Recent Publicity Surrounding the 2009 Family Smoking Prevention and Tobacco Control Act: A Critique of Attempted Use of the Health Belief Model Center

Recent Publicity Surrounding the 2009 Family Smoking Prevention and Tobacco Control Act: A Critique of Attempted Use of the Health Belief Model Centered on Public Intervention via Graphic Warnings on Cigarette Labels – Dan Carroll
The Obama administration began working on legislation shortly after the election with a particular emphasis on the control and prevention of smoking at a young age and subsequent media influence on children related to the encouragement of future tobacco use. This legislation was passed around Capitol Hill after being negotiated with lobbyists, pundits, anti-smoking campaign organizers, and the nation’s leading cigarette seller, Phillip Morris. Eventually released in late June of 2009 under the name “2009 Family Smoking Prevention and Tobacco Control Act,” the bill dictated that the Food and Drug Administration would now have regulatory authority over tobacco products in the United States. This control came with additional changes to the original 1970 substitution of the previous disclaimer “Caution: Cigarette Smoking May Be Hazardous to Your Health” with the updated “Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health.” The 2009 legislation enhanced the forty year old warning to one of nine statement options, all including the word “WARNING:” in all capital letters. Some of the examples include “Cigarettes are addictive” or “Tobacco smoke can harm your children/nonsmokers” along with more blunt statements like “Cigarettes cause fatal lung disease/cancer/strokes and heart disease” or just “Smoking can kill you.” Eight out of the nine warnings emphasize the danger and or damage risk represented by smoking cigarettes, but only one, “Quitting smoking now greatly reduces serious risks to your health,” had any positivity within its message to encourage the cessation of smoking cigarettes. The most recent publicity that the legislation has seen, after first receiving close scrutiny in a US District Court case in Western Kentucky (Commonwealth Brands Inc vs. the United States), was a November 2010 unveiling of the graphic images that will be used alongside the tobacco warnings starting as early as 2012. (1) In the next several pages, I am going to provide compelling evidence from past government backed anti-smoking attempts using similar tactics to warn consumers with graphic images on labels of cigarette packets, along with analysis of the established public health theories and empirical evidence supporting my argument that the approach, intervention, and expectations of the 2009 Family Smoking Prevention and Tobacco Control Act as it specifically relates to cigarette warning labels are flawed.
There are three dominant uses of public health theory that are detectable within the approach taken by the creators of the legislation that are significantly lacking in effectiveness as shown by both empirical data and publications written with regard to the success of using certain health models in a general fashion via mass media (i.e. cigarette warning labels). I am also prepared to present the argument that the chosen public health model, though not as productive as newer multi-level and multi-sectoral interventions (as suggested by the Balbach article in Tobacco Control, 2006), could have been made to generate more positive results had it been used more effectively. My primary observation with regard to the new cigarette warning labels was the overwhelming use of the health belief model as a nearly stand-alone approach to reaching current smokers with the message of danger and inherent risk in cigarette consumption. (2) Secondarily, the cue to action intended as a component of the health belief model is rendered ineffective over a short period of time due to an unvaried and bland set of messages that quickly blend in with the surroundings as modern mass media overloads the sensory systems of consumers. The third significant flaw that can be anticipated with initialization of the warning label legislation is simply the resistance of the public to hear the message due to the perceived sources generating the label content. The Social Reactance Theory is absolutely essential to consider when an entire nation of smokers are the target of a single intervention being forced upon a society that sees the authorities as a threat to their already infringed upon right to purchase and consume cigarettes freely.
As a counter-proposal to the current approach, I will carefully articulate changes that are supported by evidence explaining how each major flaw identified in the legislation could be reversed to improve the potential chances for effectiveness of the bill. I will define the new theory usage proposed to address the specific flaws that exist in each of the three cases outlined in this paper. I will provide details on how the Health Belief Model could have been used more correctly to achieve the desired goals of the intervention. I will propose an idea that incorporates the “Jolt” or “Catastrophic Theory” to improve upon the weak usage of the health belief model’s “cue to action” that was identified earlier in my argument. I will also lay out a declaration of change to the affect on the public by more appropriately using the Social Reactance Theory to create the environment of an opportunity to modify behaviors without the implication of threat or dictation from authorities.
Flaw in Usage of the Health Belief Model
As a primary and well known public health theory, the Health Belief Model has been widely used in public health for upwards of fifty years with some positive feedback relating to interventions involving individual behavior. Since its inception, many new outlooks on how to approach public health dilemmas have come about, much to the credit of Irwin Rosenstock, Godfrey Hochbaum, and Stephen Kegels’ original work under the U.S. Public Health Service. (3) It is also widely known that the original ideas behind the model were infantile with respect to the information and expertise available to the public health campaigns of modern day, and evidence is shown by the prompt clarifications or additions given to the Health Belief Model such as the sixth component of the model, self-efficacy. Many sources elaborate on the facts that point to the health belief model’s failure to account for the extreme complexity of human behavior. Rather than using the model as a resource with which to analyze the problem and proceed to further research the details of the behaviors and the optimal demographics that should be targeted with the approach of the campaign, too many significant U.S. public health interventions have relied on a loose and generalized structure inspired by the factors of the health belief model.
I would emphatically point to the first two components of the health belief model, which is the central focus and role played by the strongly worded WARNING labels and graphic visual images intended to carry the message of the intervention, as an established an inexcusably avoidable flaw that severely limits the impact of the legislation on smoking rates in the United States. The perceived susceptibility to falling victim to fatal lung disease, cancer, strokes, heart disease, or death is grossly underestimated by each individual smoker as evidenced by the work of Neil Weinstein almost thirty years ago in his studies investigating the tendency for people to be unrealistically optimistic about future life events. (4) Further studies, such as the work of Ayanian and Cleary investigating perceived susceptibility among cigarette smokers, even more clearly points to the fact that those specifically targeted individuals intended for realization and behavior modification as a result of the 2009 Act are far from experiencing the degree of impact assumed for a reasoned and logical decision maker.(5)
The second component of the health belief model, perceived severity of death or debilitating illness as a result of cigarette consumption is largely negated when the target of the message believe themselves to be far less likely to become involved in dealing with a severe health impact in the first place. (2,3) For those that are considering the likelihood of experiencing a real and negative outcome as a result of smoking, more often than not, have been consuming cigarettes for a substantial period of time during their lives and have not only heard each of the warning messages in other formats in the past, but also tend to internalize the risk as unavoidable given their long history of addiction to smoking tobacco products.
The net resulting impact of the combination of the perceived susceptibility and severity of risk from cigarette use is far less productive in this approach because the message is both over concentrated on the negative dangers of smoking and not an original idea in any way. The emphasis on horrific imagery and deeply damaging physical injury from tobacco use will turn the target of such intervention away as they seek avoidance of the issue and the internal feelings of depression and doom that await them post consumption. The attempt of the campaign is fighting the much stronger desire for immediate gratification of nicotine found in the tobacco smoke. (6) The nucleus of my critique lies in the both the decision to make use of the health belief model in the first place, especially considering the other options developed in the field of social sciences over the past few decades, and the poor attention to detail in constructing how to most effectively use the health belief model in this instance. I will proceed to further detail my suggested changes later in the section covering my counter-proposal.
Cue to Action Lacking Effectiveness and Longevity
While still a component of the health belief model, the second distinct oversight on the part of the writers of the 2009 Family Smoking Prevention and Tobacco Control Act is also the fifth component of the model, added to the existing four factors at a later time. The “cue to action” was designed to augment the model in order to meet the need for a motivation or “push” to act and make a change to the negative behavior. (3) The logical intention that one would conclude is desired by the use of alarming warning labels with graphic images depicting disturbing disease and health impacts that eventually lead to an early expiration is a clear direction to cease smoking cigarettes and preserve lifespan.
The first failure in the assumption that a “cue to action” would be effective in the 21st century is quite simply complete ignorance of similar past attempts to utilize this technique to generate results. (2) Not only have similar campaigns endorsed by the U.S. public health departments failed, but the exact same intervention was used in several other countries including Australia, Canada, and the United Kingdom. Very few publications show evidence of significant drops in smoking rates due solely to the exposure to graphic images and warnings on cigarette labels. Some of the only evidence to be found was taken out of context in a Financial Times article citing senior research fellow Lois Biener of the UMass Center for Survey Research for saying “graphic images are ‘very effective’ in anti-smoking campaigns” but failing to qualify that the publication was not analyzing cigarette labels. The campaigns Biener had cited were television and mass media ad campaigns, which interestingly were said to be eclipsed in effectiveness by personal stories with strong emotional arousal as opposed to the strong negative arousal found in ads with graphic and disturbing imagery. (7)
The latest news from the British and Canadian smoking campaigns are mixed, with Canada recently halting a move to expand upon the original idea with larger images in favor of concentrating on efforts to reduce levels of contraband cigarettes. (8) The move will leave citizens wondering how much of the influence to stop the program from proceeding forward is attributable to the three major tobacco companies with a significant financial stake in the game.
Recent changes in Russia have led to an attempted crack down on smoking by the Ministry of Health and Social Development in that country. New regulations require thirty percent of the front of packages to be covered by a warning label. Few details were available as to the variations in labels since the announcement was made this summer 2010. According to the World Health Organization, sixty percent of Russian men smoke and the numbers have been rising steadily since the collapse of the Soviet Union in 1991, particularly among young women. Russia, however, is still far behind the west in smoking prevention and control, largely due to the affordability of cigarettes in that country. The current price ranges just above one US dollar and previous attempts to raise excise taxes significantly enough to double the price of cigarettes were unsuccessful. (9)
The end result of the US legislation leaves the public with more of a brief novel interest in the new graphic images rather than substantial motivation to change their behaviors, particularly after the novelty wears off. (10) This attempt to produce action can end up generating more harm than good for the public as it provides an illusion of choice without properly informing the cigarette consumer of all their options. My biggest concern personally is the validation it may provide for a company like Phillip Morris given that they support such “lame duck” attempts at improving health. (2)
Failure to Consider the Public’s Reaction to Authority
The clear flaw of not considering the evidence given by the Social Reactance Theory, which explains the relationship between subordinates and authority, in this case the individual cigarette consumer and the Food and Drug Administration, prevents the effectiveness of the limited positive aspects found in the bill. The legislation makes special note to prevent the cigarette companies from referencing the FDA or placing a statement that might be construed as endorsement by the FDA, such as “in compliance with FDA regulations.” Regardless of which U.S. regulatory agency is producing the requirements for cigarette labels sold within U.S. borders, consumers of cigarettes will inevitably look at the warning as an infringement upon freedom originated by an authoritative body. The most significant potential downfall of the failure to properly recognize the social reactance theory in this particular campaign is the effect on how cigarette companies will be viewed by consumers. If the negative connotations of authority are passed even further from the producers of the deadly tobacco products to the very public health organizations that are hired by taxpayers to reduce tobacco consumption and save lives in the future, the opposite of the intended result will occur. Tobacco producers will become more powerful as blame is shifted from them to lawmakers who seek to take away freedoms in a country that was based on the very ideals of life, liberty, and the pursuit of happiness with the catalyst of freedom. It is no mystery then, as to why Phillip Morris, the makers of a symbol of freedom in cigarette choices, Marlboro brand, was a significant player in construction of the legislation and continues to claim full support and cooperation for the bill. (2)
The original intention of the legislation as indicated by the Obama administration was to assist in the reduction of smoking among adolescents and the prevention of smoking especially as it relates to the family unit. In a publication by James Sargent in the journal Preventive Medicine, evidence was found to indicate that receptivity to a cigarette promotional item was a significant player in whether a teen was more likely to become a smoker. (11) The study pointed to the fact that a reduction in cigarette promotional items would be a positive step towards the reduction of teen smoking as it is a symbol of rebellion that a susceptible teen would seek out or hold onto if available to them. My assessment of this paper led me to conclude that a cigarette label with graphic images, which is at the same time an item the teen should not be allowed to purchase given the age restrictions, would be somewhat of a trophy or bragging piece. I would also argue that an undesirable cigarette label in the hands of an adult may more frequently be improperly discarded earlier to relieve embarrassment, which would further increase availability to a teen as refuse.
As stated above, the government’s avoidance to confront the issues of rebellion and psychological reactance stems from the narrow scope used in the creation of the current intervention using the outdated health belief model. I can creatively produce an argument to validate the need for not only recognizing the impact of the campaign on teens and smokers, but also evidence how the social reactance literature gives several options to public health experts that may be combined with other techniques to successfully convince the public that they have the freedom to reject cigarette smoking as a habit. This tactic should be utilized to not only reduce the appearance of authority on the part of the public health departments but to return the natural rebellion in the direction of the true restrictions placed on cigarette consumers by the tobacco producers via the nicotine content inside the packages.

