Challenging Dogma - Spring 2011

Thursday, June 16, 2011

Why Calling a Fat Kid a Fat Kid Doesn’t Solve Childhood Obesity -Jessica Ochalek

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

Defeating Self-Efficacy

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.


Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.


While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.


As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages; physical activity is fun; obese children are also entitled to fun; obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.


Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.


Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small; anxiety and withdrawal occur when a challenge is too great; curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.


Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati.
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Monday, May 23, 2011

Countering the United States' Passive Attempts at Tackling Antibiotic Resistance - Casey Godbout

Antibiotic resistance is a major global issue that has the ability to affect any individual in a variety of circumstances. It is viewed as a pressing concern in the scientific community based on substantial costs for healthcare systems, increased morbidity and mortality, and implications for a bleak future of treating microbes. The World Health Organization's (WHO) central focus of the 2011 World Health Day was antimicrobial resistance, yet was this vital concern effectively addressed?
Resistance is an evolutionary adaptation (mutation) of a microbe due to the presence an antibiotic that tends to spread rapidly in response to excessive use and misuse. While it is now being recognized by many government and health organizations, it has been an imminent concern since the first signs of resistance to penicillin in the mid 1940s. Complacency in the 1980s, has led to a reduction in novel antibiotic development and increased number of deaths due to multidrug resistant (MDR) and extremely drug resistant (XDR) infections. In the United States alone, the annual cost of antibiotic-resistant infections ranges from $21-$34 billion and 8 million additional hospital days due to these infections (1). What was once believed to be traditionally endemic to hospital settings have subsequently become endemic in community settings as well.
Developing countries run the risk of microbes developing resistance faster due to issues of illegal, poor quality and counterfeit drugs, as well as shortages of essential medications. Additionally, individuals in poorer countries are subject to crowded and generally unsanitary conditions, which allow resistant microbes to spread and thrive (2). But why, in a medically advanced, highly developed nation do we see such excess in deaths attributable to infection with resistant microbes? Surely, the United States has the resources, sanitation, knowledge, diagnostic capabilities and greater capacity to slow the spread of inevitable adaptations and reduce illness. The answer is a unanimous yes, but the current attitude that has evolved in our society is generated by laziness, convenience of access to antibiotics and a lack of economic incentive to pursue such high standards of care.
At the patient level, individuals have grown accustomed to the ease of acquiring antibiotics from pharmacies and physicians. The first signs of a sneeze or a cough warrants the need to treat, whether or not that treatment is biologically effective. Antibiotics treat bacterial infections, not viral infections, yet patients are convinced (generally due to past experiences) that these pills still cure their symptoms. At the provider level, the conflict arises from the difficulty in conveying information to the patient, particularly when that patient is a distraught parent with a sick child. Physicians are often conflicted by the patient's need for rapid treatment, and whether or not to clinically diagnose the pathogen and take time to sufficiently explain antibiotic use to patients. This is where the overuse comes into play. On the other end, patients who do develop bacterial infections may be prescribed antibiotics and do not "take as directed" by their physician. As soon as the patient starts to feel healthy again, they discontinue use of the antibiotic, and allow any mutant/resistant microbes to survive and multiply (3). This is considered the misuse of antibiotics. Combined, overuse and misuse of antibiotics have allowed antibiotic resistance to become a serious concern in a developed nation.
In this paper, I will first analyze the flaws of the current approaches to antibiotic resistance in the United States by way of behavioral science and models. I will then make suggestions for improving the approach by synthesizing evidence-based research with patient and provider beliefs and behaviors.

