“Scared Straight”—An Intervention Gone Crooked: How Organized Prison Visits are Largely Ineffective and Detrimental to At-risk Youth –Yamrot Negussie

Introduction        

            With violence, illicit drug abuse and related crime on the rise in the 1970’s, the United States began to focus its social policies on these issues. In addition, such social issues gained attention in popular media. In 1978, director Arnold Shapiro released a documentary entitled “Scared Straight,” which followed a group of juvenile delinquents who spent a day in a maximum security prison. The visit was coordinated with the prison to expose these juveniles to the harsh realities and consequences of crime through their interactions with the inmates and the prison environment. Ultimately, the goal was to deter the young offenders from committing crime in the future. That year, the documentary won an Academy Award for “Best Documentary Feature” (14). As a result of the film, many states implemented “Scared Straight” programs targeting at-risk youth and juvenile delinquents. The programs consisted of prison tours where the participating youth were integrated into the prison population and heard personal accounts of inmates’ experiences. Often, prison inmates were instructed to dramatize their experiences and use intimidation as a tactic with the visiting youth. These sessions have been characterized as “shock probation,” traumatizing and at times, brutal. Anthony Schembri, the Secretary of the Florida Department of Juvenile Justice, visited a Scared Straight Program in a state prison and described the adolescents’ experiences as “an emotional roller coaster” (12).

            After extensive research was conducted on the ineffectiveness of the intervention, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) publicly denounced the program. In addition, the OJJDP discontinued all federal funding for any Scared Straight program in 2011 (9). However, programs with a similar framework and purpose are still currently in operation. The continuation of this program framework is particularly troubling due to the abundance of empirical evidence showing its ineffectiveness (10). There are multiple flaws within the design of Scared Straight that can even make the program counterproductive in some cases. To begin with, the very nature of the visits presents at-risk youth with a threat to their literal freedom, which in turn invokes psychological reactance. This can result in the opposite of the intended effects of the program. Additionally, the intervention assumes a rational choice model in terms of the adolescents’ subsequent decisions as a result of their prison visits. This is especially problematic considering the target population’s general lack of emotional maturity and decision making skills. Finally, there are major implications for the socialization of at-risk youth into the prison culture through these sessions. These inherent flaws in the program prevent it from accomplishing its objectives.

Flaw 1: Scared straight invokes the wrong reaction.

            The Scared Straight program exposes at-risk youth to incarceration as a potential consequence for criminal or deviant behavior. The major aspects of the prison experience that the youth are expected to process are the discomfort and degradation that inmates must endure. Also, there is an associated loss of personal control that results from being constantly monitored and dictated by prison authority figures. Adolescent visitors are given a schedule by which they must adhere to, similarly to the inmates. By matching the experience of the visitor so closely to that of the inmates, the program successfully presents the adolescents with a potential threat to their personal freedom. The prospect of ending up in prison is a literal threat to their freedom in addition to the loss of control and choice of behavior. According to social psychologist Jack Brehm, such threats can induce an unfavorable reaction. Brehm’s Theory of Psychological Reactance describes the cause and effect relationship as the following:

            Whatever freedom is threatened…the resulting reactance leads to increased             perceived attractiveness of that option. Thus, there may be two manifestations         of the occurrence of reactance: actual attempts to restore freedom, and            increased perceived attractiveness of the lost or threatened option (4).

Psychological reactance shows that there is an element of danger in showing at-risk youth the negative consequences of crime and deviance because it may actually create an appeal to this behavior. Among the principles of psychological reactance, Scared Straight programs act in accordance with that of dominance the most. I would argue that this exertion of authoritarianism also contributes to the potential for reactance on the part of the participating adolescents. Throughout the program, the participants come into contact with figures of official authority (prison guards) in addition to those of unofficial authority (convicted felons). Both parties exert their dominance over the adolescents who visit the prison.

            As stated in the theory, reactance can result in an attempt to restore freedom. Among youth advocates, there has been concern that some youth may interpret such program tactics “as a challenge to their ability to escape the consequences these programs hope will act as deterrents” (13). In other words, the program efforts could potentially backfire and engender deviant behavior instead of deterring it. There is empirical evidence showing that the program has had ineffective and counterproductive results in the past; the most well known of which was a study conducted by The Campbell Collaboration. The authors completed a meta-analysis of seven randomized trials in order to examine the deterring effects of Scared Straight programs on juvenile delinquents and at-risk youth. The study found the program framework “to be more harmful than doing nothing” and the effect to be “nearly identical and negative in direction, regardless of the meta-analytic strategy” (11). These results confirm the notion of restoring freedom in psychological reactance and engaging in the actual behavior that is condemned. The study also reveals the unsuccessful outcomes of the program, which has major implications for those who implement it.

Flaw 2: Scared Straight assumes teenagers are rational beings.

            The design of the Scared Straight program follows that of a rational choice model, which does not align properly with the target population. The objective is to expose the participating youth to the harsh consequences of criminal behavior in a way that is so jarring that the participants recall this experience in future decision-making. When confronted with the opportunity to engage in deviant behavior, the program experience will ideally be factored into one’s decision. The Health Belief Model, which explains health related behaviors, includes a cost-benefit analysis in the individual’s decision making process (2). This model, like many other individual behavioral models, assumes that the decision maker undergoes a rational weighing of costs and benefits. This is a potential weakness of the model when being applied to programs such as Scared Straight because it is not likely that the participants are rational beings. Additionally, the model assumes that the individual has the time and emotional maturity to go through this decision making process.

            Scared Straight typically targets juveniles who have already committed a crime or those who are deemed “at-risk” youth. The majority of participants are males between the ages of 14-18 who come from areas with high prevalence of crime (11). If these young men are faced with the decision to engage in crime or not, it is unlikely that they will have the maturity or time to make a rational decision. The impact of socio-emotional context, brain development and pubertal maturation was examined in a study by the Department of Psychology at Temple University. After reviewing existing research, the study  investigators found that “differential maturation in the structure and function of brain systems leaves adolescents particularly vulnerable to socio-emotional influences and risk-taking behaviors” (5). During adolescence, humans are still experiencing major changes and development in the brain and in the social context as well. Thus, the adolescents targeted by Scared Straight do not benefit from a rational choice model due to their cognitive developmental level and other influences. The program takes on a very simplistic view of behavior by assuming that exposure to an extreme negative consequence will be enough to deter at-risk youth from committing crime. In actuality, there are a number of other factors that could influence a youth’s decision to take part in deviant behavior.

Flaw 3: The program socializes at-risk youth into the sub-culture of crime.

            A major hazard of prison visits for adolescents who are already at-risk is the possibility of socializing and desensitizing the youth to the prison culture. By bringing a group of adolescents into a prison and treating them as inmates, the Scared Straight program is having them enact a role that some may internalize as inevitable for themselves. Anthony Schembri, the Secretary of the Florida Department of Juvenile Justice, hypothesized about “anticipatory socialization” in the Scared Straight Program. According to Schembri, “this process occurs when individuals perceive the certainty of an event and, upon being placed in a similar situation, begin to be socialized toward that event” (12). It is probable that the adolescents in the intervention program are aware of their status as at-risk youth—either through the subculture of violence around them or their past criminal behavior. Once put in the setting of a prison, what is to stop them from accepting the role  that has been prescribed to them? (Other than the scare tactic, which has been proven to be ineffective).

            The Scared Straight program has had a place in the media since its inception and this has contributed greatly to its socialization in our culture. In January 2011, A&E aired its own television series, “Beyond Scared Straight.” The show documents prison visits and personal accounts from the adolescents who are in the program. The presence of this program on television as entertainment trivializes the importance of the issue. In addition, it desensitizes the public to the issue of criminal behavior in adolescents. This process of desensitization to violence has been examined by psychologists in many experimental study designs. In one investigation, the authors recruited a sample of college students, showed them clips of violent movies and measured for trait aggression, sympathy, and reaction to the violent clips afterwards. The study found that “repeated exposure to media violence reduces the psychological impact of media violence in the short term, therefore desensitizing viewers to media violence” (1). These results could have significant implications for the Scared Straight program and the potential effect of exposing at-risk youth to the prison environment. Violence, illicit drug use and other illegal activities are already pervasive in the media. By familiarizing these adolescents with crime in another  context, the program only  contributes to the normalizing of this culture.