Proposed Revision to the Usage of the Health Belief Model
As generalized in my initial critique of the health belief model, I see the use of negative graphic imagery on cigarette labels as counterproductive to the goal of smoking cessation as evidenced by failed attempts in the past and publications such as the Balbach article arguing that the health belief model can actually help the tobacco industry. (2) This is further supported by the general interest Phillip Morris has shown in promoting this legislation. One could surmise that a profit-seeking manufacturer would not reasonably choose to promote any program that it had reason to believe would significantly impact its ability to sell its product and grow value for the shareholders.
A significant change that would vastly improve the labeling campaign currently proposed would be to reverse the general trend or theme in each warning. Providing information to consumers is potentially productive but that is not easy to do when the message carries with it such gloom and doom. I propose utilizing more positive messages with informative and useful tips on successful smoking cessation. Some examples would include changing the previous message of “WARNING: Cigarettes are addictive” to say “DID YOU KNOW: The addiction to nicotine in cigarettes can be overcome.” Though more impactful with the image of a happy sleeping baby, I would change the message of “smoke harming children/during pregnancy” to a more positive “SIGNIFICANT BENEFITS to children’s clean lungs are found in FRESH AIR.”
This idea can be replicated in each scenario to produce images with corresponding positive messages about enjoying life free of lung cancer, stroke and heart disease with the help of the FDA offered smoking cessation programs. Tactful inclusion of information about risks associated with tobacco consumption could be included so long as it does not shut the reader off with a message that is easier to avoid than to confront with the help and support of family members and the caring community.
Substitution of the “Cue to Action” With a “Catastrophic Jolt”
My critique of the designated usage of graphic imagery on cigarette labels focused on the tendency of a startling new sight, sound, or smell to increase adrenaline and provide a human response decreases significantly over time. A scary movie as viewed in a cinema is remembered or reflected upon as exciting and either disturbing or enjoyable based on the fact that it was usually only seen once or a handful of times at most. The most dramatic effect of a graphic image would be experienced by an individual the very first time he or she saw the label. As time goes on, the shock factor wanes and the imagery begins to blend in with the surroundings.
The publications of both L.C. Larabie and Robert West, in separate findings, indicate that a majority of successful smoking cessation attempts were as a result of an unplanned quit attempt. (12,13) The catalyst for the attempt may come in many forms, but the important fact is that success can be induced by a surprising or unexpected “cue to action.” The work on the “catastrophic” pathways that West attributed to success might also be found with the use of a cigarette label. My argument would be that, rather than a graphic image and warning on each and every cigarette label produced, a more infrequent “catastrophic” label should be put into the production mix to make the experience more unique and memorable. Additionally, the rarity of the event could invite a greater presentation of information such as a statistic consistent with the currently designed labels. If only one out of every 500 cigarette packs contain a warning related to the statistical probability of needing a tracheotomy before age 65, and that same statistical occurrence applies in the population of smokers (1 in 500) it would provide the consumer with a “catastrophic jolt” to take action to preserve their health and lifespan by calling the cessation information provided therein.
Consideration of and Potential Advantages of the Social Reactance Theory
As discussed significantly in the above sections, adherence to the effects of the social reactance theory should be combined with the use of other available public health models in order to generate a greater impact. I strongly suggest the enhancement of my “catastrophic” label proposed above by downplaying the novelty of the labeling on all other cigarette labels. Based on the published effect of cigarette promotional items in the article by James Sargent, the reduction in attractiveness of labels to prevent grabbing the attention of a child would counter the problem of social reactance and resulting value to an adolescent discussed in my critique of the public’s reaction to authority. (11) The teens interest would be mitigated if the majority of labels available to him or her were uninteresting. The significant benefit of this decision would further enhance the “jolt” felt when a consumer becomes accustomed to very plain or boring cigarette labels, only to find an exception to the rule in the form of a message that he or she is more likely to pay attention to. (14) The effectiveness of the message will be improved while making the burden on the individual’s freedom feel less overwhelming.
Conclusion
Though I have clearly provided three articulate reasons why the current 2009 Act is flawed with shortcomings, there are always ways to more creatively improve upon mass media campaigns in order to reach a target audience more effectively. Each of my counter-proposals contain room for improvement and public health officials must constantly be working to add value to their interventions and reconsider their approaches to achieve the desired expectations set forth in the project’s development.
REFERENCES
1. Reuters. US judge upholds most limits on tobacco marketing. New York: Reuters. http://www.reuters.com/article/idUSN0510760820100105
2. Balbach, ED. How the health belief model helps the tobacco industry: individuals, choice, and "information". Tob Control. 2006 Dec;15 Suppl 4:iv37-43.
3. Rosenstock, Irwin. Historical origins of the Health Belief Model. Health Education Monographs, 2(4) Winter 1974. 328-335.
4. Weinstein, Neil. Unrealistic Optimism About Future Life Events. Journal of
Personality and Social Psychology. 39(5) 1980. 806-820.
5. Ayanian, J., Cleary, P. Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers. JAMA. 281(11) Mar. 1999. 1019-1021.
6. Leatherdale, S.T., McDonald, P.W., Cameron, R., et al., 2005. A multilevel analysis examining the relationship of social influences for smoking and smoking onset. Am. J. Health Behav. 29 (6), 520–530.
7. Biener, L. Effects of Different Types of Antismoking Ads on Reducing Disparities in smoking Cessation Among Socioeconomic Subgroups. Am J Public Health. 2009 December ; 99(12): 2217–2223.
8. Reuters. U.S. unveils graphic tobacco warnings. New York/Washington DC: Reuters. http://www.reuters.com/article/idUSTRE6A937020101110
9. Reuters. Russia adopts “smoking kills” cigarette warnings. Moscow, Russia: Reuters. http://www.reuters.com/article/idUSTRE65P1E720100626
10. Financial Times. Graphic images to help US smokers quit. Washington DC: FT.com. http://www.ft.com/cms/s/0/6294c828-ecf9-11df-9912-00144feab49a.html
11. Sargent, J.D., Dalton, M., Beach, M., et al., 2000. Effect of cigarette promotions on smoking uptake among adolescents. Prev. Med. 30 (4), 320–327.
12. West, Robert. Catastrophic Pathways to Smoking Cessation: Findings
from National Survey. BMJ. 332 Feb. 2006.
13. Larabie, LC. To What Extent do Smokers Plan Quit Attempts. Tob Control. 14, 2005. 425-28.
14. Reuters. Britain considers plain packaging for cigarettes. London, UK: Reuters. http://uk.reuters.com/article/idUKTRE6AT43Z20101130