Critique 1: The Health Belief model's failure to address antibiotic resistance

The Health Belief Model assumes that people are rational when making decisions about their health. Many campaigns that address antibiotic resistance utilize this model to reduce the overuse and misuse of these drugs. These campaigns focus heavily on passive education of patients, providers, and in some cases, policy makers about resistance and adherence to antibiotic regimens. The Health Belief Model assumes that a person's health related behavior depends on their perception of the severity of antibiotic resistance, the person's susceptibility to adverse antibiotic resistance outcomes, the benefit of taking preventive action against future resistance and the barriers to taking that action (3).
To illustrate the ineffectiveness of antibiotic resistance interventions, the CDC's Get Smart: Know when Antibiotics Work campaign is an ideal example. This campaign offers substantial information about when antibiotics are appropriate for use, symptom relief for non-bacterial infections, quizzes and FAQs that test individual's knowledge of antibiotic resistance, and materials for a variety of audiences including PSAs, articles, brochures, fact sheets and developing partnerships with the CDC's campaign. The assumption is that from the established partnerships, health departments and institutions may be educated and effectively disseminate information to reduce misuse and increase adherence, while simultaneously educating the general population(5).
This campaign, among others, follows the basic assumption that once people are educated about the severity of and susceptibility to antibiotic resistance, they will make rational health-related decisions:
1. Once patients comprehend that resistance correlates to ineffective treatments and potential mortality, they will reduce their demand for antibiotics.
2. Once they realize their susceptibility to antibiotic resistant microbes they will not misuse antibiotics, and adhere to their regimen.
3. Once they are educated they will understand the benefits, albeit future benefits, of not taking antibiotics with a viral infection.
4. Once they are educated there will no longer be barriers keeping them from utilizing antibiotics correctly and effectively.
These four critical perceptions of the HBM are complete fallacies in regard to antibiotic resistance. As clean-cut as they may appear, common medical practice has driven patients towards far-fetched perceptions of the growing problem.
Perceived susceptibility is low among the majority of patients. Most patients (and this applies to many disease-related situations) may not believe that this will affect them or their children directly. Additionally, even when the patient recognizes their own susceptibility, action will not occur unless the individual perceives the severity to be at such a significant level that it will cause detrimental results. People, particularly people engaging in health-related decision-making, are not rational and focus substantially on the present. This realization therefore supports the discrepancies of the HBM, because it does not address emotional factors such as fear, cultural beliefs, and social and economic factors.

Intervention I:

When tackling the issue of antibiotic resistance there is no doubt that effective education strategies are a necessary component to any intervention. Understanding the concepts associated with resistance is essential for policy-makers, public health leaders, physicians and patients as well as clear communication between parties. Education alone cannot solely be associated with resulting action however, and therefore an intervention must seek to rise above and beyond current methodologies.
Education can be classified as either passive or active. Passive education strategies aim to provide information and let the learner internalize this information and subsequently do what they want with it. Active learning strategies aim to teach by "doing." In regards to physicians, utilizing active learning strategies vs. listening to an hour lecture with PowerPoint, for example, has shown to be more beneficial. Working in one-on-one or group settings such a workshops, outreach groups, or building sessions may be most effective in physician and institutional change (3). It will help physicians at the group level, begin a cultural change and practice how to handle demanding patients by conveying the appropriate messages.
Critique 2: You can teach an old dog new tricks
Differences among antibiotic prescribing practices and use from place to place can best be validated by the Situated Learning Theory. The main premise of this behavioral theory is that "learning is not an accumulation of information, but a transformation of the individual who is moving toward full membership in the professional community" (6). Learning is also perceived as an enculturation process, in which after observation of behavior of other members of the community, individuals pick up the skills, imitate behavior and act in accordance with the community's norms (7). In the context of hospital and healthcare settings, knowledge is not solely based on what was learned, for example, in medical school, but rather what was adapted as a community and culture within the health institution. With this in mind, physicians practicing in certain health settings may be more or less likely to prescribe antibiotics to patients depending their institutions behaviors and norms. It is therefore likely to be difficult to alter any behaviors within an established medical culture, unless the adaptation is at a group level.
A major drawback in addressing antibiotic resistance comes from the preheld attitudes and beliefs of both practitioners and patients about antibiotic use. Intervention strategies that assume that passive education will result in new affirmed beliefs and a change in action are highly mistaken. Additionally, intervention strategies that assume that the proper use of antibiotics in the context of physicians, patients and healthcare systems are mutually exclusive also find little hope in reducing resistance.
Evidence-based research has concluded that internal clinician factors including knowledge, experience and training are primary factors in unnecessary prescribing of antibiotics as well as clinician specialty and level of training. The highest prescribers of antibiotics for colds, acute respiratory infections (ARIs) and bronchitis are likely to be older and practice in rural areas (4). All of these factors support differences in the culture of prescribing. Interventions like the CDC's Get Smart Campaign which focus primarily on passive learning, rather than group level, interactive teaching methods have a difficult time altering physician practices.
Patients are similar to physicians, in that they have grown accustomed to particular beliefs of antibiotic use through the hospital culture and general society. Studies show how patients seeking care for ARIs expect to receive antibiotics, and patients or parents who expect, receive them more frequently based on prior experiences. Being provided information via website, brochure, PSA, or by a doctor does not mean a patient will all of a sudden stop demanding antibiotics or appropriately adhere to their antibiotic regimen. Sociodemographic factors have also been found to be associated with excess antibiotic use, which may be related to different attitudes, knowledge and expectations in varying populations as well as physicians' attitudes about particular groups. The highest use of antibiotic therapy for colds, ARIs and bronchitis treatment falls within the <5 years of age category (3). This is representative of parents' expectations that doctors will always have the ability to provide quick antibiotic treatment that will cure their children, and alternately how doctors are faced with immense pressure from patients and social norms to do so.
A recently published study, implemented a methicillin-resistant Staphylococcus aureus (MRSA) bundle in VA hospitals across the U.S. in order to assess and prevent health care associated infections with MRSA. This initiative included universal surveillance, contact precautions, and hand hygiene practices, all of which should be the common culture of health institutions. The bundle proved to be highly effective in identifying and reducing the number of health care-associated MRSA infections. The other main focus of the study was to attempt to implement an institutional culture change. It is unbelievable that hand hygiene, contact precautions and surveillance methods are not the mainstream culture, but rather need to be implemented by means of a bundle within healthcare institutions (8).
Intervention 2: Fueling Fire with Fire
Since the Situated Learning Theory shows how physicians learn from "doing", their peers, and their adaptations to their environmental norms, this theory can also be used to counter current practices and beliefs. In many studies, physicians have expressed the need for effective dissemination and the need for more direct guidance, due to the fact that many do not perceive particular diseases or medical practices as growing problems. Physicians have commented how they comprehend the significance of a problem, but continue to aim their focus on other more immediate health issues such as myocardial infarctions (9). It is difficult to emphasize antibiotic resistance and enforce good practice particularly when it tends to lead to adverse effects on people other than the immediate recipient of the drugs (10).
Other physicians have emphasized a combination of their learning, and that their held beliefs about what are "major" issues in the medical world are strongly emphasized in their medical training and over many years in practice (9). In order to address these belief differences it is important to try and make the beliefs of pressing health problems as universal as possible, which can first try to be accomplished during medical training and developing core values. Following medical training it is up to the environment of the health care institution to effectively develop a well-rounded set of beliefs and practices surrounding antibiotic prescriptions and limiting resistance. This will make it easier for physicians to express medical knowledge and culture to patients effectively while still maintaining a strong patient-provider relationship.
Critique 3: Antibiotic resistance interventions are implemented at specific levels of the health care hierarchy and not as a concerted effort between patients, providers and policy-makers.
The American Medical Association (AMA), World Health Organization (WHO), Infectious Disease Society of America (IDSA), Centers for Disease Control (CDC), Food and Drug Administration (FDA), United States Department of Agriculture (USDA) and countless other organizations have blatantly recognized, and many have developed, recommendations, guidelines, and a vast array of materials designated to reduce antibiotic resistance both in hospitals and community settings. Many healthcare institutions currently have antibiotic resistance guidelines in place that their health professionals are assumed to appropriately adhere to, while completely disregarding economic, pharmaceutical, patient, and social norm pressures to act otherwise (11).
Guidelines are in place in many hospital settings that address prescribing antibiotics to patients, however guidelines are just that, they guide physicians when making decisions. As noted in critique 2, physicians, particularly older physicians, have difficulty adapting and forming new habits, particularly in an area that has remained stagnant and relatively consistent for many years. The CDC could update recommendations every 6-months with the newest evidence-based research, however without enforcement and concerted effort there will never be progress.
Currently the U.S. does not systematically gather data on antibiotic prescriptions and use that can be utilized to understand the manner and the degree to which antibiotics are used (1). Surveillance is also important to determine antibiotic resistance trends for a wide range of infections and pathogens, as well as the type/quantity of antibiotics most commonly used in patient care. It is considered inappropriate use when physicians prescribe broad spectrum antibiotics to a patient with an infection that must be attacked by a narrow spectrum antibiotic and vice versa. Developing trends observed by these surveillance systems, would offer support to physicians when making decisions about which antibiotics to use (if any) and relaying this information to patients (1).
Physicians and patients can do their part to reduce antibiotic resistance by prescribing appropriate antibiotics (or no antibiotics for viral infections) and adhere to antibiotic regimens, respectively. Unfortunately, these actions merely slow the emergence and transmission of resistance so the focus must also be on policy-makers and the government to keep up with resistance.
Pharmaceutical companies have placed antibiotic development on the back burner. Five new antibiotics were approved between 2003-2007, compared to 16 new antibiotics between 1983-1987 (12). In 2008, only 15 antibiotics of 167 under development had a totally new mechanism of action to tackle multidrug resistance (13). Since the 1960s only four new classes of antibiotics have been introduced and most of the new antibiotics are simply chemical derivatives of these basic scaffolds (14). Pharmaceutical companies have little incentive to develop new antibiotics due to high failure rates in clinical trials, as well as poor return on investment since they are taken for only a short period of time (13).
Another area of government regulation is antibiotic use in livestock. The largest use of antibiotics worldwide is in the production of animals for human consumption and secondly, as additives in animal feeds over long-term, low-level use (prime conditions for microbes to mutate and spread resistant strains) (15). While this is great for the producers seeking to produce large, healthy animals to sell to consumers, it is dangerous in regard to increasing antibiotic resistance. The same antibiotics used in the feed and to stimulate growth are also those used by humans to treat infections. The European Union (EU) is years ahead of the United States, and officially banned the use of antibiotics for animal growth in 2006 (16). Again, recommendations have been made by the IDSA and other organizations to ban non-judicious antibiotic use in animals, plants and marine environments; however these recommendations are not viewed as urgent problems.
The lack of new antibiotics for the future and antibiotic use in livestock production are incredibly dense, multifaceted topics that could be addressed more in depth in extended interventions. They are discussed briefly here to illustrate the depth and magnitude of the emergence of antibiotic resistant microbes and to point out that current intervention strategies do nothing to change them.
Intervention 3: Utilizing the Diffusion of Innovations Theory to initiate change

