and particularly youth, do not want to be lectured or told what to do. (11)
In the case of smoking, youth see performance of this behavior as a rebellion (11). Texting and driving, on the other hand, has more to do with illusions of control and the culture of instant gratification facilitated by technology. But, in either case, how youth views the behavior and how they prefer to be addressed must be established in order properly frame the issue through campaign tone, imagery and delivery. The construction of a communication effort can play a major role in affecting people’s perception of information (12).
Lastly, the ‘Truth’ campaign experienced continued success due to branding. While most public health campaigns felt the unique nature of their subject matter inherently separated them from the traditional advertising, ‘Truth’ looked to the successes of commercial advertisers and embraced the idea of brand-identity as a major trigger for youth behavior (11). Branding is a marketing tool, which is increasingly being used in social contexts because of its ability to create important associations between consumers and products, or similarly, individuals and behaviors (13). “Public health branding aims to induce behavior change so that the individual is motivated to engage in beneficial health-related behavior. (14)” While the commercial and public health models of branding differ, the tenant of establishing relationships and recognition between the brand and those committing to the brand either through purchase or behavior remains the same (13). The ‘Truth’ campaign was able to utilize branding in a way that enforced youth identity through recognition.
Unlike the ‘Truth’ campaign, the ‘It Can Wait’ campaign fails to recognize the need for qualitative research in establishing its message and how traditional methods of advertising can be applied to public health communication efforts.

‘It Can Wait’ and other texting and driving initiatives fail to acknowledge social context.

The collective public health response to the texting and driving problem has, thus far, been a series of efforts, not particularly linked, that employ a number of social science and marketing-based tactics. Celebrities have signed on as anti-texting and driving spokespeople, even Oprah, the queen of – well, everything, has begun a campaign against the unhealthy behavior (5-6). Laws have been enacted in many states and there is federal effort to see that more states begin to adopt bans against texting while driving (4). Campaigns like ‘It Can Wait’ have attempted to strike an emotional chord with the public in order to discourage the behavior. While all of these efforts have certain merits and can play a role in bringing about change, they will prove futile without an umbrella acknowledgement of the social context.
In order to determine the fundamental causes of a behavior, as with disease or other public health problems, investigators must determine the social conditions under which individual behaviors, or risk factors, are born (15). In the case of texting while driving, this requires an acknowledgement of the role of technology and instant communication mechanisms that have become ingrained in American life. There is an ability and expectance to access information immediately that cannot be ignored. While we know the risks associated with texting while driving, is it unrealistic to think that an individual who receives a text, a facebook message or a tweet would want to view it immediately? The answer is no, in fact it is normal in today’s culture to want and be able to access information immediately.
Having a sense of this cultural normative behavior is imperative to the development of public health campaigns and subsequent methods of combating the behavior. For instance, if a behavior is performed due to deeply ingrained cultural cues, it may be extraordinarily difficult for individuals to overcome that behavior. While enforcement can work to derail a behavior, if enforcement is difficult to achieve, as with texting and driving, the solution may lie in providing individuals with another viable (safer) way to perform culturally ingrained behaviors. “Complex, interrelated behaviors such as nutrition or unprotected sexual behavior are difficult to change through simple communication of health risks and benefits – the social context in which they occur needs to be recognized, and associations and relationships between desired goods for the consumer can be an effective strategy to promote health behavior. (13)”
Ultimately, the failure of current public health initiatives to account for the social context of texting and driving has negatively affected the campaign strategy. While it is still early in terms of responding to this particular public health problem and knowing the outcomes of that response, lessons from past campaigns show us that addressing and influencing normative behavior is most effective.
Most notably, the designated driver campaign serves as a prime model for this type of effort: “The designated driver concept was invented in the Nordic countries. It promotes a new social norm that the driver doesn’t drink. Pollsters found a very sharp rise in the reported use of designated drivers such that four years into the campaign, a majority of Americans said they had either served as a designated driver or been driven home by one. During that period, alcohol-related traffic fatalities dropped by 25 percent. (16)”