Crossing T’s And DOTing I’s: Is DOTS Enough To Improve Treatment Adherence?-Molly McCoy

Public Health Problem: Long-Term Medication Adherence in Tuberculosis

Tuberculosis (TB) infection and disease is an ongoing, long-existent global public health problem. TB is the leading infectious cause of adult death and disability in the world and is estimated to infect up to one third of the world's population and result in between two and three million deaths annually.(1) Although TB is treatable with antibiotics with a high cure-rate for those who are immune-competent, multi-drug resistant tuberculosis (MDR-TB) has emerged as a major obstacle for the control of TB worldwide.(2) MDR-TB is a result of incomplete or ineffective TB treatment. MDR-TB cases range up to 27% of cases as reported by the World Health Organization (WHO) and occur in areas with already established TB control programs, such as the WHO DOTS (directly observed treatment, short course) program.(3)
In 2009, the estimates for global burden of Tuberculosis were: 9.4 million incident cases, 14 million prevalent cases, and 1.3 million deaths among HIV-negative people.(4) These rates persist despite effective tuberculosis antibiotics having been available since the 1940’s.(5) Prevention, diagnosis, and treatment of tuberculosis latent infection and disease are becoming increasingly complex due to the development of drug-resistance and co-infection with Human Immunodeficiency Virus (HIV).
One of the biggest challenges faced in treatment of both active disease and latent infection is adherence to the treatment regimen.(6) The problem of low retention rates in treatment can be attributed to 1) the regimen’s length, which is nine months in the short-course regimen, 2) the number of pills in the regimen and side-effects, 3) low access to medical care, and 4) the effect of feeling better before treatment is complete, which can occur even months prior to completion.(6) All of these factors can lead to the behavior of stopping treatment. In addition, patients who are HIV-infected have even more complicated treatment regimens, which may lead to poorer adherence in this sub-population despite likelihood of more severe TB symptoms.(6)
The result of treatment default has severe consequences for both the individual and the community in which they live. For the individual, it can result in prolonged disease, relapse, development of drug-resistance, or even death.(5,6) Drug resistances is a problem because second round treatment is difficult, as some drugs may no longer work against that patient’s strain and second-line drugs to which it would be susceptible still are expensive and may be inaccessible. Treatment failure is also a problem for the greater community, because if the patient relapses he/she can infect others. If the strain of M. tuberculosis has developed drug-resistance, any infection transmission to others will be with this already resistant strain. At some DOTS program sites, adherence is reported to be as low as 50%.(5) Therefore, effective public health interventions, or the bolstering of current programs, are desperately needed to increase treatment adherence, particularly for high burden countries.
Intervention: Directly Observed Therapy, Short-course (DOTS)
The goal of TB control is to break the cycle of transmission by treating TB cases as early and efficiently as possible. In this effort, the WHO launched the ‘Directly Observed Therapy, Short-course’ (DOTS) strategy in 1994 in areas where tuberculosis disease burden was high.(7) The broader program strategy includes five key elements: political commitment, accessible laboratory services, strict supervision of each dose of treatment (DOT), uninterrupted supply of medications, and effective surveillance and monitoring systems for patient follow-up.(8) This strategy involves patients being directly observed when they take their medication every day over the six or nine months of treatment (short-course for latent infection and active disease respectively).(9) Observers can be “health workers, employers, or any responsible community member”.(9) The objective of DOTS is to ensure that patients complete their treatment course, and this in turn improves cure rates.(9) Cure rates have been reported up to 95% at various DOTS sites, unfortunately these results have not been replicated consistently under everyday conditions as opposed to clinical trials.(8) With such a comprehensive approach, it is hard to see why in some places the DOTS strategy could fail.
According to their 2010 global report, WHO declared that “between 1995 and 2009, a total of 41 million TB patients were successfully treated in DOTS programmes, and up to 6 million lives were saved including 2 million among women and children”.(4) This is evidence of great strides in the fight against TB. It is also important to note that as their target for treatment completion is 85%, and that for 2009 13/22 (59%) high burden countries met the target.(4) DOTS is considered to be the gold standard in treatment of TB.(7) However, some studies have found no significant differences in cure rates for patients in DOT compared with the control group who had self-administered treatment.(10) It is important to determine the effectiveness of the DOTS intervention, and where it falls short of the mark.
Despite DOTS program implementation across the world, there are still close to 9.5 million new cases per year worldwide.(4) Some countries still cannot achieve the WHO target of at least 85% treatment compliance.(4) Some reviews of the strategy find no difference in cure rates or rates of treatment completion between DOTS and the previously used self-administered treatment (SAT) model.(5,8)
Daunting questions remain: With treatment made readily available, why are some DOTS programs failing where others succeed? Why would people make the irrational health decision to discontinue treatment? What can public health do to rectify the flaws of DOTS interventions, as they currently exist?
To begin to answer these questions, we must first identify key elements of the DOTS program that are flawed. This critique will use theories of health behavior to explain where DOTS went wrong, and to formulate innovative strategies to increase TB treatment adherence in future interventions. First, although the overall program approach is composed of five key elements that take into consideration factors outside clinic treatment, the intervention itself is still rooted in individual-centered health behaviors models. Second, the DOTS approach fails to account for environmental and social factors influencing patient treatment adherence behavior. Finally, there is even potential for negative labeling and stigma under the current DOTS intervention.
Critique One: Use of Health Belief Model
The DOTS approach is inherently based on the patient making the rational decision to seek treatment, once diagnosed, and finish that treatment course until they are cured, based on weighing the pros and cons of that decision. If the patient were to make an irrational decision, as in not to accept or to discontinue treatment, the program fails. The only barriers to making the irrational decision that the program employs is the rigid approach at strict adherence through DOT, which makes patients accountable to the care-giver, and thus keeping them in treatment. Basically, this approach assumes that people will want to be cured of tuberculosis so they will go through the treatment plan as advised by the clinician. This foundation philosophy is similar to the health belief model.
The health belief model views health behavior change as based on a rational appraisal of the balance between the barriers to and benefits of action.(11) According to this model, the perceived seriousness of, and susceptibility to, a disease influence individual's perceived threat of disease.(11) So if tuberculosis is perceived to be a serious condition by the individual, and they are susceptible to death due to TB if they do not seek treatment, and the perceived threat of death is great, then they will seek treatment. Also, if they are in treatment, and they perceive the seriousness of their symptoms to be great, and believe they are susceptible to relapse if they quit treatment, then they will perceive that the treat of re-infection is great and will stay in treatment.
Similarly, perceived benefits and perceived barriers influence perceptions of the effectiveness of health behavior, which is this case in submitting to DOT.(11) Perceived benefits would be disease cure, assuming the patients believe the drugs will lead to a cure. Perceived barriers considered by the DOTS approach include drug supply and funding, which they impart as key elements of the program. The patient may or may not be aware of these measures, and may believe he/she does not have the money to pay for treatment, which would make going to the clinic at all an ineffective behavior if they believe they cannot access the treatment even if they do believe it works. There are other potential perceived barriers to treatment effectiveness, which the approach does not account for, some of which will be discussed later in this analysis.
This theory focuses on cognitive variables as part of behavior change, and assumes that attitudes and beliefs, as well as expectations of future events and outcomes, are major determinants of health related behaviors.(11) In the face of certain alternatives, this theory proposes that individuals will choose the action that will most likely lead to positive outcomes.(11) The program makes the assumption that patients will believe that the medications work, and therefore want the treatment. Depending on the region, there may be distrust of western medicine, alternative/traditional beliefs about cause and cure of tuberculosis, and numbers of patients stopping treatment early who then get sick again. All of these factors could affect the individual’s attitudes about the behavior of accepting treatment for nine months, and are not considered in individual-level models.
High-perceived threat, low barriers and high-perceived benefits to action increase the likelihood of engaging in the recommended behavior.(11) It has been suggested that the health belief model focuses on a single threat and prevention behavior and do not include possible additional threats competing for the individual's attention.(11) The DOTS approach functions mainly in the developing world, where these programs are most needed, so there are numerous competing threats the patient may weigh in when considering taking medication according to the regimen or not, as well as perceived barriers.
The patient may lose time and wages by making the required trip to the clinic every day, which may be substantial barriers for the patient in accessing treatment. The competing threat of job loss may be perceived as a greater threat than that of infection relapse or even infecting others. The occurrence of other illnesses may deter a patient from traveling as that may pose a greater thereat than the chronic TB. In addition, the side effects of taking medication may be severe enough to compete with severity of symptoms, or may hinder work performance, again posing the threat of job loss or forced time away from work. These outside threats may become a greater weight on the decision scale especially in the last months of treatment, when the patient will feel much better, even though there are still low levels of bacilli circulating that could multiply and cause a complete relapse. One study found that the largest contributing factor in patient non-adherence was due to patients “beginning to feel better” and that this accounted for 45.1% of treatment dropout among those who left treatment.(12)
While the health belief model may predict adherence in some situations, it has not been found to do so for "risk reduction behaviors that are more linked to socially determined or unconscious motivations".(11) When applying this theory to long-term medication adherence, it is also important for the influence of socio- psychological factors to be considered. For example, cultural beliefs about TB – such as its relationship with witchcraft or belief in traditional versus western medicine, could reduce an adherence intervention's effectiveness.(11) The theory is limiting in its dependence largely on rational processes and does not allow explicitly for the impacts of emotions or self-esteem on behavior, which may be related to a stigmatized disease such as tuberculosis.(11)
In the broader scope, the DOTS approach intends to control the spread of TB by one prevention method, which is treatment of all active cases. It is as if the DOTS plan has blinders on to all the outside factors that could cause it to fail.
Critique Two: DOTS Approach Does Not Account for Behavior-Influencing Social and Environmental Factors