Proposed Intervention

            As an alternative to the Scared Straight program, I would propose a community-based prevention program that utilizes different tactics to deter at-risk youth from criminal behavior. This would be implemented as a weekly after school session in local community centers for adolescents from ages 14-17. Sessions would consist of skills-building workshops for participants. These skills would include socio-cognitive, problem solving and employment based skills. Since the program would not be court mandated, there would have to be incentives to participate. As a community program, we could collaborate with nearby schools to arrange proper incentives. In addition, we would recruit local youth for an advisory committee in order to gain their personal perspectives. The intervention’s major objective would be to empower youth by emphasizing ownership over one’s decisions and essentially creating a movement around personal agency. The program would take advantage of the current age of social networks and media in order to disseminate the messages. Ultimately, the intervention would socialize these at-risk youth into a culture of productivity and opportunity. This is in stark contrast to demoralized and degrading culture of the Scared Straight program. 

Defense 1: The intervention empowers youth instead of threatening them.

            One of the major flaws within the Scared Straight program was the intimidation tactic that essentially threatened the freedom of its participants. This proposed intervention would be tested before implementation for the potential invocation of psychological reactance.  Program managers could run a test version of the program and recruit adolescents to give their feedback on the messages taken from the session. We would want to test for perceived pressure or threats to personal choice. Instead of causing reactance, this program would use the Theory of Psychological Reactance to inform the methods used. For example, there would be no exertion of dominance from those supervising the program. For adolescents, authority figures  such as police officers would not be the most effective communicators. Rather, we would mobilize a group of local community members who could serve as leaders in the program. It is important that these community leaders are recognized and respected by the adolescents who are participating in the program. This aspect of familiarity serves to effectively captivate the target audience and bolster the credibility of the message being delivered. For instance, if the program could recruit a successful athlete or business owner who is rooted in the community, the participants could easily identify with them. Their accounts of resilience and ultimate success would be ideal sources of support for the program’s objectives.

            By emphasizing the participant’s ownership of their own decisions, the program would empower the adolescents instead of scorning them as the Scared Straight Program did. This perception of one’s ability to execute decisions is described within the psychological concept of Self-efficacy. This refers to “subjective judgments of one’s capabilities to organize and execute course of action to attain designated goals” (6). Unlike the Scared Straight program, this alternative intervention would foster positive perceptions of control, outcome expectations and self-esteem through integrated workshops. The idea is to create a sense of identity and control over one’s identity. Whereas the Scared Straight program already assigns participants an identity and takes away this sense of control.

Defense 2: The intervention utilizes the peer-group to influence behavior.

            The alternative approach to intervening with at-risk youth would utilize the theory of diffusion innovation to influence decision making. Adolescence is a period of time when we are easily influenced by what our peers are doing in addition to what is perceived as trendy or “cool” at the time. The social science Theory of Diffusion Innovation explains how a population adopts a product or behavior through diffusion throughout the population (3). In addition, the “key to adoption is that the person must perceive the [behavior] as new or innovative” (3). Our goal as a new intervention program, would be to present the community program as something novel and different from what the community is used to. After assessing the makeup of the networks within the adolescent community, we would initially target those with the most social influence. The Diffusion of Innovation Theory would define these adolescents as the “Innovators.” According to the model, the spread of behavior through a specific population must start with the innovators (3). In the same way that these teenagers are the individuals who initiate fashion trends within their circles, we would aim for them to spark an interest in our program. This method of influencing behavior through the spread of popularity is much more realistic for our target audience than the notion that they will engage in a certain behavior because it is rational. This approach takes into account the social factors that often manipulate adolescents’ behavior patterns.

Defense 3: The program socializes at-risk in a positive manner.

            The proposed intervention strategy will result in favorable behavioral outcomes as opposed to the Scared Straight program because it socializes youth into a positive culture. The social context of prison visits is not healthy for an adolescent who is already bombarded with images and stories of criminal behavior by the media. The alternative program recognizes the importance of the social environment and how an adolescent may interact with it. According to the Social Cognitive Theory, a person’s behavior is influenced by the social environment in addition to reinforcements, observations and expectations that accompany the social context (3). Therefore, it is extremely important that this program utilizes the principles of the theory in order to affect its participants. The idea of reinforcement is particularly useful in the new intervention because weekly sessions allow program managers to track and reward positive behavior. For example, for participants who abstain from illegal activity and are able to avoid encounters with law enforcement or the court system, there can be rewards such as organized trips to other cities. This type of positive reinforcement reminds the participants who stay out of trouble that by abstaining from criminal behavior, they are creating other opportunities for themselves.

            Another concept of the Social Cognitive Theory that is modeled within the alternative program is observational learning. This concept asserts that “people can witness and observe a behavior conducted by others, and then reproduce those actions” (3). By recruiting role models who have refrained from engaging in criminal behavior, the program is providing a model from which the participating adolescents can observe and imitate. These community members would be relatively young and recognized by the participants so that they could easily connect with them. Unlike the Scared Straight program, which utilizes authority figures such as prison guards and menacing prison inmates, this program relies on positive figures. In a society that is plagued with violence, substance abuse and crime, it is imperative that at-risk youth are exposed to a healthier social context from which they can function. A major goal of this intervention is to change adolescents’ perceived norms of behavior through observation and reinforcement.

Conclusion

            Scared Straight was a program that was implemented with honorable intentions—to deter at-risk youth from engaging in dangerous behaviors such as violence, illicit drug use and other illegal activities. However, it has become evident that the program itself is a danger to at-risk adolescents. There is a multitude of literature reviewing the ineffectiveness and risks associated with the intervention strategy. The program’s scare tactics produce undesirable results such as re-offending and deviant behavior. Furthermore, the Scared Straight program socializes its participants into a culture that it wants them to avert. The implications of this program are scary for the future of at-risk youth. I believe that there must be a shift from these law enforcement based programs to community based programs for adolescents. I propose an intervention that does not invoke reactance in its participants. Rather, it empowers them to take ownership over their personal decisions. This comprehensive  program could successfully train at-risk youth to engage in productive behavior so that they will have a more appealing alternative to criminal behavior.

REFERENCES

1. Avraamides M, Fanti K, Henrich C, Vanman E. Desensitization to Media Violence             Over a Short Period of Time. Aggressive Behavior 2009; 35, 179-187.

2. Becker M, Rosenstock I, Strecher V. Social Learning Theory and the Health Belief             Model. Health Education Quarterly 1988; 15:2, 175-183.

3. Boston University School of Public Health. Behavioral Change Models: Diffusion             of Innovation Theory. Boston, MA: Boston University School of Public Health.           http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-        Models4.html

4. Brehm  J. Psychological Reactance: Theory and Applications. Advances in             Consumer Research 1989; 72-75.

5. Chein J, Smith A, Steinberg L. Impact of socio-emotional context, brain             development, and pubertal maturation on adolescent risk-taking. Hormones &         Behavior 2013; 64(2): 323-332.

6. Cleary T, Zimmerman B. Adolescents’ development of personal agency (pp. 47). In:       Cleary T, Zimmerman B, ed. Self-efficacy Beliefs of Adolescents. 2006.

7. Dymnicki A, Henry D, Weissberg R. Understanding How Programs Work to             Prevent Overt Aggressive Behaviors: A Meta-analysis of Mediators of             Elementary School–Based             Programs. Journal of School Violence 2011; 10:4,   315-337.

8. Hendrikson H. Beyond Bars. State Legislatures 2012; 38(2): 28-29.

9. Office of Juvenile Justice and Delinquency Prevention. Justice Department             Discourages the Use of “Scared Straight” Programs. Washington, DC:             OJJDP.             https://www.ncjrs.gov/html/ojjdp/news_at_glance/234084/topstory.html

10. Office of the Surgeon General (US). Youth Violence: A Report of the Surgeon             General. Rockville, MD: Office of the Surgeon General (US), 2001.

11. Petrosino A, Turpin C, Buehler J. “Scared Straight” and other juvenile awareness     programs for preventing juvenile delinquency. Campbell Systematic Reviews,        2004.

12. Schembri A. Scared Straight Programs: Jail and Detention Tours. Tallahassee,             FL: Florida Department of Juvenile Justice, 2006.