Since it is difficult to promote health behavior change and initiate new guidelines and policies that physicians and providers will ultimately follow, a new overall approach must be used. The Diffusion of Innovations theory is an excellent theory for addressing changes in health behavior at the group level. The framework specifically addresses innovation, style of communication, steps in decision making and the social context. According to Ralph Linton, diffusion include three distinct processes, "presentation of the new culture element or elements to the society, acceptance by the society, and the integration of the acceptance by the society, and the integration of the accepted element or elements into the preexisting culture" (17).
An intervention developed using the Diffusion of Innovations Theory addresses all of the drawbacks of current antibiotic resistance campaigns and approaches. The innovation is the new culture of healthcare institutions recognizing antibiotic resistance as a major health concern and physician's appropriately using antibiotics to cure bacterial infections and effectively communicate with patients. It will also include individuals within the institutions that will make sure physician's are judiciously prescribing antibiotics and will include a surveillance method as described earlier. The next aspect is the relative advantage, or the degree to which the innovation is perceived as better than prior interventions (i.e. effectiveness and cost efficiency). Reducing the emergence of multidrug resistant infections, will reduce the cost per patient within the hospital setting since multidrug resistant infections tend to resort to more expensive, last resort regimens (10).
The intervention will then address the complexity of the issue. Incorporating active learning sessions for physicians and health care professionals within a hospital will teach and reinforce the issues and implemented guidelines. There will also be bulleted reminders posted within the hospital to serve as reminders, including important facts to convey to patients.
It will be the hope that early adopters will already share the belief that antibiotic resistance is a major problem, and begin to implement changes within their institutions. It has been shown that the more charismatic and well-known particular individuals or institutions implementing the change are, the more likely others will be influenced to follow (18). Current interventions include utilizing many different modes of communication to get the word out to patients. While these modes are easy to access, they provide a plethora of conflicting opinion from source to source, and studies have shown that face-to-face exchange, specifically between a person regarded as highly professional and knowledgeable communicating with a patient, will result in a desired change of attitude. Lastly, the process can be summarized by the following:
1. Researchers gather knowledge about the growing problem and resulting effects of antibiotic resistance at the patient, physician, and health care system/economic levels.
2. The healthcare institutions and physicians are persuaded about advantages of the proposed innovation (i.e. reduce per patient costs, reduce length of stay in hospitals, reduce/slow antibiotic resistance)
3. The institutions and physicians engage in active learning activities (i.e. workshops, communication strategies, communicating with professionals about innovation) that will lead to choosing and adopting the innovation
4. The innovation is incorporated into the institution and daily practice of the physician which will be monitored
5. Reinforcement of the innovation will be achieved via discussion groups, seminars between nearby hospitals, and presentation of evidence-based findings (18).