The DOTS overall approach tries to incorporate “political commitment, accessible laboratory services, strict uninterrupted supply of medications, and effective surveillance and monitoring systems for patient follow-up”(4,8) in addition to supervision of each dose of treatment (DOT). Despite consideration of many practical issues that could arise in facilitation of DOTS strategy, it fails to consider social or environmental factors of the area in which it will be introduced.
The advantages of DOT are that people can be closely monitored and that there is a social process with peer pressure that may improve adherence.(5) In this way, one aspect of social influence is considered, but this is the only allowance for it. The disadvantages associated with DOT are that it moves away from adherence models of communication with cooperation between patient and provider back to a traditional medical approach with the patient as the passive recipient of advice and treatment.(5)
Patients may not like feeling as though they have no power in their treatment plan, as in the DOTS program, which is entirely clinician-managed. The paternalistic enforcement of observed drug swallowing may cue the natural human tendency to rebel, especially after months of forced directives. This method could actually make it less likely that the patient will return for subsequent treatments, if they feel they have no control, as the doctor has all of the power. Finally, it may make adherence worse if it is rigidly applied in an authoritarian setting or where people are expected to travel considerable distances to have their treatment supervised. The alternative of course, is to simply not return to the clinic for treatment. After months of medication, and finally feeling better, the odds that the patient will return under such conditions may be unlikely, considering the reduction in perceived severity of disease and risk of relapse with mitigation of symptoms. Not returning to the clinic may be perceived by the patient as a way to take back that control.
Another social factor that should be taken into consideration are role of the family in decision-making, which may be very different depending on the age and sex of the patient. If the patient is female or a child, in some cultures the decision to attend or not attend treatment may not be up to the patient.
Resource implications for a DOTS policy are substantial, particularly in low and middle-income countries where the caseload is high. Therefore, the strategy should be proven effective in the area before wasting countries already limited resources. DOTS strives for an uninterrupted supply chain of medication, yet one study found that “running out of drugs at home” was the patient-reported cause of treatment default in 25.4% of those who dropped out of treatment, which could occur in programs implemented with the pill-count method of observation.(12)
DOTS also does not directly account for staff time to manage DOT, which can put a great strain on the overall system. A chaotic clinic environment may influence the patient’s perception that his/her attendance causes problems for the rest of the clinic, and that doctors do not have time for them. Doctors may even lose credibility if the patient sees they are struggling and begin to question whether the treatment will really work.
In a study of risk factors for treatment discontinuation in DOTS programs in India, it was reported that alcoholism, illiteracy, having other commitments during treatment, inadequate knowledge of TB, poor patient provider interaction, lack of support from health staff, and dissatisfaction with services provided were all factors independently associated with treatment default.(13) Another environmental factor that could affect medication adherence is when care providers do not provide adequate explanation of treatment course and the importance of adherence. One study cited that 25.7% of dropout rate was due to “lack of knowledge on the benefits of completing the course” of treatment.(12) A study conducted in Nepal found that non-adherence was significantly associated with unemployment, low-status occupation, low annual income, and cost of travel to TB treatment facility.(14) This shows that socio-economic status is yet another factor for treatment default which should be considered when developing interventions.
There is strong evidence that there are many social and environmental factors that should be considered when running a DOTS program. Currently, social and environmental factors as not considered in DOTS implementation.
Critique Three: Potential for Negative Labeling and Stigmatization Associated with Tuberculosis Treatment
There is an ongoing presence of stigmatization associated with TB disease particularly in developing nations that has been well documented.(15) Understanding the origins of TB stigma is integral to reducing its impact on health.(15) As beliefs about the origins and transmission of TB may vary by culture, often resulting in stigmatism, seeking treatment can be a very delicate matter.(11) Although there is geographic and cultural variation in the explanations for why TB is stigmatized, most authors identify the perceived contagiousness of TB as a leading cause of stigmatization.(15) Lack of knowledge regarding routes of TB transmission may also contribute to TB stigma.(15)
In areas with high HIV prevalence, where HIV and TB co-infection is common, the association between the two diseases has contributed to the stigmatization of TB.(15) TB is perceived as a marker for HIV positivity; therefore, HIV-associated stigma is transferred to TB-infected individuals, regardless of their HIV-status.
Other causes of TB stigma include the perceived associations of TB with malnutrition, poverty, being foreign-born (U.S.), and of low social class.(15) Finally, TB stigma may occur because an affected individual’s community believes he or she must have done something to deserve to be infected.(15) This judgment may reflect the belief that TB is divine punishment for a moral or personal failing, which then justifies the stigmatization.
Social stigmatization can also lead to negative labeling of TB patients. Internalization of negative labels brought on by stigma associated with transmission of TB can have great psychological effects and could affect treatment adherence. TB-infected individuals perceive themselves to be at risk for a number of stigma-related social and economic consequences. Because the most common result of TB stigma is isolation from other members of the community, TB infection can substantially impact economic opportunities.(15) For those who do seek treatment, studies suggest an increasingly negative and demoralizing effect of DOT on patients.(5)
Several studies suggest that health-care providers and at-risk community members perceive TB stigma to have a more substantial impact on women’s health-care-seeking behavior than on men’s.(7,12,15) This could in part account for the lower disease rates in women, if women fear TB as a diagnosis and decide not to seek care.
Fear of stigmatization can delay diagnosis, and deter acceptance of treatment, and even continuing treatment once it has begun. Developing a reputation as a dirty or diseased individual could be a great deterrent in continuation of treatment. Unfortunately, the DOTS program as of now does nothing to ensure confidentiality of treatment. If treatment were self-administered at home, it would be unlikely that the community would know what pills the person was taking, whereas attendance to a TB clinic or to a general facility on a daily basis may not be conspicuous enough to hide the truth.
Revamping the DOTS Strategy
Tuberculosis is an extremely complicated disease, with a long and complex treatment regimen that must be followed consistently to achieve a good outcome. There is no easy answer to why the DOTS program fails in some places. It is a challenge to design, create, implement, and evaluate an intervention to increase treatment adherence. The DOTS approach has made a great impact in most places. It is not easy to create dynamic, sound interventions that account for the multitude of factors that contribute to the complexity of this disease and the human behaviors that affect its treatment. However, improvements can be made to address the shortcomings of the program using social and behavioral health principles.
As shown in the critique of the DOTS approach, there are several flaws that require development or expansion. The first critique addressed the use of the health belief model as the underlying foundation of the DOTS strategy. As an alternative, incorporation of other more comprehensive models could be used to account for more influences of human behavior in making new interventions. For example, learning theories presume that adherence to medical regimens requires social support and freedom from physical and social barriers.(16) One study’s results support the use of these theories in that adherence counseling had a positive effect on adherence, while engaging in other risk behaviors had a negative effect on adherence.(16) These models allow for irrational behavior, which the health belief model does not. This would be an improvement because it will allow for expansion to factors other than perceived severity and susceptibility and perceived barriers and benefits. By allowing for the possibility that humans may make irrational decisions, the influences that lead to irrationality could more clearly be seen. Considering internal impacts of emotions and self-esteem and external impacts such as social and environmental factors can help to accomplish this.
The second criticism of the DOTS strategy was that it failed to account for social and environmental factors. Leaving these factors out of consideration came at great losses of patients not returning to clinic for treatment.(17) In order for the DOTS intervention to work, it must be bolstered with consideration of social and environmental factors that are site specific where feasible. In many studies it has been reported that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation).(3,9,10) This suggests that there are significant environmental barriers that must be taken into consideration in updating the DOTS strategy. If used, DOT should be flexible and convenient regardless if conducted at a health facility or in patients home with a nurse. The emphasis should shift in practice from pill counting towards patient-centered treatment support, together with education on what to expect from disease and medication.
One study reported that provider attitudes were poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their schedules, rather than their patients’.(12) This is clearly not an example of a supportive environment. Interventions are needed to improve clinician-patient communications and staff attitudes so that patients do not encounter a clinic environment in which they feel demeaned.
A social factor not previously incorporated in the DOTS strategy is family involvement. As noted, the head of the household may make decisions on whether or not other members of the family will be permitted to go to treatment everyday. Factors that could affect this decision include economic feasibility, social stigma, or mode of transport to TB treatment site. By involving the family from the beginning of treatment, there is a higher likelihood of treatment adherence, resulting from receiving the same education the patient receives. Incorporation of the family in treatment could work in TB control by screening family members for the disease while they’re at the clinic. If a patient feels supported by his/her family, they may be more likely to feel acceptance of their disease and receive the treatment without default. Family support could also work to increase self-efficacy and self-esteem, even in the face of stigmatism from others in community. In a similar intervention, improvement of patient education messages and adherence counseling should also me implemented.
Another social intervention that proved to be successful in practice was a ‘cultural intervention’ which involved five elements: 1) the same interventionist nurse was used for the same patient at each clinic visit in order to establish a relationship, 2) family members names were noted in medical chart in order for the nurse to inquire about the patients family at subsequent visits, 3) A common Latino proverb was stated by the nurse at each visit, which subsequently became the logo for the study and was put onto stickers and small gifts for nurses to distribute to participants at random visits, 4) Educational materials were culturally adapted and written at sixth-grade reading level, 5) All nurses were fluent in Spanish.(18) These elements were all based around core Latino values and culture, which made the intervention tailored to the population they were serving. This intervention uses the principle of liking in order to help the patients relate to the nurse and in turn, improves their adherence to treatment.
The final flaw in this critique was failure of the DOTS program to address stigmatism in its strategy, and the potential for negative labeling that this could incur. One possible intervention would be widespread education campaigns. One reason stigmatism is so prevalent is a lack of knowledge on routes of transmission, as well as association with many negative characteristics, such as poverty, poor hygiene, malnutrition etc. Collective cognitive change is slow, so an education campaign certainly will not change social norms on its own to eliminate stigmatism towards TB, but it could reduce it with time. While some studies report lack of knowledge as a main factor in stigma development, others have noted that education campaigns are ineffective.(15) Therefore, tailoring education campaigns to a specific audience and using effective social theories and principles is imperative in their development.
Although community and institutional norms ultimately mediate stigmatization, wide-scale interventions to change these norms can be difficult. A smaller-scale intervention that could be utilized is support groups for people who are in treatment. The groups extend a social support and sense of belonging that could help to limit the internalization of negative associations with TB as labels. These have been effective in reducing HIV/AIDS stigmatization in Voluntary Counseling and Testing (VCT) centers that hold support groups. This seems to be a promising approach in helping TB-infected individuals resist TB stigma, particularly through TB clubs, says one assessment.(15)
Finally, it is essential to continue to develop other interventions—for example, counseling TB-infected patients or introducing default-screening policies in high TB prevalence areas—to reduce TB stigma. It is also important to supplement this bottom-up approach to reducing TB stigma with an assessment of interventions designed to directly address stigmatizing community norms about TB.
Since its implementation in 1994, DOTS has accomplished great things in TB treatment. However, treatment adherence continues to be a serious problem in TB control. The DOTS strategy is built on traditional health belief models that fail to consider environmental and social factors contributing to alternative behaviors. Overall, the DOTS approach’s biggest downfall is in its failure to customize each implementation program site. By not tailoring the program to account for the social and environmental factors that will potentially influence behavior in that region, and making the assumption that patients behave rationally and stay in treatment without additional interventions, significant numbers of patients quit treatment. With several modifications, including integration of more comprehensive theories such as learning theories, increasing flexibility of treatment plans, opening communication lines between patients and providers, moving towards patient-centered care, improving patient education, instituting adherence counseling, developing evidence-based education campaigns, forming support groups and involving families in treatment, and utilizing core values of the culture to improve clinic and treatment experience.