13. Strategies for Youth. How to Avoid the Failures of Scared Straight. Cambridge,             MA: Strategies for Youth. http://strategiesforyouth.org/for-police/how-            to/how-to-scared-straight/

14. The New York Times. Movies. New York: The New York Times.             http://www.nytimes.com/movies/movie/43074/Scared-Straight-/overview

Optimizing Promotion Of HIV Pre-Exposure Prophylaxis Using Group Intervention Theories, Framing, And Avoidance Of Psychological Reactance– Kevin Maloney

Introduction

There are an estimated 35.3 million people living with human immunodeficiency virus (HIV) infection worldwide (1). Of these, 1.1 million are living in the United States (2). Progress in treatment options and prevention strategies has led to a 33% decline in the global incidence rate of HIV, since 2001 (1). Despite forward progress, the rate of new infections has increased in some populations (1-2). In the United States, there are approximately 50,000 new HIV infections every year (2). From 2008 to 2010, the number of new infections per year among men who have sex with men (MSM) increased from approximately 26,700 to 29,800, a 12% change (2). MSM represent just 4% of the US population, but male to male sexual contact was believed to be the mode of transmission for 63% of all new infections in 2010 (2). There are a variety of factors believed to contribute to the HIV epidemic among MSM, including unprotected anal intercourse (UAI), concentration of the community viral load among MSM, and lack of awareness of HIV status (3). Concurrent with the rise in HIV incidence rate among MSM are more data that show increased UAI among MSM (3). From 2005 to 2011, the percentage of MSM reporting UAI in the past 12 months rose from 48% to 57% (3).

Given the decreased reliability of condoms as a realistic primary prevention strategy, public health professionals have long searched for other solutions, such as vaccines or the use of antiretrovirals for chemoprophylaxis (4). Chemoprophylaxis of HIV has now been shown to be efficacious with two approaches. The first, known as treatment as prevention, involves the early usage of antiretroviral drugs in HIV-positive people, with the goal of achieving viral suppression and reducing infectivity (5). The second approach, known as pre-exposure prophylaxis (PrEP), is more controversial (6-8) and involves the usage of antiretroviral drugs in HIV-uninfected, but high-risk persons, with the intention of preventing infection (9). A 2010 randomized controlled trial of 2499 HIV-uninfected men or transgender women who have sex with men showed that once-daily tenofovir disoproxil fumarate (FTC-TDF; a combination of antiretroviral drugs used for the treatment of HIV-infection) provided a 44% reduction (p=0.005) in HIV-incidence, when compared to placebo. Among study subjects with a detectable blood level of the study drug, there was a 92% reduction (p<0.001) in HIV incidence (9). On July 16^th, 2012, the Food and Drug Administration (FDA) approved Truvada^TM, an antiretroviral manufactured by Gilead Sciences for the treatment of HIV-infection (10), for use as PrEP (11). PrEP has been suggested for use in multiple high risk populations (4), but this paper is limited to the promotion of PrEP among MSM in the US.

Despite the potential to greatly protect against HIV-infection, a limited number of MSM know about PrEP and almost none are using it (12). The low immediate uptake of PrEP has been discussed in a number of recent widely circulated editorials, including one by Christopher Glazek in The New Yorker (7). Glazek explores the tepid response to PrEP and points out a number of concerns by healthcare professionals about PrEP efficacy and toxicity. Advocates for HIV-infected persons, Glazek explains, are also concerned about the availability of antiretrovirals in resource limited settings or the emergence of viral resistance to Truvada^TM, which is a first line drug to treat HIV. Other public health officials are worried about the implications of suggesting that there is an alternative to condom usage. These opponents have publicly argued against PrEP usage. A further setback to PrEP implementation is the unprecedented decision by Gilead Sciences not to promote or research Truvada^TM as PrEP. (7) In the absence of Gilead Sciences’ participation in the promotion of Truvada^TM as PrEP, public health officials have failed to create campaigns that would adequately promote its use. Perhaps, it was initially assumed that the benefits of PrEP alone would be enough to promote its use. This “if you build it, they will come” approach to intervention promotion did not work (7-8, 12). In response to low interest in PrEP, advocates have started to make promotional materials. These materials have not effectively increased interest in PrEP (7-8, 12). This paper will critique three aspects of the campaign to promote PrEP that have contributed to its ineffectiveness along with solutions to those challenges.

Critique 1: Reliance on the Health Belief Model

The primary way that PrEP has been promoted is through the use of educational campaigns, such as fact sheets and videos. These promotional materials have emphasized the health benefits of PrEP (i.e. HIV risk reduction) and have served as informative educational tools. These materials are essential resources for people already interested in PrEP, but do little to actually disseminate information and promote interest in the intervention. Using health education as a way to promote an intervention is a common approach, which relies on rational decision making. The model of behavior, known as the Health Belief Model, assumes that people make rational choices about health by weighing the risk for and severity of a disease, with the costs and benefits of adopting a new behavior (13). In this logic structure, a public health official would only need to educate and inform a person about a disease, while offering education about interventions or alternative behaviors that prevent that disease. The Health Belief Model can be an effective strategy for one time interventions, like vaccines; unfortunately, the Health Belief Model is not a very effective way to promote an intervention that may need sustained commitment or a more complex decision calculus (14).

The Health Belief Model is not an effective approach for the promotion of PrEP (14-15). To understand why, it is helpful to analyze the assumptions that the Health Belief Model uses. First, the Health Belief Model for PrEP requires that MSM accurately perceive their own risk for HIV infection. Research has shown that while many MSM are able to accurately define behaviors that are high risk for HIV, they inaccurately use those criteria while assessing their own risk (16). As a result, many men perceive their own personal risk for HIV to be lower than what it actually is. Second, the Health Belief Model assumes that MSM perceive HIV/AIDS to be severe. Advancements in treatment options, and the common belief that HIV can be managed with “one pill, once a day,” may have decreased community perception of HIV disease severity (17). Many MSM now perceive HIV to be an inconvenient, but manageable disease. This reduction in the perception of disease severity may partially explain the decrease in condom usage among MSM (3, 17). Taken together, the miscalculation of HIV susceptibility and diminishing perception of HIV severity are major barriers to individuals self-necessitating PrEP (14-17). Third, the Health Belief Model requires an individual to negotiate the perceived benefits of PrEP with the perceived costs. While the educational materials that have been created could be used to aid in this decisional analysis, it is unlikely that most MSM would take the time to carefully assess each factor (14). Decisions about PrEP are more likely to be made based on a quick assessment and emotional instinct. The second problem with the implementation of PrEP are those emotional instincts, such as reactance, that occur.

Critique 2: Activation of Psychological Reactance

            The use of educational materials to promote PrEP may create reactance and have opposite the intended effect. Psychological Reactance Theory shows that people hold tightly to their beliefs and statements, even when given logical reason to change position. This occurs because people take ownership of their beliefs. Challenging someone’s behaviors or beliefs is to take something away and violate their freedom. The natural response to having something taken away is to hold tighter. (18)

Psychological reactance occurs in health campaigns when people feel that someone else is telling them how to live or behave. The implications of reactance and the clinging to behaviors often results in increased frequency or magnitude of the bad health behavior (18). Since sexual contact was first identified as a way to transmit HIV, authoritative figures have been telling MSM how to have sex (19). Compounded with decades of stigma against homosexuality and same-sex sexual relationships, many MSM may be feeling attacked and defensive of the way they have sex, establishing them as a high reactance group (19). As such, reactance may be another contributing factor to why men are using condoms less. In that context, it is difficult to continue telling men who to have sex with, how to have sex, and how to manage HIV risk.

In the case of PrEP promotion, the response by many MSM is likely aversion to being told to adopt yet another strategy to avoid HIV. Many of the promotional materials being presented are steeped in medical information and statistics, so the message is received as a patronizing instruction (20). The underlying message is: “you’re not being safe enough, so you need to take a pill now as well.” With reactance, the introduction of PrEP is viewed as another way that authoritative healthcare figures are exerting control over the sex lives of MSM (18-20).

Psychological reactance is also occurring in the resistance by medical professionals and HIV advocates to shift away from a condoms-only approach to HIV prevention (21). For almost three decades, public health professionals have asserted (and believed) that condoms are the only way to practice safe penetrative anal sex among MSM (4). For three decades, that was largely true. Accepting an HIV prevention strategy that does not completely rely on that approach is a difficult change for many advocates. The result is a backlash to PrEP that questions everything from medication safety to efficacy. The reaction has been a well-articulated campaign against PrEP. The framing of this rhetoric by both health care professionals and patient advocates is the third problem with the campaign to promote PrEP.