A Social Norms Approach to Reducing Texting While Driving
A campaign whose aim is to realize and redefine socially normative behaviors, such as texting and driving, should focus on increasing awareness through multiple channels, establishing a memorable message that empowers individuals and easing the transition of behaviors.
Creating a Memorable Message
Any public health campaign that is looking to influence behavior, and ultimately change behavior, must find a way to not only reach individuals, but to keep their attention. A memorable message is an important way of branding a behavior to meet the needs of the target population.
For texting and driving, a new ad campaign, modeled after the designated driver campaign, could be established that uses alliteration to communicate a new behavior. Tandem Texting. The premise would be that each individual assigns someone to be their ‘Tandem Texter’, so that when operating a vehicle the designated individual would be responsible for sending or responding to any text messages that the driver would otherwise handle. The alliteration of the message makes it catchy, which is important in becoming memorable. Additionally, the mechanism of assigning someone to be your ‘Tandem Texter’ introduces a new behavior, which serves to replace the old behavior of texting while driving and allows for a new sense of ‘control’ over the situation.
Creating a new behavior through branding is an important way to ‘add value’ for the individual and encourage movement away from the unhealthy behavior. “Public health brands can also add value to the practical benefits of engaging in a preventive or health-promoting behavior beyond its immediate practical benefits. (13)” ‘Tandem Texting’ would empower individuals to perform a new behavior rather than pass judgment on the performance of an existing one, which is an especially important characteristic in reaching out to teenagers.
Increased Awareness and Communication of Message
One of the positive aspects of recent initiatives involving texting and driving has been the flow of information. While there are many flaws, and no single initiative seems to be particularly effective, the news media attention and celebrity endorsement of anti-texting and driving campaigns can only help, not hinder, changes in social behavior.
Going forward, awareness efforts should continue both nationally and on state and community levels. Additionally, these awareness efforts should be coupled with the communication of the new message and behavior we are looking to promote. “The general lesson is clear. If choice architects want to shift behavior and to do so with a nudge, they might simply inform people about what other people are doing. (17)” In order for the new behavior to gain mainstream acceptance, it is important that people see it as common practice. Community-based efforts become increasingly important under this context; leaders in communities need to exhibit the new behavior so that others will follow suit, as is true of herd behavior. “Herd behavior is often said to occur when many people take the same action, because some mimic the actions of other. (18)”
Herd behavior can be accounted for not only at the local level, but also nationally. Television and film are important outlets for communicating a public health message and encouraging behavior change. A major way to target teenagers and encourage behavior change is by exhibiting these behaviors in individuals they idolize on screen, though exhibition of these behaviors should not be explicit. “Perhaps one way to persuade people to make the change from the old to the new is to make the new more familiar and to increase involvement and participation in the changeover. (10)” Rather than celebrities preaching the behavior, characters in television and film should act out the desired behavior as if it is a normal activity, thus creating the fact. Knowing that teenagers, and often adults, emulate things they see on screen, especially idioms, any public health campaign would be remiss to ignore this mode of communicating its message.
“The question of whether closer “local” norms of a group or more distant “global” community norms should be addressed in a particular norms correction initiative is a complex one, and must take into account the culture of the group in question and the context and social ecology of the community. Ideally both can be addressed together through a combination of primary and secondary prevention strategies such as small group norms interventions and community-wide social norms media campaigns. In most cases either general campus-wide campaigns or more local group norms challenging interventions can result in behavior change, although there may be some groups who are resistant to campus-wide interventions. Selecting the most relevant and salient norms for a particular intervention and the appropriate strategy for changing those norms is an important part of the planning process of a social norms intervention. (19)”

Utilizing Enforcement and New Technology
The issue of distracted driving is a complex one. Its complexity is particularly relevant when it comes to enforcement and the development of new technologies. It must be understood that there is no way to completely eradicate distracted driving because there is no way to protect against all contributing behaviors; daydreaming, etc. But, there are factual elements that we can apply in order to use enforcement and new technology to reduce risk from particular behaviors.
It has been established by a variety of sources that texting while driving is much more dangerous than numerous other distractive activities, including simply talking on ones cell phone (1-20). Knowing this, it is important that new technologies be researched and development that eliminate the need for the mechanical behavior of texting that proves most dangerous on the road. Efforts to develop and implement these new technologies should not be ignored, simply because the new behaviors pose certain risks of distraction, as well. It is statistically proven that texting is far more dangerous than engaging in conversation and that fact should influence how we move forward with public health campaigns and technological efforts aimed at reducing the harmful effects of distracted driving (20). Promoting the use of Bluetooth, speakerphone or VoiceTXT technologies may be an effective intermediary step in public health initiatives to combat texting while driving because they are proven to be safer alternatives (20). Cultural change of social norms is the ideal goal in changing texting while driving behavior, but it is important to recognize that these efforts take time and complementary policies and innovations can prove beneficial in the interim.
It seems self-evident that any successful public health initiative attempting to change unhealthy public behavior should have the support and assistance of its governing bodies. It is unfortunate that to date only 19 states and the District of Columbia have policies in place that ban texting while driving (4). Even though there is a question as to whether enforcement of texting while driving laws is viable, having the laws in place is necessary to provide validity to public health efforts working to combat the behavior.
In Conclusion
The campaign I envision would address illusions of control and perceived risk by supplanting them with a new behavior mechanism that involves role-assignment and call to action of individuals. This behavior mechanism will be effective communicated through local and national channels and will have a clear, yet catchy slogan to encourage involvement and brand the behavior: Tandem Texting. The campaign in no way preaches or tells individuals what they should or should not do; rather it encourages a new behavior through formation of a new social norm. New technologies and roles for enforcement will continue to be taken into account because they are inextricably linked to the social context of the behavior.





















REFERENCES

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