References


1. Smith-Nonini S. When "the program is good, but the disease is better": lessons from Peru on drug-resistant tuberculosis. Med Anthropol. 2005;24(3):265-296.

2. Enarson DA, Billo NE. Critical evaluation of the Global DOTS Expansion Plan. Bull. World Health Organ. 2007;85(5):395-398; discussion 399-403.

3. Resch SC, Salomon JA, Murray M, Weinstein MC. Cost-effectiveness of treating multidrug-resistant tuberculosis. PLoS Med. 2006;3(7):e241.

4. Global tuberculosis control 2010. 2010.

5. Volmink J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev. 2003;(1):CD003343.

6. Amuha MG, Kutyabami P, Kitutu FE, Odoi-Adome R, Kalyango JN. Non-adherence to anti-TB drugs among TB/HIV co-infected patients in Mbarara Hospital Uganda: prevalence and associated factors. Afr Health Sci. 2009;9 Suppl 1:S8-15.

7. Lienhardt C, Ogden JA. Tuberculosis control in resource-poor countries: have we reached the limits of the universal paradigm? Trop. Med. Int. Health. 2004;9(7):833-841.

8. Radilla-Chávez P, Laniado-Laborín R. Results of directly observed treatment for tuberculosis in Ensenada, Mexico: not all DOTS programs are created equally. Int. J. Tuberc. Lung Dis. 2007;11(3):289-292.

9. Ntshanga SP, Rustomjee R, Mabaso MLH. Evaluation of directly observed therapy for tuberculosis in KwaZulu-Natal, South Africa. Trans. R. Soc. Trop. Med. Hyg. 2009;103(6):571-574.

10. Khan MA, Walley JD, Witter SN, Shah SK, Javeed S. Tuberculosis patient adherence to direct observation: results of a social study in Pakistan. Health Policy Plan. 2005;20(6):354-365.

11. Munro S, Lewin S, Swart T, Volmink J. A review of health behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS? BMC Public Health. 2007;7:104.

12. Kaona FAD, Tuba M, Siziya S, Sikaona L. An assessment of factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment. BMC Public Health. 2004;4:68.

13. Vijay S, Kumar P, Chauhan LS, et al. Risk factors associated with default among new smear positive TB patients treated under DOTS in India. PLoS ONE. 2010;5(4):e10043.

14. Mishra P, Hansen EH, Sabroe S, Kafle KK. Socio-economic status and adherence to tuberculosis treatment: a case-control study in a district of Nepal. Int. J. Tuberc. Lung Dis. 2005;9(10):1134-1139.

15. Courtwright A, Turner AN. Tuberculosis and stigmatization: pathways and interventions. Public Health Rep. 2010;125 Suppl 4:34-42.

16. Hovell M, Blumberg E, Gil-Trejo L, et al. Predictors of adherence to treatment for latent tuberculosis infection in high-risk Latino adolescents: a behavioral epidemiological analysis. Soc Sci Med. 2003;56(8):1789-1796.

17. Abuaku B, Tan H, Li X, Chen M, Huang X. Treatment default and death among tuberculosis patients in Hunan, China. Scand. J. Infect. Dis. 2010;42(4):281-287.

18. Ailinger RL, Martyn D, Lasus H, Lima Garcia N. The effect of a cultural intervention on adherence to latent tuberculosis infection therapy in Latino immigrants. Public Health Nurs. 2010;27(2):115-120.

Flaws of The 5-a-day Campaign –Sungeun Kim

The effects of diet on health have been emphasized over a few decades, and research has shown that a high intake of fruits and vegetables has a role in protecting against the development of chronic diseases and obesity. Healthy People 2010 recommends consuming ≥2 servings of fruits and ≥3 servings of vegetables a day for children (1). However, according to National Health and Nutrition Examination Survey (NHANES) data, average daily intake of fruits and vegetables for children is 3.7 servings, and only 18 to 20% of children consume 5 or more than 5 servings (2).
First of all, a higher intake of fruits and vegetables is related to a decrease in the incidence of obesity. Obesity is a rapidly growing health problem that is not just threat to adults. Childhood obesity has been grown dramatically over a few decades (3). Overweight or obese children are more likely to become obese adults. There are several negative effects of obesity on health, such as increased risk of heart disease, high blood pressure, diabetes, breathing problems, and trouble sleeping. Emotional problems are another consequence of childhood obesity because obese children tend to have lower self-esteem (4).
With development of new technologies, people tend to be less physically active and to eat more. These days, there are numerous processed or convenient foods that contain high amounts of calories, sugar, salts, and saturated fats. These foods are also available in schools. . Vegetables and fruits have high amounts of water and fiber and low energy density. Research has shown that dietary fiber increases satiety and decreases later hunger, resulting in less eating and weight loss in the long term (5). If children feel more satiety, there is a lower chance they will eat from unhealthy sources such as vending machines and snack bars. The high content of water in vegetables and fruits leads children to eat less food that is high energy. This means that filling up the stomach with vegetables and fruits can help control hunger and reduce energy intake (2). Since one of the contributing factors to obesity is a diet of high energy density and low nutrition density foods, adding vegetables and fruits to one’s diet can help to prevent and treat obesity and weight problems.
There are many campaigns to convince people to eat more vegetables and fruits. One well-known campaign is the 5-a-day campaign. This campaign has been initiated by the government targeting the general population, particularly children. It emphasizes the importance of having at least five servings of vegetables and fruits every day. However, according to the national diet and nutrition survey published by the Food Standards Agency, it was found that children eat less vegetables and fruits compared with the past (6). It turns out that the 5-a-day has not been successful in persuading people to have a healthier eating habit. There are several flaws in this campaign that makes it inefficient.