Critique 3: Ineffective Use of Framing Theory

            The usage of PrEP is a controversial and new approach to HIV prevention, with vocal opponents on either side of the debate (6-8). Proponents of PrEP have been persistent in discussing the benefits of PrEP as a tool to reduce risk for HIV acquisition and a pathway to maintain health. Opponents of PrEP question the implications of PrEP on the individual level, as well as on the community level. On the individual level, opponents look at the paradox of using a drug in a person who is actually healthy and introducing the risk of side effects and toxicities. The potential to increase sexual risk, along with poor compliance to a daily regimen of medication, are factors often used as evidence against PrEP efficacy. Other opponents worry about the community implications of using Truvada^TM in HIV uninfected persons, including the distribution of drugs in resource limited settings and the selection for and dissemination of Truvada^TM resistant HIV in the community. Finally, there has even been speculation of the validity of study data and ulterior motivations of study investigators, the government, and Gilead Sciences. (7) The collective opposition to PrEP is likely encouraging both MSM and the healthcare providers who would prescribe PrEP to be skeptical and avoidant of use. The reason opponents of PrEP have been more convincing is due to the way the discourse has been presented (22-23). Framing Theory shows why the ideas opposing PrEP resonate much stronger with MSM and healthcare professionals.

Framing theory explains that an audience responds to discourse based more on an emotional response and less on facts (22-23). As such, people are much more likely to be convinced by an argument that speaks to their core values. To capture this emotional response, a properly framed argument is constructed surrounding a core value, which is supported by a core position, metaphors, symbolism, and catch phrases. The core value should be universal and in the subconscience of the target audience. Examples of strong core values are freedom, security, and love. The core position is the actual argument being communicated. The metaphors, catch phrases, and imagery are used during communication of the core position, in order to associate the argument being stated with the desired core value. (23)

Opponents of PrEP rely heavily on core values like safety (PrEP is a dangerous medication with toxicities), freedom (PrEP compromises a person’s freedom by requiring compliance to a daily drug regimen; PrEP is a ploy by “Big Pharma” to sell drugs), and tradition (medications should only be used in sick people). (7) These arguments speak to the core values of MSM as well as healthcare providers. There are clear images in these frames, such as doctors prescribing a pill that will make people sick or predatory corporations trying to turn a profit at the expense of the public. Comparatively, proponents of PrEP are much more likely to use health as a way to frame PrEP. The flaw is that health is not a particularly strong core value when used in a frame. This may be counter intuitive, but the tangible value of health is difficult to conceptualize until it is lost (14). As a result, people often don’t respond strongly to campaigns that use health as the core value (23). The advocates for PrEP have failed to adequately frame the intervention in a way that addresses the core values of high risk MSM.

Solution 1: Group Level Approaches to PrEP Implementation

            Advocates for PrEP can avoid the fallacies of the Health Belief Model by shifting away from an intervention that focuses exclusively on changing behavior on the individual level. One approach to influencing the normative behaviors of a population is to use strategies employed in marketing (24). Gilead Sciences is not promoting PrEP the way any other medication would be (7), so it is the job of PrEP advocates to do the marketing. A marketing based approach would follow a very careful campaign design strategy. Rather than define the intervention and create a campaign based on selling the merits of PrEP, advocates should first question what the needs and core values of its target population are (25). By identifying these characteristics, a campaign can be designed without any specific information about PrEP. Because PrEP is an ideal intervention for sexually active MSM at high risk for HIV, the campaign should include values important to that population. The common experience with this group is sexual encounters without a condom. Therefore, the campaign should incorporate messages that use sex as a primary core value. The core position of this campaign would be: “PrEP keeps sex enjoyable by offering a second line of defense when condoms are skipped.” The fear that this type of message will cause men to have more unprotected sex does not acknowledge that many MSM are already not using condoms (3). By adding PrEP, the risk for HIV acquisition is dramatically decreased. A campaign based on sex acknowledges the prevalence of UAI and invokes the core values desired by this population (19). The campaign can take cues from some of the more effective condom and HIV prevention campaigns that feature attractive men and employ sexual innuendo (19, 25, 26).

            The second component to the group level implementation of PrEP is to analyze the Diffusion of Innovations Model (27-28). The Diffusion of Innovations Model identifies an S-curve of innovation adoption, in which the proportion of the population that adopts an innovation grows slowly, then accelerates quickly, and finally tapering off. A small group of innovators are the first people to adopt a new innovation. The innovators are followed by a second, slightly larger group known as early adopters, who are followed by a large early majority and then late majority. Once a product or innovation has reached the early majority, its uptake accelerates dramatically as the innovation becomes popular. This phenomena occurs due to the herd-mentality and desire to participate in trends. Diffusion of Innovations is often a natural process, but by taking advantage of how this pattern occurs, advocates for PrEP can accelerate the process in the same way that marketers create demand for a product. To do this, it is important to understand the transition from slow early adoption to accelerated population adoption. Early adopters often begin buying a new product because it is scarce and only the innovators have it. The early and late majority will buy the product once social proof has developed and the product is viewed as trendy. (28)

PrEP is a new intervention and so far only a few innovators have started to use it (12). The challenge now is to encourage early adopters to use PrEP by creating the idea of scarcity. Instead of the product itself (PrEP) being promoted as scarce, the benefit of PrEP (reduced risk for HIV) could be promoted as a scarce (i.e. brand new and unique) opportunity to reduce HIV-risk. The message will be: “This is a whole new way to protect against HIV and there is nothing else like it.” The campaign will also attempt to create social proof by creating the illusion that PrEP is already popular. To do this, the campaign should incorporate testimonials and statements from men who are using PrEP, explaining how it has improved their lives.

Solution 2: Understand The Role Of Reactance In Health Promotion Campaigns

            The reactance created by PrEP promotion is avoidable, if there is attention paid to this psychological reactance during the planning of the campaign (18). As discussed previously, reactance can often occur if the audience feels that an authoritative figure is commanding which behavior is acceptable and which is not. A great way to avoid the reactance is to have the message communicated from someone that the target audience identifies with (29). This similarity will reduce the likelihood that the audience feels like it is being told what to do. The messenger cannot be a scientist or healthcare professional, because they are seen as authority figures (18-20, 29). Since this particular campaign for PrEP is being targeted toward MSM, the messenger should be a gay (appearing) man who is speaking as a peer (29-31). A great approach would include real men discussing their real experiences with PrEP and how it has impacted their life. If the messenger is seen as an equal or peer, the reactance will be minimized (29).

To avoid reactance in healthcare professionals, who are the gate-keepers for prescribing and promoting PrEP, there needs to be well designed physician oriented trainings. These trainings should focus on promoting PrEP as a single option to reduce HIV risk in a provider’s practice (21). The goal would be to deemphasize the failures of condom campaigns and safer-sex counseling and focus instead on adding to the tools that a provider has available. In this way, it reduces the possibility that a provider or public health advocate feels criticized for using other strategies in the past.

A key part of avoiding reactance is to actually do research (25). Before old strategies are selected and the campaign is implemented, formative research should occur to determine whether those strategies are effective or actually create reactance. Focus groups can serve as a way to collect ideas from the target audience. Qualitative interviews can discuss certain themes more in depth, if needed. From focus group research the campaign can be proposed. Finally, before launching the campaign, the idea should be presented to a sample from the target population for quantitative assessment. Tools like the Therapeutic Reactance Scale (32) and the Questionnaire for Measuring Psychological Reactance (33) can be used or adapted to detect psychological reactance in the sample based on the proposed PrEP advertisements. The sample should be surveyed to determine what the emotional response to a particular advertisement is, if it creates reactance or not, and if it effectively promotes any interest in PrEP.

Another factor to consider with psychological reactance is how it can be used to intentionally create a desired emotional response. For example, part of the campaign to promote PrEP can be messaging that directly draws attention to the opponents of PrEP. The message in this part of the campaign will focus on the doctors and pharmaceutical industry forces that are trying to keep PrEP away from people. HIV-prevention strategies that do not rely on just condoms have long been desired by MSM (4, 7-8, 17) and it would be a powerful statement to point out that PrEP is being withheld. Counter-industry campaigns have been effective in other public health campaigns, like the successful Truth Campaign for smoking cessation (25). The take away feeling is a desire to have what is being restricted.

Solution 3: Reframe the Rhetoric Using Strong Core Values

            The final part of the campaign that needs to be restructured is the framing of the debate over the effectiveness of PrEP as an HIV prevention strategy and the appropriateness of using antiretroviral drugs in HIV-uninfected persons. The proponents of PrEP are confident that the primary research supports implementing PrEP as an effective way to reduce HIV-risk. It is important to now communicate that confidence outside of the context of data and scientific literature. It has not been effective to allow the data to stand alone. Furthermore, it is not effective to just assert that PrEP is useful for its potential to maintain health (i.e. HIV uninfected status) (23). Instead, the defense and promotion of PrEP should be re-framed to have stronger core values. The actual goal of the message does not need to be different (PrEP is safe and effective) but the way in which the message is communicated will need to change.