1. Infectious Diseases Society of America (IDSA) Combating Antimicrobial Resistance: Policy Recommendations to Save Lives. Clinical Infectious Diseases 2011; 52(S5):S397-S428.
2. Gould, I.M. Coping with antibiotic resistance: the impending crisis. International J of Antimicrobial Agents 2010; 36:S1-S2.
3. Ranji SR, Steinman MA, Shojania KG, Sundaram V, Lewis R, Arnold S, Gonzales R.
Antibiotic Prescribing Behavior. Vol. 4 of: Shojania KG, McDonald KM, Wachter RM, OwensDK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Agency for Healthcare Research and Quality 2006. AHRQ Publication No. 04(06)-0051-4.
4. Sharma, M., Romas, J.A. Chapter 4: Health Belief Model. In: Theoretical Foundations of Health Education and Health Promotion. Sudbury, MA: Jones & Bartlett. pgs 31-44.
5. Centers for Disease Control (CDC). Get Smart: Know When Antibiotics Work Campaign. 2011.
6. Hmelo, C.E., Evenson, D.H. Introduction: Problem-Based Learning: Gaining Insights on Learning Interactions through Multiple Methods of Inquiry (pgs. 1-19). In: Hmelo, C.E., Evenson, D.H., ed. Problem-Based Learning: A Research Perspective on Learning Interactions. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 2000.
7. Brown, J. S., Collins, A., & Dugid, P. (1989). Situated cognition and the culture of learning. Educational Researcher, 18, 32-42.
8. Jain, Rajiv, Kralovic, S.M., Evans, M.E., Ambrose, M.,Simbartl, L.A., Obrosky, S., Render, M.L., Freyberg, M.S., Jernigan, J.A., Muder, R.R., Miller, L.J., and Roselle, G.A. Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. N Engl J Med 2011; 364:15.
9. Barlow, G., Nathwani, D., Myers, E., Sullivan, F., Stevens, N., Duffy, R., Davey, P. Identifying Barriers to the Rapid Administration of Appropriate Antibiotics in Community-Acquired Pneumonia. J of Antimicrobial Chemotherapy 2008; 61:442-451.
10. ReAct - Action on Antibiotic Resistance: Economic Aspects of Antibiotic Resistance.
11. University of Pennsylvania Medical Center Guidelines for Antimicrobial Therapy. 2011. Accessed from /table%20of%20contents.htm.

12. Stubbings, William and Labishiniski, H. New Antibiotics for antibiotic-resistant bacteria. Biology Reports 2009; I:40.
13. Fischbach, M.A., Walsh, C.T. Antibiotic for Emerging Pathogens. Science 2009; 325: 1089-1093.
14. Braine, Theresa. Race Against Time to Develop New Antibiotics. Bull World Health Organization 2011; 89:88-89.
15. Silbergeld, E.K., Graham, J., Price, L.B. Industrial Food Animal Production, Antimicrobial Resistance and Human Health. Annual Review of Public Health 2008; 29:151-169.
16. Smith DL, Dushoff J, Morris G Jr (2005) Agricultural antibiotics and human health. PLoS Med 2(8): e232.
17. Dearing, J.D. Applying Diffusion of Innovations Theory to Intervention Development. Res Soc Work Pract 2009: 19:503-518.
18. Sanson-Fisher, R. W. Diffusion of Innovation Theory for Clinical Change. MJA 2004; 180: S55-56.