1. The 5-a-day campaign does not take into account the fact that target population is composed of various socio-economic, cultural, and racial backgrounds.
According to the social contextual model of health behavior change, social context is important to make health behavioral changes. Socio-economic, race, and culture impacts health behaviors widely, such as dietary patterns and physical activity (7). Many diverse groups have low amounts of vegetables and fruit consumption: Female adolescents, American Indian (low fruit intake), African-American (low vegetable intake), and those in the middle and lower socio-economic level (8). However, the 5-a-day campaign does not consider the characteristic difference in the population. Instead, it delivers the same message to all of the population. National data suggest that school-aged children consume lower amounts of vegetables and fruits than the 2005 diet guidelines recommendations. This is particularly significant among children from low income families (2). Children and adolescents from low income families are most likely to have the fewest servings of fruit and vegetables. According to Consumer Expenditure Survey data, while a person from an average socio-economic household spends $5.02 to buy fruit and vegetable, a person from low socio-economic households only spends $3.50 for vegetables and fruits per week (2).
According to Abraham maslow’s hierarchy of needs theory, there is a hierarchy of five levels of basic needs, which are physiological needs, safety, love/belonging, esteem, and self-actualization. In the hierarchy of five basic needs, one does not want the second need until the first need is satisfied. Humans are motivated to the next higher level of need once lower needs are met (9). Children who are from a low income family do not worry about eating five servings of fruit and vegetables per day, although it would improve their future health. They would rather focus on physiological needs. Because vegetables and fruits are more expansive than other foods, like high calorie foods, it is often inevitable that low socio-economic parents buy unhealthy foods. In addition, the recent depressed economy may lead low income families buy fewer vegetables and fruits. Because these children’s lower needs are not met, the message about various benefits of eating fruits and vegetables is not going to change their dietary habits.
A population’s characteristics, such as income and culture that might influence dietary intake should be considered for the intervention (7). Understanding different patterns of healthy behaviors between different socioeconomic positions and other aspects of the social environment is crucial for creating a successful intervention. Therefore, the intervention should be designed to reduce the gap among children’s differences. A different approach should be made to communicate effectively with all the population. For example, for African American, green leafy vegetables are popular, and cooked vegetables are more preferred. Cooking demonstrations with teachers at schools could be one approach. Cooking healthy foods with other friends and teachers could increase their interest and they will be more likely to eat vegetables and fruits. Bringing that recipe home may lead their mothers cook for them. For low income family children, their situation should be taken into account and incorporated into an intervention. For those children, school meals might be the only source where they can obtain fruits and vegetables. Because their physiological needs are not met, their priority of resource allocation is not health related (9). Their parents would not care about buying fresh fruits and vegetables for their family’s health. Intervention should focus on improving school meals, since school meals are accessible to most children with a low socio-economic status. Research done by the Food and Nutrition Services of the United States Department of Agriculture shows that students in the National Lunch School Program are more likely to have fruit juice and more vegetables than those who do not participate in school meals. This result demonstrates the importance of school meals for low income children in terms of having enough vegetables and fruits (2)

2. 5-a-day neglects one of the most important components in changing one’s behaviors: motivation.

Because motivation leads a person to make behavioral changes, it is a critical aspect that should be considered in an intervention designed to change behaviors. Self-Determination Theory suggests that making and maintaining a behavioral change is related to motivation (10). To obtain motivation to initiate and maintain new behavioral patterns, autonomy should be developed. Motivation is differentiated into two categories, controlled motivation and autonomous motivation (11). Controlled motivation occurs when a person is under pressure and an environment is controlled. With controlled motivation, one is likely to fail to persist with behavioral changes over the long-term. Contrary to controlled motivation, autonomous motivation does not come from external pressure, rather from internal worth that one considers important. One feels satisfaction from the activity. Self-Determination Theory suggests much higher success rates for maintaining a behavioral change than controlled motivation (11). Self-Determination theory proposes that pressure and control have negative effects on autonomy, leading to a lower quality of motivation (12). Therefore, it is important to respect one’s opinions and values to encourage autonomous motivation to support this need. However, 5-a-day campaign focuses on increasing the awareness about the importance of eating vegetables and fruits by using controlled motivation.
According to Self-Determination Theory, the problem with the 5-a-day campaign is that it is based on controlled motivation. It gives both negative effects of not having five servings of fruits and vegetables per day and positive effects of having them, and pushes children to eat more of them. If children have eaten vegetables and fruits because a teacher or parents tells them to do so, it is unlikely one will maintain that eating habit because that behavior comes from controlled motivation (13). This theory proposes a lack of autonomos motivation as the main reason for failure to keep healthy eating habits because controlled motivation is associated with poor performance
outcomes.
A successful intervention can be created by applying Self-Determination Theory to it. The best way to motivate children to eat more vegetables and fruits should be considered before the intervention is initiated. First of all, an autonomy supportive environment should be created (10). Each person has to make their own decisions and be encouraged to make choices by themselves. Since children spend most of their time at shools, schools can have a huge impact on children’s eating habits. Schools have been considered as a main location to lower obesity rates and promote healthy eating habits for children (1). A possible intervention could be that children learn about vegetables and fruits. Teachers would introduce a variety of vegetables and fruits in colors and taste. Once a week, there would be a list of choices of fruits and vegetables on the table in class. Each child would pick whatever they like, eat them, and share what they feel and what they like about them. They will talk about what values are important to them, and the connection between their values and a healthy diet. Some children think healthy behaviors are boring and no fun. But in this way, children will find having vegetables and fruits can be fun and interesting. Once they find autonomous motivation, it may lead them to eat more of vegetables and fruits even outside of school. Finding out that healthy eating habits are intriguing will help to encourage children to keep doing it for a lifetime.

3. 5-a-day campaign does not explain the issue of self efficacy.

In the self-efficacy theory, how people think, motivate, and behave themselves depends on their self-efficacy. People who have higher self- efficacy are more confident about completing a task and willing to try and overcome it. In contrast, people who do not trust their abilities to succeed at something are more likely to avoid and give up rather than putting efforts actively (14). Therefore, self -efficacy is one of the most important factors in determining one’s behaviors for achieving a goal. One of the flaws that the 5-a-day has is that it ignores the impact on self efficacy on behavior changes. Eating 5 servings of fruits and vegetables could be impossible for some people, particularly on those who do not eat vegetables and fruits now. At least 5 servings of fruits and vegetables every day for adults is difficult to achieve, and it is even more difficult for children to have this amount. According to the self-efficacy theory, children may give up having a healthy diet because it seems to be hard and out of their scope. Therefore, self-efficacy should be taken into account as the main factor in an intervention. Because the average consumption of vegetables and fruits among children is about 3 servings, it is not practical to persuade them to have at least 5servings.
To make an intervention effective, the campaign should encourage children’s perceptions that a goal is achievable. Instead of delivering the message to consume at least 5 servings of fruits and vegetables, tell children to increase consumption by half or one serving, and gradually increase them as they reach their goals. Increasing by half to one serving is not threatened to most children, and therefore they are more likely to achieve a goal and maintain it due to higher self-efficacy.
Self-efficacy theory suggests that seeing people similar to oneself succeed increases observers’ beliefs that they have abilities to complete that task as well. Children’s self-efficacy changes substantially depending upon the peers that they are surrounded by (14). A great amount of social learning occurs from peers. Thus, self-efficacy can be enhanced through peer influences (14). This can be used to create an effective intervention. One possible intervention would be that each child writes a goal at school related to increasing vegetables and fruits consumption once a week, and after a week, they will share their experience and feelings, how they achieved their goals and what obstacles they had to achieve a goal. Whether or not they achieve a goal, there will be no prize or punishment. After sharing, they will set another goal. As children observe their peers who are similar to them succeed to complete a goal, they would obtain higher self-efficacy that leads them to feel more confident about accomplishing a task, and therefore encourages them to put more efforts on it.

Conclusion

The 5-a-day campaign has been initiated to help all people, particularly children, to have healthy eating habits. However, it turns out that this campaign does not have huge effects on peoples’ diets. First of all, it does not reflect different characteristics of population in terms of culture, race, and racial backgrounds. Because social context determines peoples’ diets, various approaches for different people should be done to persuade them to make behavioral changes. Another flaw of the 5-a-day campaign is that it ignores the importance of autonomous motivation. Controlled motivation seems to work at first, but behavioral changes cannot be maintained with controlled motivation. Intervention should be designed to increase children’s interest about eating vegetables and fruits and help them to relate their own values for a healthy diet. Lastly, the 5-a-day campaign does not include the concept of self-efficacy. Children are more likely to attempt a task when it is more achievable and realistic. Because at least having 5 servings of vegetables and fruits per day is difficult to accomplish for most children, increasing a mild to moderate amount of their current consumption would have more powerful influence on their diets. The importance of having vegetables and fruits has been emphasized for a few decades and there are many campaigns encouraging eating them. The 5-a-day campaign has been shown to be inefficient, even though a tremendous amount of money has spent. Because the majority of habits are determined during childhood, it is important to have a healthy diet from an early age. School is the place where children spend the most time, and therefore it can be the most potent venue to encourage them to eat more fruits and vegetables. Therefore, there is a strong need to implement an effective intervention that takes place at school.