            Successful core values will create an emotional response in the target audience that will be more compelling than facts or statistics alone (22-23). For many MSM, using condoms consistently is a challenge and there is constant anxiety of HIV infection (17). PrEP can be a second line of defense when passion precludes rational decision making and condoms are not used. In this way, PrEP is a provision for security and not simply a tool for health maintenance. Therefore, the promotion of PrEP should focus on security as its core value instead of health. The core position of this message is that “mistakes happen, but everyone deserves to be protected.” Catch phrases could be created from the type of familiar messages used in insurance advertisements. For example, phrases like “peace of mind” (Chubb Group of Insurance Company; 34); “when accidents happen, [PrEP] is there” (State Farm®; 35); and “responsibility, what’s your policy?” (Liberty Mutual Insurance; 36) are effective ways to frame security. Additional analogy could be made with a comparison to birth control medications, which similarly protects against a potential consequence of sex without a condom. This core value can be used in written media as well as promotional materials, like videos.

Conclusion

Advocates for PrEP may be remembering the 1980s and 1990s, when fear of HIV fueled the mobilization of community advocacy and quick uptake of new ways to fight AIDS. With the advancements in HIV treatment, it is likely that community fear of HIV has diminished and taken a back seat to other community aspirations, like marriage equality and non-discrimination policies. Given this environment, it is unlikely that fear will create excitement about PrEP. A well strategized marketing campaign for PrEP can surpass community apathy and promote increased use of PrEP among high risk MSM.

References

1.      Joint United Nations Programme on HIV/AIDS (UNAIDS). Global Report: UNAIDS report on the global AIDS epidemic 2013. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS, 2013.

2.     Centers for Disease Control and Prevention. HIV In The United States: At A Glance. Atlanta, Georgia: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, 2013.

3.     Centers for Disease Control and Prevention. HIV Testing and Risk Behaviors Among Gay, Bisexual, and Other Men Who Have Sex With Men – the United States. Atlanta, Georgia. November 29^th, 2013, Morbidity and Mortality Weekly Report, 2013.

4.     Mayer KH. Thinking About An AIDS End Game. Lancet, 2013; 382(9903): 1462-1464.

5.     Cohen MS., Chen YQ., McCauley M., et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine, 2011; 365(6): 493-505.

6.     Grady D. Prevention In A Pill Has Risks Of Its Own (Section D5, May 15, 2012). In: The New York Times. New York, NY: The New York Times Company, 2012.

7.     Glazek C. Why Is No One On The First Treatment To Prevent H.I.V.? (October 1, 2013). In: The New Yorker Online. New York, NY: Condé Nast, 2013. Accessed: December 8, 2013. http://www.newyorker.com/online/blogs/elements/2013/10/the-battle-over-truvada-and-the-first-treatment-to-prevent-hiv.html

8.     Murphy T. Is This The New Condom? (September 9, 2013). In: Out Magazine Online. Los Angeles, CA: HereMedia Inc, 2013. Accessed: December 8, 2013. http://www.out.com/news-opinion/2013/09/09/hiv-prevention-new-condom-truvada-pill-prep

9.     Grant RM., Lama JR., Anderson PL., et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex With Men. New England Journal of Medicine, 2010; 363(27): 2587-2599.

10.  Truvada, Gilead Sciences; www.truvada.com Accessed: December 8, 2013.

11.   U.S. Food and Drug Administration. FDA approves first drug for reducing the risk of sexually acquired HIV infection. FDA News Release, July 16, 2012.

12.  Krakower DS., Mimiaga MJ., Rosenberger JG, et al. Limited Awareness and Low Immediate Uptake of Pre-Exposure Prophylaxis among Men Who Have Sex With Men Using an Internet Social Networking Site. PLoS One, 2012; 7(3): e33119.

13.  Janz NK, and Becker MH. The health belief model: a decade later. Health Education Quarterly, 1984; 11(1): 1-47.

14.  Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology, 2003; 22(4): 424-428.

15.  Kowalewski MR, Henson KD, and Longshore D. Rethinking perceived risk and health behavior: a critical review of HIV prevention research. Health Education & Behavior, 1997; 24(3): 313-325.

16.  Klein H, and Tilley DL. Perceptions of HIV risk among internet-using, HIV-negative barebacking men. Am J Mens Health, 2012; 6(4): 280-293.

17.  Balan IC, Carballo-Dieguez A, Ventuneac A, et al. Are HIV-Negative men who have sex with men and who bareback concerned about HIV infection? Implications for HIV risk reduction interventions. Arch Sex Behav, 2013; 42(2): 279-289.

18.  Brehm SS, and Brehm JW. Psychological reactance: A theory of freedom and control. New York: Academic Press, 1981.

19.  Mason TL. A test of psychological reactance theory and risk-related sexual behaviors among HIV-positive men who have sex with men. Electronic thesis or dissertation. Ohio State University, 2003. https://etd.ohiolink.edu/

20. Graybar SR, Antonuccio DO, Boutilier LR. Psychological reactance as a factor affecting patient compliance to physician advice. Scandinavian Journal of Behaviour Therapy, 1989; 18(1): 43-51.

21.  de Almeida Neto AC, and Chen TF. When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making. Pharm World Sci, 2008; 30(1): 3-8.

22. Chapman S, and Lupton D. The fight for public health: principles and practice of media advocacy. London: BMJ Publishing Group, 1994.

23. Menashe CL, and Siegel M. The power of a frame: An analysis of newspaper coverage of tobacco issues- United States, 1985-1996. J Health Commun, 1998; 3(4): 307-325.

24. Luca NR, and Suggs LS. Theory and model use in social marketing health interventions. J Health Commun 2013; 18(1): 20-40.

25. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco control, 2001: 10: 3-5.

26. Svenkerud PJ, and Singhai A. Enhancing the effectiveness of HIV/AIDS prevention programs targeted to unique population groups in Thailand: lessons learned from applying concepts of diffusion of innovation and social marketing. J Health Commun, 1998; 3(3): 193-216.

27.  Gladwell M. The Tipping Point: How little things can make a big difference. Introduction. Boston, MA: Little, Brown and Company, 2000: pp 3-14.

28. Dearing JW. Applying diffusion of innovation theory to intervention development. Res Soc Work Pract, 2009; 19(5): 505-518.

29. Silvia PJ. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 2005; 27(3): 277-284.

30. Calloway DS, Long-White DN, and Corbin DE. Reducing the Risk of HIV/AIDS in African American College Students: An Exploratory Investigation of the Efficacy of a Peer Educator Approach. Health Promot Pract, 2013. [Epub Ahead of Print: October 13, 2013]

31.  Roye CF, and Hudson M. Developing a culturally appropriate video to promote dual-method use by urban teens: rationale and methodology. AIDS Educ Prev, 2003; 15(2): 148-158.

32. Dowd ET, Milne CR, Wise SL. The therapeutic reactance scale: a measure of psychological reactance. Journal of Counseling and Development, 1991; 69: 541-545.

33. Merz J. Fragebogen zur Messung der psychologischen Reaktanze. [Questionnaire for measuring psychological reactance]. Diagnostica, 1983; 29: 75-82.

34. Chubb Group of Insurance Company, Chubb Corporation; http://www.chubb.com/ Accessed: December 12, 2013.

35. State Farm®, State Farm Insurance; https://www.statefarm.com/ Accessed: December 12, 2013.

36. The Responsibility Project, Liberty Mutual Insurance; http://responsibility-project.libertymutual.com/ Accessed: December 12, 2013.

Fat. And it Seems There is Nothing We can Do About It. A Summary of the Three Year Frustrations of a Future Registered Dietitian - Sara Kubetin

Currently in the United States, there are more people who are overweight than there are people who are of normal weight.  The words “obesity epidemic” are consistently plastered in the headlines of newspapers, websites, blogs, magazines, television news programs, talk shows, etc.  Obesity rates have been continuously climbing for the last few decades because the field of public health has been ineffective in even slowing the rate of increase in our waistlines.  As of 2010, 35.7% of American adults are considered obese.¹  This is the highest the obesity rate has ever been in this country.  This high rate exists in spite of countless efforts, initiatives, national objectives and goals, and health professionals trying desperately to decrease the statistic.  More than one third of Americans remain obese because our country’s entire approach to treating the problem is severely flawed.  Our methods of treating this disease are ineffective because obesity is a complicated disease that requires a multi-level public health intervention involving public opinion, Registered Dietitians, and the food industry.

            To be classified as obese, a person’s Body Mass Index (a ratio of weight to height)  must exceed 30 kilograms per meter squared.¹  The causes of obesity are numerous as are the comorbidities and complications associated with the disease.  From a clinical standpoint, obesity is caused by an imbalance in energy intake—energy consumption is higher than energy expenditure.²  This energy imbalance leads to weight gain.  Energy imbalance in the long-term causes obesity.²  In a broader view, obesity is an unfortunate product of our society.  Several risk factors for obesity are far beyond the control of the individual and include factors such as socioeconomic status, race, ethnicity, language, geographic location, family history, gender, and age.²  Current obesity interventions focus far too closely on the factors over which the individual has control.  In order to elicit large scale change, obesity interventions must focus on attacking external risk factors. 

This critique will focus on the three main problems with our current approach to addressing obesity.  First, many current obesity interventions are individual-level treatment interventions in spite of mounting research that indicates individual-level weight loss methods are ineffective.  Second, the gatekeepers to finding and executing a proper solution to the problem, Registered Dietitians, are highly undervalued.  Finally, the food industry has a tremendous amount of power over what people in our country are eating.  Most public health interventions fail to harness consumer power and use it to their advantage.

The Obese Stand Alone

            On the individual level, the only treatment for obesity is weight loss.  While this may sound simple, achieving significant, long-term weight loss is difficult, has a high attrition rate, and should not be the main focus of obesity intervention programs.  Weight loss is not going to decrease the obesity rates in the US for three main reasons.  First, the vast majority of individuals who are obese and manage to lose weight do not lose enough weight to be placed out of the obese BMI category.³  This means, even if a significant number of individuals who are obese manage to lose weight, the statistic will not change.  This does not mean that losing weight is not beneficial to the individual and to the population in general.  It has been shown that even a 10% weight loss in obese individuals is related to an increase in overall health and quality of life and a decrease in prevalence of comorbidities, regardless of post-weight loss BMI.⁴  That being said, if the true goal of our nation is to reduce obesity rates, the focus must be placed on prevention rather than treatment of the disease.  Moreover, current approaches to weight loss are flawed. 

Weight loss has the potential to help individuals who are already obese;  however, current approaches to weight loss are not very effective and follow traditional models of health that do not take enough external factors into account.   This is evidenced by the relatively low success rate of obese individuals.³  A review by Wing and Phelan assessed the success rate of long-term weight loss based on the results of several studies.  The definitions of successful, long-term weight loss varied across the different studies, but using an algorithm, Wing and Phelan estimated that approximately only 20% of individuals who purposely lose weight maintain their weight loss.³  Additionally, using data from the National Weight Control Registry, they estimated that the odds of weight regain decrease by 50% when individuals successfully maintain a weight loss for two years or longer.³  They also identified several factors that contribute to weight regain including loss of control while eating, decreases in physical activity, and other lapses in healthful behaviors.³  This study shows that achieving and maintaining weight loss is very challenging.  It is important to note that Wing and Phelan only addressed individual behaviors that contributed to weight regain.  This demonstrates that most weight loss interventions tend to focus on healthy changes only at the individual level. 

Finally, the public strongly holds individuals responsible for the obesity epidemic.  A study by Lusk and Ellison sought to determine the public’s perception of who or what is to blame for the rise in obesity.⁵  They surveyed a diverse panel of 800 subjects using a questionnaire that asked “who of these seven entities is to blame for the rise in obesity”—government policies, food manufacturers, grocery stores, restaurants, farmers, parents, or individuals?⁵  Overwhelmingly, respondents blamed individuals for the rise in obesity with 80% blaming individuals.⁵  Combining this evidence with what was elucidated by Wing and Phelan, it is clear that there is a major disconnect in the treatment of obesity.  The public believes that obesity is caused at the individual level and is, therefore, an individual problem.  However, it has been proven that individuals are relatively unsuccessful at fixing the problem on their own.  Herein lies the problem.  The public’s perception of obesity needs to change in order for other changes to occur.  Additionally, current approaches to weight loss must shift from individual to group interventions.

RD:  Two letters after my name that mean seem to mean nothing

            When most people meet a Registered Dietitian, they do not quite grasp exactly what an RD does.  According to the Academy of Nutrition and Dietetics (AND, the professional organization of RDs), a Registered Dietitian is “a food and nutrition expert who has met the minimum academic and professional requirements to qualify for the credential ‘RD.’”⁶  These academic requirements include the attainment of a bachelor’s degree in nutritional sciences from an accredited program, the completion of a six month dietetic internship, and the passing of a national examination in order to obtain a license.  Once a license is obtained, RDs must continue their education for the remainder of their careers by earning continuing education credits.  Although it is currently not required by the AND, many RDs go on to earn advanced degrees or other certifications.  It is important to point out that there is currently no regulation on the word “nutritionist.⁶”  Anyone who has even the most basic knowledge of nutrition can legally refer to themselves as a nutritionist.  A nutritionist’s education level could range from earning a collegiate degree in nutrition to simply reading about nutrition on the internet.  Registered Dietitians are frequently referred to as or are confused with nutritionists.  This confusion greatly undervalues the profession.

            Because of RDs are trained to be nutrition experts, RDs play a critical role in addressing the obesity epidemic.  However, it is difficult for RDs to step into this role when the profession is so unrecognized.  This lack of recognition exists for a variety of reasons.  First, the AND does not require a Master’s degree in order to obtain an RD license.  Many other health professions already require the attainment of a higher degree beyond that of a bachelor’s degree.  Not requiring at least a Master’s degree for the practice of dietetics does a disservice to the profession as a whole.  If all members of this profession had a higher education, the average pay of RDs would increase.  Currently, the average starting salary of an RD is between $42,000 and $55,000 a year.⁶  This is significantly less than the starting salary of other health professionals.  Registered Nurses who also only need a bachelor’s degree make an average starting salary between $50,000 and $60,000.⁷  Physical Therapists and Occupational Therapists are required to achieve at least a Master’s degree and have an average starting salary between $56,000 and $80,000.⁷  This information shows that if RDs were required to hold a Master’s degree, their starting salaries would logically be higher. 

Second, the current population of RDs is very homogenous.  As of 2008, 89% of RDs identify themselves as Caucasian.⁸  Additionally, around 96% of RDs are female.⁹  This lack of diversity has several implications.  In the US, there is still a large gap in the salaries of men and women.⁹  This gap exists in the RD profession.  On average, the few males working in the dietetics profession earn around $5000 more a year than their female counterparts.⁹  Because the profession is mostly made up of females, the majority of RDs  are underpaid because of their sex.  Lack of diversity also affects how RDs are viewed by the public.  Research has shown that individuals are more likely to receive a message effectively and take action when the message is given to them by someone similar to themselves.  For example, a study by Halliday-Boykins et al. looked at therapist ethnic similarity on youth outcomes.¹⁰  The study found that “youths whose caregivers were ethnically matched with their therapists demonstrated greater decreases in symptoms, longer times in treatment, and increased likelihood of discharge for meeting treatment goals relative to youths whose caregivers and therapists were not ethnically matched.”¹⁰  This means therapists were more effective when their patient was of the same ethnicity.  RDs often see patients in the same type of counseling setting; therefore this theory likely also applies to the field of dietetics.  This implies a significant portion of the population will not connect effectively with the current RDs. It can be hypothesized that counseling by an RD will not be as successful for minorities or males because they are dissimilar from the average white, female population of dietitians. 

The education of Registered Dietitians has a strong focus on treatment of the individual.  The core courses that are included in accredited dietetics programs have very little focus on community nutrition.  Of the long list of coursework required to obtain an RD license, few courses teach a community-based or population level approach to improving health.¹¹  This is why a large portion of RDs pursue clinical careers in the hospital setting or outpatient careers involving one-on-one counseling.⁶  As previously stated, this individual level approach has not been effective in reducing the obesity rates in the US.  If RDs are truly essential for an effective intervention in this epidemic, their education must change to place a greater emphasis on population-level health improvement.