References
1. Mary, S., Karen, M.K., Ramona, R.O., & Karen, G. (2008). Creating Healthy Food and Eating Environments: Policy and Environmental Approaches. Public Health, 29, 253-272.
2. Robinson-O'Brien, R., Burgess-Champoux, T., Haines, J., Hannan, P.J ., & Neumark-Sztainer, D. (2010). Associations Between School Meals Offered Through the National School Lunch Program and the School Breakfast Program and Fruit and Vegetable Intake Among Ethnically Diverse, Low-Income Children. JOURNAL OF SCHOOL HEALTH, 80 (10), 487-492.
3. Rolls, B.J. (2010). Dietary strategies for the prevention and treatment of obesity. PROCEEDINGS OF THE NUTRITION SOCIETY, 69(1), 70-79.
4. Obesity In Children And Teens. (2008, May). Accessed November 17 2010 at http://aacap.org/page.ww?name=Obesity+in+Children+and+Teens§ion=Facts+for+Families
5. Tetens, I., & Alinia, S. (2009). The role of fruit consumption in the prevention of obesity.
6. Accessed December 1, 2010 at http://www.guardian.co.uk/society/2003/jan/20/medicineandhealth.publichealth.
7. Sorensen, J Glorian, Stoddard, Anne M, Dubowitz., et al. (2007). The Influence of Social Context on Changes in Fruit and Vegetable Consumption: Results of the Healthy Directions Studies. American Journal of Public Health. 97, 1216-1227.
8. Young, Elizabeth M & Fors, Stuart W.(2001). Factors Related to the Eating Habits of Students in Grades 9-12. Journal of School Health, 71, 483-889.
9. Accessed November 23, 2010 at http://www.abrahammaslow.com/m_motivation/Hierarchy_of_Needs.asp
10. Marlene N.S., Paulo N. V., Silvia R. C., et al.(2010). Using self-determination theory to promote physical activity and weight control: a randomized controlled trial in women. Journal of Behavioral Medicine, 33, 110-122.
11. Richard M. R., Heather P., Edward L. D., et al. (2008). Facilitating health behavioral change and its maintenance: Interventions based on Self-Determination Theory. The European Health Psychologist, 10.
12. Ricahrd M. R., Kelly B. (2002). Autonomy support and need satisfaction in the motivation and well-being of gymnasts. Journal of Applied Sport Psychology, 15, 372-390.
13. Phillip M.W., Diane E. M., & Kimberly P. G. (2008). Understanding motivation for exercise: A self-determination theory perspective. Canadian Psychology, 49, 250-256.
14. Accessed November 26, 2010 at http://www.apla.org/accionmutua/pdf/Self_Efficacy_Theory.pdf

Britain and the Trouble of ‘Glassing’: A Narrow Approach to a Broad Problem – Caroline Pantridge

In recent years, an increasing amount of public health research has begun focusing on the relationship between alcohol and various forms of violence. Perhaps unsurprisingly, a high number of sexual assaults, physical assaults, and robberies occur when the perpetrator is under the influence of alcohol. While alcohol-related violence occurs around the globe, England in particular struggles with high levels. The British Crime Survey, published in 2000, put the number of alcohol-related violence incidents at 1.2 million, with half of these occurring around bars and nightclubs on weekend nights (1). England is increasingly concerned with its younger generation as they relate to these numbers, as well. In a report that looked at hospital admissions as an indicator of incidents done by the British Government’s Home Office, 6,657 people under age 18 were hospitalized for alcohol-related reasons in 1998, and this number jumped to 8,889 by 2006 (2). The same report singles out “glassing” as an alcohol-related assault of particular concern. The Home Office writes “in glassing incidents the perpetrator either thrusts a glass directly at a person’s face or body, or across it in a slapping-style motion…another common glassing approach is to throw the bottle or glass so that it becomes an exploding projectile” (2). When it comes to glassing attacks, pint glasses are most often cited in reported assaults, and up to 1,000 people a week suffer from injuries to the face as a result of such drunken attacks (2).
Increased attention is being focused on glassing by British politicians and agencies, particularly in the past year, as these realities have come to light. Though multiple proposals exist for mediating the damage done by glass, specifically, one of the current interventions gaining publicity is the development and introduction of shatterproof pint glasses (16). The use of safer vessels is a way to change an aspect of the nightlife environment that often contributes to significant injuries (1). This past February, the Home Office and Design Out Crime unveiled two innovative models. Gregory Katz writes “one has a thin bio-resin coating on the inside that strengthens it, and the other bonds two thin layers of glass together in the same way as car windshields” (8). Though still made of glass, which is most appealing to the typical beer consumer, these pints can no longer act as lethal weapons. Even if glasses crack, the resin binds the pieces together to prevent dangerous shards. Employees at Design Out Crime studied the different ways in which glasses were used to inflict harm and are touting the new prototypes as a way towards broader social change and overall safer drinking environments (2). After the pilot phase which is occurring at multiple high profile bars in order to test the safety and cost-effectiveness of the glasses, the Home Office plans to introduce the glasses on a voluntary basis (8).
While the replacement of dangerous pint glasses with safer alternatives is certainly innovative and addresses an environmental risk factor for violence, there are multiple flaws to this being a main approach for addressing alcohol-related violent incidents in England. On an intervention-specific level, the Home Office does not appear to have developed an effective way of framing and selling these new glasses to bars and nightclubs. Furthermore, on a broader level, this intervention fails to address other factors that contribute to violence in both the bar-specific environment as well as at the overall community level.
Making the Switch
One of the main issues with the shatterproof glasses intervention as it is now is the lack of a marketing plan to prompt bars to adopt the new technology. As it stands now, glasses will be made available on a voluntary basis to vendors. In order to affect any real change in the country, and to be considered an environmental change intervention, a vast majority, if not all, bars and nightclubs will have to make the switch to shatterproof glasses. By currently treating bars as essentially individual entities, it can be argued that the Home Office is relying on the Health Belief Model as the approach for creating buy-in to the glasses.
The Health Belief Model works on an individual level, in this case bar by bar, and looks at perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (4). Operating under these assumptions, bar owners must consider in a rational manner the following before reaching a decision: have a number of glassing incidents occurred in recent memory? How severe were they? Were people brought to the hospital, or were confrontations easily broken up by bar staff? Finally, perceived benefits would have to be weighed, such as the creation of a safer environment, and perhaps fewer glasses to replace from general wear and tear. Perceived barriers to action can manifest in multiple forms, such as customer backlash. For bars that actually do regularly deal with violent incidents, switching glasses might create feelings of a tarnished image stemming from the admission that the bar was not particularly safe before. Perhaps more importantly, bars that recall no recent incidents or relatively mild ones will have low motivation to participate, focusing only on barriers to change given their low perceived susceptibility to conflict.
Relying on individual bars to make rational calculations about the benefits of switching to shatterproof pints, rather than more broadly requiring structural change, threatens to undermine the goal of reducing glassing incidents. While the Home Office and Design Out Crime might not be able to recognize disadvantages to making the switch, since promoting safety seems inherently desirable and advantageous, they may underestimate strong factors promoting the status quo, such as the long history and glorification of the classic pint in England, not to mention simply the inconvenience and logistical concerns that come with changing over inventory. In a recent study done by Simon Moore and his team in England bars were asked to voluntarily participate in a pilot program aimed at reducing intoxication and disorder around licensed establishments. While their study produced some interesting findings, the response rate for participation was not large enough to justify future trials. Simon et al write “problem premises cannot be relied on to voluntarily address alcohol-related harm. The only feasible recruitment method for a future trial would require the support of the police” (10). Thus, a voluntary basis policy with no real incentivizing is flawed and likely to be ineffective in promoting adoption of the glasses. Furthermore, as part of the same initiative, similar tactics need to be developed and employed with major alcoholic beverage companies, as they often furnish bars with their own distinctive pints. The government needs to consider strengthening the intervention through the use of framing theory, the process of appealing to ideals and self-interest, to ensure success.