Big Business in our Mouths

            The food industry is a very powerful driving force behind what types of foods are consumed in America.  Through advertising and pricing strategies, the food industry dictates who consumes what type of food in our country.  Currently, there is a perception that eating healthier food is a lot more expensive.  A meta-analysis was recently published by the Harvard School of Public Health demonstrating this exact phenomenon.  However, the media got hold of this article and press release and twisted the results of the study to create a sensationalized story that strongly implies eating healthier is not significantly more expensive.^12,13,14 

            The meta-analysis done by Rao et al. looked at the results from several studies analyzing the prices of healthier versus less healthy foods and diet patterns.¹⁵  The studies included in the review were conducted in many different countries and all had developed some sort of model for quantifying the average difference in price of healthy foods versus less healthy foods.¹⁵  Rao et al. combined the results of the studies and came up with a mean difference in price between eating healthy foods and eating unhealthy foods.  Using random effects models, the researchers determined that healthier diets cost, on average, $1.50 more per person per day.¹⁵  The media is using this statistic to say that it really does not cost that much more to consume a healthier diet because $1.50 is not that much money.^12,13,14  However, as the Rao analysis astutely points out, for individuals and families of low socioeconomic status, this $1.50 per person per day makes a big difference.¹⁵ 

Using basic math, several conclusions can be drawn.  According to the United States Department of Labor, the yearly salary making Federal Minimum wage is $15,080.   In a household with two individuals earning minimum wage, there is a total household income of $30,160 a year.  For a family of four, if it costs $1.50 per day per person to eat healthier, the total cost will be  $2190 for a whole year.  Based on a household income of $30,160, eating healthier food will cost 7.3% of yearly income.  This percentage does not account for the total cost of food.  This 7.3% only accounts for eating healthier.  According to the USDA, as of October 2013 a family of four with young children on a “thrifty” or less expensive meal budget will spend an average of $556.30 on food per month.  For a whole year, cost of food would be $6,675.60.  Assuming this family is only making minimum wage, they are already spending 22% of their yearly income on food.  Add the 7.3% to make their food healthier, and they are spending almost 30% of their yearly income on food.  Most families cannot afford to be spending this high a percentage of their income on food. 

The media has taken the $1.50 extra a day statistic and is twisting into an individual problem.  Many news websites state that this extra amount of money is much less in the long run compared to medical bills associated with the outcomes of eating an unhealthy diet.^{12,13, 14}  However, families making minimum wage cannot afford to pay extra to buy healthier food.  Therefore, they have to consume lower quality products, will likely develop obesity, and will suffer from associated health problems.  They cannot afford to avoid future medical bills because they have other expenses such as clothing, housing, and car payments that take priority over eating healthier.  This demonstrates yet another way that the media is blaming individuals for a public health problem even though individuals do not have control over the issue.  Low income families are not choosing to eat unhealthy food; they simply do not have a choice. 

This is where the food industry plays a major role in helping reduce obesity rates.  The food industry has the ability to make healthier, affordable food available to low income families.  If Walmart can make a 100% whole wheat loaf of bread the same price as a loaf of regular white bread and make inexpensive fruit and vegetables available the same price equality can be achieved for other foods.¹⁶

Proposed Intervention: If obesity is a national problem, it should be treated like one

            It is clear that the current public health interventions for the treatment of obesity and reduction of obesity rates in America are not working.  In order to fix this, a new approach to the problem must be taken.  A successful obesity intervention cannot target individuals because individuals are not to blame for the obesity epidemic.  Currently, it is the view of the public that individuals are responsible for the spread of this disease, but several external factors are at work and must be addressed.  The proposed intervention has three components that are different from previous plans.  First, individual approaches to weight loss must transition to group level approaches in order to produce long-term weight loss and change the public’s view about the root causes of obesity.  Second, the value of RDs must increase in order for them to participate fully in the new approaches and to be able to deliver effective messages to the public.  Finally, changes in the food industry must occur in order to elicit large-scale changes in the diet of the nation.  If all three of these changes were to take place, the obesity rates would steadily begin to decline and quality of life for all Americans would increase.

Changing the Obesity Perception

            As previously stated, individual level weight loss strategies have a relatively low success rate in terms of maintenance of long-term, significant weight loss.  Therefore, alternative weight loss methods must be employed in order to provoke a significant decrease in the number of individuals who are already obese.  Currently, Weight Watchers (WW) is viewed as one of the more successful methods for weight loss.¹⁷  In 2006, the state of Tennessee partnered with WW to offer the program at a discounted rate to Medicaid beneficiaries.¹⁷  A retrospective study was published in 2012 assessing the effectiveness of this partnering which lasted from January 2006 to January 2009.¹⁷  Mitchell et al. assessed the association between WW meeting attendance and weight loss.  The researchers found that individuals who attended two or less meetings only lost 0.5% of their original weight while individuals who attended 13 or more meetings lost 6.4% of their original weight.¹⁷  They also found that weight loss increased with increasing meeting attendance.  While this study has a few limitations including a homogenous sample (female, minority, low income) and a limited follow-up period, it still has important implications.¹⁷  This study demonstrates that when given the opportunity to join a structured, group weight loss program, low income individuals were able to lose more weight successfully.¹⁷  Based on this finding, if all other states offered a similar Weight Watchers/Medicaid program, a significant portion of the US population could potentially lose weight.  The Tennessee study demonstrates that being involved in a support group with other individuals aspiring to a similar goal (weight loss) can help people modify their behavior more effectively.  Individuals who are obese need support from others in similar situations, as well as support from the public.

In order for drastic changes to occur, the public’s opinion about individuals who are obese must change.  In a study performed by Puhl et al., more than 370 videos from news websites were analyzed to determine the portrayal of the obese to the public.¹⁸  The study concluded that, in the 370 videos, “65% of overweight/obese adults and 77% of overweight/obese youth were portrayed in a negative, stigmatizing manner across multiple obesity-related topics covered in online news videos.”¹⁸  As previously mentioned, the public generally blames individuals for the obesity epidemic so these results are not entirely surprising.  This public view of obesity needs to change and the stigma needs to fade away before obesity rates can drop.  In order for this to happen, individuals who are obese need to know that they are not alone and need to be portrayed in a more positive light in the media.  For example, Puhl et al. states that many camera angles of obese individuals are purposely unflattering and zoom in on specific body parts rather than showing the whole person.¹⁸  Instead, obese individuals could be portrayed as actual, full human beings rather than simply unflattering body parts.    Public health interventions need to have a stronger voice in that convinces the public that obesity is not an individual problem.  I believe that Registered Dietitians can provide this voice.

Increasing the Value of an Invaluable Profession

            As previously mentioned, Registered Dietitians make significantly less money than other health professionals of similar importance with regards to patient health.  Additionally, the current population of RDs is homogenous and made up mostly of white females.  In order for RDs to have a greater impact on eliminating the obesity epidemic, several aspects of the profession need to change.  First of all, the Academy for Nutrition and Dietetics needs to require the attainment of a Master’s degree in order to obtain a dietetic license.  The AND agrees with this statement.  According to their 2012 visioning report, “RD salaries were 40-45% less than salaries of other non-physician health professionals” and “Education beyond the bachelor’s degree continues to be associated with hourly wage gains.”¹⁹  Based on this information, the AND needs to enforce this new educational requirement in order to increase the value of the profession.  Moreover, requiring RDs to pursue a higher education will increase their knowledge of other aspects of nutrition beyond a clinical scope.  An RD with a Master’s degree will have more education and more experience working in community nutrition, non-profit organizations, and public health promotion.¹⁹  Increasing the value of the profession will attract more students to the profession and will, therefore, increase the diversity of RDs.  When the diversity of the RD population increases, a greater variety and proportion of obese individuals will be effectively reached and treated.   

            Furthermore, RDs need to become the voice of people who are obese.  RDs have the opportunity to talk to and counsel many people who are obese about their disease, their possible weight loss goals, and their struggles.  Therefore, RDs are likely much more sensitive to the issue than other healthcare professionals, the media, or even the government.  Part of the education of a Registered Dietitian includes practicing counseling techniques that can elicit motivation and change in an individual without creating blame for the individual’s current state of health.  RDs need to become more present in the media and deliver these positive counseling techniques to a larger audience.  This can be done on a large scale, such as on national television, or on a smaller scale through social media or blogging.  When RDs create a stronger public presence, more recognition will be gained for the field of dietetics as a whole both from the public and other healthcare professionals.  If RDs can steer the public towards attributing the obesity epidemic to policies and the food industry and place a greater emphasis on prevention, a true impact in the obesity rate will be seen.

Change the Market, Change the Waistlines

            The food industry is a consumer-driven business.  Major food companies will respond to public demands for a certain kind of food.  A perfect example of this phenomenon is the development and distribution of trans fats in our food supply.  Back in the 1960s, research indicated that the consumption of excess saturated fat increased the risk of heart disease.²⁰  In response to this discovery, the public began to avoid saturated fats such as those found in butter, baked goods, and other processed foods.  This is what drove the food industry to produce trans fats—hydrogenated, unsaturated fats with similar properties to saturated fats.²⁰  At this time, the health risks associated with excess consumption of trans fats were not yet known.  The food industry exploded with products boasting that they were free of saturated fats and began feeding Americans margarine, Crisco, and baked goods made with hydrogenated oils.  Finally, in 1993, the Nurses’ Health Study elucidated the relationship between trans fat intake and increased risk for heart disease.²⁰  In 2006, food manufacturers were required to add trans fats to the Nutrition Facts label.²⁰  Eventually, the risks of trans fat consumption became widely known by the public and people did not want to consume this type of fat.  In response, the food industry removed trans fats from their products and came up with alternatives.²⁰ 

Presently, in 2013, the FDA removed trans fats from their “Generally Recognized as Safe” list.²¹  This is a prime demonstration of the power of the consumer over the food industry.  When people did not want saturated fat, the food industry gave the public trans fats.  Now, people do not want trans fats so the food industry is giving the market un-hydrogenated alternatives.  Several other examples of the consumer driven nature of the food industry include the increased availability of Greek yogurt, products free of high fructose corn syrup, organic products, whole grain products, convenience foods, and frozen foods just to name a few.  These products are now at nearly every grocery store because the public wants them.  Public health campaigns need to harness consumer-power to their advantage.

            If public health interventions can convince the public that they want healthier, more affordable products, the food industry will respond by producing them.  There are several ways to accomplish this.  As previously mentioned, a disproportionate amount of individuals of low socio-economic status are obese.  These low income individuals and families are often eligible for food assistance programs such as Women, Infants and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP).  WIC and SNAP differ in several ways including who is eligible for benefits and the type of food that can be purchased.  WIC only allows certain types of food to be purchased that tend to be healthier options—whole grains, fruits, vegetables, low fat dairy, etc.²²  Additionally, only pregnant women, breastfeeding women, infants, and children under the age of 5 are eligible for WIC benefits.²²  SNAP, which is afforded to a greater number of people, does not regulate the type of food for which the assistance can be used.²³  SNAP benefits can be used to purchase an apple or a candy bar.  In fact, the USDA website states “Soft drinks, candy, cookies, snack crackers, and ice cream are food items and are therefore eligible items.”²³  Low SES individuals are going to be more attracted to items like this because they are less expensive.  SNAP benefits need to change its list of eligible food items to encourage healthier eating habits.  Because WIC only allows the purchase of healthier foods, the country is holding pregnant women and young children at a higher standard than the rest of the low income population.  This is not just.  All low SES families should be held at this high standard.  Everyone deserves to eat healthy food, even low income individuals.  The USDA must change the SNAP policies and frame the change using the core value of justice.  This change in SNAP will lessen the purchase of cheap, unhealthy food.  The food industry will respond to this by making less expensive, healthier products available so that they do not lose money.  This change in the food market will then have positive benefits for the whole population, including those not eligible for SNAP.

            Public health campaigns can increase public demand for healthier products in other ways.  Television and internet advertising are powerful tools used by the food industry to sell less healthy products.  These tools can also be used by public health campaigns to sell healthier foods.  Using similar strategies to those used by the food industry will be more powerful in swaying the public towards favoring healthier products.  Rather than boasting the healthy benefits of fruits and vegetables, public health campaigns should highlight other benefits including increasing one’s freedom and independence, increasing one’s attractiveness, consumption by celebrities, or increasing one’s popularity.  If food companies can use these methods to get people to buy products, public health should use them too.

Concluding Remarks

This intervention will help reduce the impact of external risk factors for obesity including low SES, race, gender, ethnicity, language, and geographic location.  Increasing the value of Registered Dietitians will earn them greater respect in the healthcare field and from the public and they will therefore be able to have a stronger voice in the media.  The dietetics profession will become more diverse and be able to reach out to a larger portion of the population effectively regardless of race, ethnicity, sex, or language.  Once we convince the public that individuals are not to blame for the obesity epidemic, public call for a larger scale intervention will occur.  This will increase the demand for healthier food at affordable prices, which will dictate what the food industry is producing.  As healthier, affordable food becomes available, it will be easier for individuals who are obese to lose weight and will prevent future obesity. 

References

1.         Centers for Disease Control and Prevention. Prevalence of Obesity in the United States, 2009-2010. NCHS Data Brief. Hyattsville, MD: National Center for Health Statistics 2012.

2.         Nelms M, Sucher K, Lacey K, Long Roth S. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Wadsworth, 2011.

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4.         National Heart, Lung, and Blood Institute.  Obesity Education Initiative Expert Panel on the Identification E. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI, 1998.

5.         Lusk JL, Ellison B. Who is to blame for the rise in obesity? Appetite. 2013;68:14–20.

6.         Academy of Nutrition and Dietetics.  What is a registered dietitian? Chicago, IL: Academy of Nutrition and Dietetics. http://www.eatright.org/About/Content

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7.         Recruirter.com. Salaries for Healthcare Professionals. Farminton, CT: http://www.recruiter.com/salaries/healthcare-professionals-salary.html.

8.         Stein K. The Educational Pipeline and Diversity in Dietetics. J Acad Nutr Diet. 2012;112(6):791–800.

9.         Pollard P, Taylor M, Daher N. Gender-based wage differentials among registered dietitians. Heal Care Manag. 2007;26(1):52–63.

10.       Halliday-Boykins CA, Schoenwald SK, Letourneau EJ. Caregiver-Therapist Ethnic Similarity Predicts Youth Outcomes From an Empirically Based Treatment. J Consult Clin Psychol. 2005;73(5):808–818.

11.       Boston University. Didactic Program in Dietetics. Boston, MA: http://www.bu.edu/academics/sar/programs/nutrition-dietetics/dpd/.

12.       CNN Health:  The Chart.  Healthy eating costs you $1.50 more a day. http://thechart.blogs.cnn.com/2013/12/05/healthy-eating-costs-you-1-50-more-a-day/.

13.       NPR: The Salt. Godoy M. What Separates A Healthy and Unhealthy Diet?  Just $1.50 Per Day. http://www.npr.org/blogs/thesalt/2013/12/05/249072685/what-separates-a-healthy-and-unhealthy-diet-just-1-50-per-day.

14.       NY Daily News: Health.  Healthiest diets cost about $1.50 more per day than unhealthiest: study. http://www.nydailynews.com/life-style/health/healthiest-diets-cost-1-50-day-study-article-1.1540043.

15.       Rao M, Afshin A, Singh G, Mozaffarian D. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ Open. 2013;3(12):e004277.

16.       Walmart: The heart-healthy pantry. http://wm13.walmart.com/food-entertaining/Articles/The_Heart-Healthy_Pantry/697/.

17.       Mitchell NS, Ellison MC, Hill JO, Tsai AG. Evaluation of the Effectiveness of Making Weight Watchers Available to Tennessee Medicaid (TennCare) Recipients. J Gen Intern Med. 2013;28(1):12–17.

18.       Puhl RM, Peterson JL, DePierre JA, Luedicke J. Headless, Hungry, and Unhealthy: A Video Content Analysis of Obese Persons Portrayed in Online News. J Health Commun. 2013;18(6):686–702.

19.       Academy of Nutrition and Dietetics. Visioning Report. Chicago, IL: AND, 2012.

20.      Remig V, Franklin B, Margolis S, Kostas G, Nece T, Street JC. Trans Fats in America: A Review of Their Use, Consumption, Health Implications, and Regulation. J Am Diet Assoc. 2010;110(4):585–592.

21.       Food and Drug Administration. FDA Targets Trans Fat in Processed Foods. Silver Spring, MD:  Food and Drug Administration. http://www.fda.gov/forconsumers/consumerupdates/ucm372915.htm.

22. United States Department of Agriculture. Women Infants and Children. WIC Food Packages - Regulatory Requirements for WIC-Eligible Foods.  USDA. http://www.fns.usda.gov/wic/wic-food-packages-regulatory-requirements-wic-eligible-foods.

23. United States Department of Agriculture.  Supplemental Nutrition Assistance Program (SNAP) Eligible Food Items. USDA. http://www.fns.usda.gov/snap/eligible-food-items.