More than the Glasses
The Design Out Crime glassing intervention is also flawed in that it fails to take into account other environmental factors within bars and other establishments that can contribute to alcohol-related violence. In order for incidents of glassing to actually diminish, not only do shatterproof glasses need to be widespread, but other precautionary changes must occur in bar environments, as well. While glasses undoubtedly inflict more severe injuries in the short term, and are thus of particular concern, other environmental factors contribute to the provocation of violence in the first place, not the least of which is levels of alcohol consumption.
There are a number of preventive measures that can be taken to reduce situational risk factors that contribute to alcohol-related violence. As it stands now, exposure to nightlife in popular urban centers is associated with higher chances of violent victimization (10). Simon Moore and his team state that “unfocused interventions are likely to be less effective than interventions that are responsive to the risks and needs of individual premises” (10). As it stands now, the shatterproof pint glasses are an unfocused intervention ironically due to their very narrow scope. Some bars could certainly benefit from more than simply a glass intervention. Research shows that victimization is more likely to occur the more alcohol people consume (1). Bar management decisions around the offering of cheap beer or shot specials can pose much larger environmental risk than simply the presence of glassware (16).
High levels of intoxication also contribute to violence perpetration in that it affects how individuals react to certain stimuli. Behavior in general is related to overall setting, triggering events, cognitive skills and thoughts, and considerations of rewards or punishments (9). Just as with victimization, perpetrators of alcohol-related violence report drinking for lengthy periods of time before their offense (9). Research on alcohol’s effects, as well as the attention-allocation model, provide reasoning for this phenomenon. Peter Giancola et al write “alcohol-induced impairment creates a narrowing or ‘myopic’ effect on attention that restricts the range of internal and external cues that can be perceived and processed” (6). As a result, people in this state often recognize only the most salient social cues, some of which may be deemed provocative, rather than the presence of subtler inhibitory cues (6) Bars must keep in mind that the environment they create through alcohol consumption, as well as other environmental factors, can contribute significantly to the risk of alcohol-related violence, since alcohol is a drug that does in fact impair judgment.
Furthermore, in the Bar Violence Study conducted in Buffalo, New York, it was found that participants characterized bars that were “smokier, higher in temperature, dirtier, darker, more crowded, and more likely to have competitive games” to be more susceptible to violent behavior (12). This study found that it was often the characteristics of the bar establishments themselves, rather than the typical clientele, that determined levels of violence (12). Given these risk factors, it is clear that more than simply pint glasses must be revised in order to decrease alcohol-related violent incidents. By focusing on glassing as a main concern, the British government should be careful not to lose sight of the more upstream issues in bar environments that contribute to violence and how they, as well, can be mediated.
Moving Further Upstream
At the heart of the matter, the major flaw of the shatterproof pint glass intervention is that it does nothing to address one of the major roots of the problem when it comes to alcohol-related violence: high levels of drinking. Thus it can be considered a very downstream approach. While not an unworthy intervention, replacing glasses looks to mediate the effects of a problematic drinking culture without attempting to remedy any of the factors that contribute to this culture. Heavy drinking frequency is significantly related to violence frequency (11). The United Kingdom, in particular, struggles with a rate of alcohol consumption that rivals fellow industrialized nations. The Wall Street Journal reported that “per capita consumption of alcohol in the U.K. rose 19% between 1980 and 2007, compared with a 13% decline for all 30 countries in the Organization for Economic Cooperation and Development” (16). Shatterproof pint glasses must be part of a comprehensive community level approach to alcohol and related violence in order to truly reduce attacks.
Currently, the biggest factor in glassings in England is likely not the glasses themselves, but, as David Jernigan of the Johns Hopkins Bloomberg School of Public Health notes, “the longer hours for pubs, cheap supermarket booze and the advent of ‘alcopops,’ premixed cocktails favored by young drinkers” (16) The general availability of cheap alcohol outside of nightclubs and other establishments is a major concern; one that threatens to severely undermine positive changes enacted by individual bars (16). In order to effectively start preventing violence, Britain must consider broader policy changes related to where alcohol is allowed to be sold, at what price, and looking at hours of operation for these establishments. Until structural changes happen on the community or nationwide level, current drinking behaviors in the country are likely to persist (7). In order for any behavior change to be feasible, and before any sort of social norming around appropriate levels of consumption can occur, the environment as a whole must be conducive. Shatterproof glasses are a miniscule component of the overall drinking scene.
Strengthening the Approach
The effectiveness of the shatterproof pint glass is dependent on its pairing with a broader view of environmental change. While there are few best practices for violence prevention, there exist quite a few for reducing alcohol consumption, the factor which is fueling much of this situational violence. The British government should focus its efforts on environmental change on three different levels, rather than just one. First of all, it must lobby for widespread use of the shatterproof glass at the most specific level. Then, it must investigate further environmental risk factors that can be reduced at the establishment level. Finally, policies must be enacted at the community or national level to address community-wide risk factors for violence. Taken together, these three tiers of environmental management can start reducing violence and create a conducive environment for behavior change around alcohol use.
Creating Buy-in
In order to significantly reduce glass attacks, the British government must create buy-in for its shatterproof glass product from bar owners on a large and widespread scale. Since legislation mandating the new technology might not be necessary or politically feasible, greater attention must be given to an effective marketing strategy. The main tenets of the strategy should include a branding approach for the glass and the values that it offers particular bar establishments, as well as a campaign to target the most influential bars in any given area first with the intervention. Reliance on the nudge effect, as well as branding effects, can broaden the scope of the intervention without provoking the possible negative reaction that ‘requiring’ shatterproof glasses might elicit.
The marketing campaign should start in the most popular nightlife destinations and pitches should be made in the relatively public arena of the city or town’s licensing board or club manager meetings. Though attention and airtime should be given to cost-effectiveness and logistical concerns, the pitch should focus on the public status that the bar can attain by being on the cutting edge of new technology, while still holding on to all the symbolic value that the traditional pint glass holds. Nudging relates to the role that social influence can have in effecting change at a community level. Richard Thaler and Cass Sunstein write in their book that “social influences come in two basic categories: the first involves information…the second involves peer pressure” (14). Peer pressure can be used to the campaign’s advantage if all the bar owners in a particular area are in the same room, especially if a few influential establishments can be won over in advance. People increasingly conform to ideas when they have to own up to their decision in public, and when influential people are seen to advocate for a particular appropriate behavior (14).
The way that information about the shatterproof pint glasses is conveyed will be crucial to their success, and this is where branding methods can come into play. Contrary to assumptions made by the Health Belief Model, for example, humans often do not make decisions in rational ways. Hence, why it might seem logical for everyone to simply adopt the safer glasses, appeals will likely have to be made on an emotional level to ensure a high level of buy-in. Douglas Evans and Gerard Hastings write “a branded message is a strategic communication designed to elicit a particular set of beneficial associations in the mind of the consumer which become linked to the brand’s identity” (5). In addition to positive associations, brands are also most successful when they are seen as offering solutions to problems. For this particular intervention, information needs to be gathered by consumers in order to determine the main criteria for a good night out on the town. After all, no one is likely to include glassing incidents as part of their end goal when going out. Once information is gathered, the Home Office and its partners need to emphasize not safety (which, though logically positive, is not particularly compelling), but rather the sentiments of fun, carefree socialization, and lack of drama that are given a chance to flourish in the absence of flying glass shards. It must be stressed that making a relatively small environmental change within the bar environment can save all consumers from a dangerous end to the night. Presenting positive imagery of vibrant night life without the presence of confrontation, pint glasses as weapons, and police or medical intervention will appeal to the idealized view in the bar owner’s mind (5-31).
Finally, in order to employ the peer pressure idea from the nudging concept, as well as invoke the concept of ownership, the Home Office should develop a physical icon that bars can post on a door or window which signifies their participation in the intervention. Once it becomes public knowledge that a certain establishment supports decreases in violence and a promotion of safety, the bar is more likely to live up to this expectation and continue using shatterproof glasses as well as encourage others to participate. The intervention can become a part of the bar’s identity (5).
Targeting More than a Glass
In order to significantly reduce alcohol-related violence, glassing included, more than just the glassware in any given bar environment must be addressed. In addition to vigorously campaigning for shatterproof pints, other preventative measures should be taken in bars, coupled with follow-up enforcement mechanisms.
The National Institute on Alcohol Abuse and Alcoholism cites the regulation of happy hour promotions as well as responsible beverage server programs for bars as promising and effective strategies in reducing alcohol abuse (13-250). In the Bar Violence Study done in Buffalo, New York which investigated situational risk factors for violent behavior, bars with staff that were trained in more responsible serving practices as well as in conflict reduction skills demonstrated “fewer instances of severe aggression by patrons” post-training (12). Tighter regulations around the serving of intoxicated persons and more information for bartenders and bouncers on defusing tensions can help prevent situations from escalating, shatterproof glasses or not.
Aside from staff, bar environments can be physically altered to promote healthier socialization and relaxation rather than confrontation. Tracey Budd writes about how people “can be primed into certain forms of behavior by offering simple and apparently irrelevant cues”(1) By the same token, bars with more lighting, decreased crowd sizes and cleaner facilities might be interpreted as less accepting of violence. The attention-allocation model postulates that due to the effects of alcohol myopia, attention can become focused on a narrow set of social cues. Thus, it is important that these cues signify a distraction from aggressive behavior rather than a provocation (6) Trained staff members can provide this distraction to an extent, as can other environmental factors. Peter Giancola and his team point to laboratory studies that found that “adding mirrors and video cameras to a room was effective in suppressing aggression towards others” since “the person is forced to compare their initial impulse to aggress with personal and social norms that admonish such inappropriate behavior” (6). Bar management strategies can thus be effective in reducing violence, if enforced.
Enforcement of stricter bar regulations must be part of a more comprehensive intervention along with the shatterproof glasses. The city of Cardiff in England has had success with this system. Their police force documents assaults and disturbances at local establishments and places them in a “red zone” if their numbers get too high. Improvement plans are then developed by the police which include installing more cameras and employing more bouncers and other personnel (16). Since enacting these policies, “better pub management has helped cut alcohol-related crime and disorder inside Cardiff’s pubs and clubs from 2,442 incidents in 2006 to 1,552 in 2008” (16). British officials should take notice of this decline and attempt to implement similar measures on a broader national scale.
Community Level Change
To truly start tackling the problem of glass attacks, community level policies must be enacted to start the transformation of the drinking culture and further ready the stage for further reaching behavior change among the masses. Proven policy strategies including restricting bar hours and alcohol availability, increasing drink prices, and consistent enforcement should be the focus of the British government’s overall approach to alcohol-related violence (13).
Restricting alcohol availability is necessary not only to ensure that patrons frequenting bars cannot continue drinking indefinitely, but also to reduce the number that show up already quite intoxicated from liquor easily obtained elsewhere. Mary McMurran and her team found that most alcohol-related incidents that they studied occurred in the middle of the night, or between 11pm and 2am (9). Enforcing bar closing times within this window is likely to cut down on risky scenarios, as has been proven in various studies including one done in Brazil in which monthly assaults fell from 48 to 25 per month after a new law mandating bars to close at 11pm took effect (3-2278). Raising alcohol taxes and prices is also an effective tactic in reducing alcohol-related consequences. Alexander Wagenaar and his team found that, in an aggregation of studies involving alcohol and price points, higher prices were “significantly and inversely related to all outcome categories examined, including alcohol-related…violence, traffic crash fatalities and drunk driving, rates of STDs…drug use, and crime” (15). These strategies have also been found effective by the NIAAA in the United States. Once again, the British Government must take a more sweeping and ambitious approach in order to decrease violent behaviors.
Conclusion:
A community-level, comprehensive environmental management approach must be prioritized and undertaken by the United Kingdom in order to effect any real positive change in alcohol-related violence. Community-wide interventions are a proven strategy (7). While shatterproof pint glasses represent an innovative and even beneficial approach to the problem of glassing, they must be used widely and in tandem with other more upper level policy approaches.
REFERENCES:
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