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Critique of the Eat Smart Play Hard Campaign to Prevent Childhood Obesity-Gauri Apte

Overweight and obesity are significant public health problems in the United States (US). [1] The number of overweight adolescents has tripled in the last years and prevalence among younger children has more than doubled (See figure 1). [2,3,4] Not only has the proportion of overweight individuals increased but the heaviest children in a recent National Health and Nutrition Examination (NHANES) survey were markedly heavier than those in previous surveys. [2,3]
Being overweight during childhood and adolescence increases the risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and type 2 diabetes as a youth.[5] It also has a large number of long-term adverse health outcomes. Overweight adolescents have a 70 percent chance of becoming overweight or obese adults, which increases to 80 percent if one or more parent is overweight or obese. [6] Obesity in adulthood increases the risk of diabetes, high blood pressure, high cholesterol, asthma, arthritis, and a general poor health status [7].
Understanding the causes of childhood obesity can provide the opportunity to focus resources, interventions and research in directions that would be most beneficial in addressing the problem. The causes of childhood obesity are multi-factorial. Excess weight in children and adolescents is generally caused by a lack of physical activity, unhealthy eating patterns resulting in excess energy intake, or a combination of the two. Genetics and social factors, such as socio-economic status, race/ethnicity, media and marketing, and the physical environment – also influence energy consumption and expenditure. Most factors leading to being overweight and obese do not work in isolation and solely targeting one factor may not going to make a significant impact on the growing problem. [8] Specific causes for the increase in prevalence of childhood obesity are not clear and establishing causality is difficult since it involves research which must employ long study times to see if there is an interaction of factors leading to an increase in the prevalence or the prevention of obesity during childhood and adolescence. Under-reporting total food intake, misreporting of what was eaten, and over reporting physical activity are all likely potential biases that may affect the outcomes of studies in this area.[9]
This paper briefly describes the current intervention for prevention of childhood obesity and proposes a new modified intervention. It presents three critiques of this current intervention and then defends the new intervention as a tool to overcome these critiques. In the end it gives a conclusion derived from this exercise.

Current Interventions: The Eat Smart, Play Hard Campaign (ESPH)
This campaign is a part of the U.S Department of Health and Human Service's 'Childhood Obesity Prevention' program [10] and is funded by the U.S Department of Agriculture (USDA). This campaign is a national nutrition education and promotion campaign designed by USDA's Food and Nutrition Service (FNS) to convey science-based, behavior-focused and motivational messages about healthy eating and physical activity. [11]
Messages developed for the campaign are based on the most recent edition of the Dietary Guidelines for Americans [12] and the Food Guide Pyramid. [13]
The initial campaign messages focus on four basic themes: breakfast, snacks, balance and physical activity. The program is designed to: 1) Encourage families to adopt behaviors that are consistent with the Dietary Guidelines for Americans and the Food Guide Pyramid; 2) Communicate behavioral and motivational nutrition education and physical activity messages to children and caregivers; and 3) Foster positive behavior change to promote nutrition and health, and reduce the risk for obesity and chronic diseases.
The target audience for this campaign is the diverse population of children (ages 2 to 18 years) and their caregivers including include parents, guardians, child care providers, after school providers, and teachers. The campaign is designed to reach the target group where they live, work, learn and play using multiple communication vehicles, approaches and channels. The campaign has a spokes-character- the Power Panther and his nephew Slurp to promote healthy eating and to encourage physical activity in children and their families. Power Panther encourages children to eat healthy foods and get more exercise.

Proposed Intervention:
For an intervention for prevention of childhood obesity to be successful, it has to be community-based, involving a community or a social group of people and has to involve social marketing and advertising. [26] However a well recognized potential downside of the community-based programs and social marketing campaigns targeting obesity is their promotion; the social desirability of thinness, which is exacerbated by the media.[27,28,29] Given the uncertainty of the balance between 'benefit' and harm associated with community-based programs and social marketing campaigns, approach to controlling the increasing prevalence of this condition should focus on the benefits of a healthy diet and physical activity rather than on obesity per se. This promotion of a healthy diet and increased physical activity would be expected to lead to the achievement of weight control in current generations, and the prevention of weight gain in future generations. [30]
The proposed intervention will make use of social networks and groups that children and adolescents are a part of in order to communicate healthy behaviors. These networks will involve peers who influence and can be influenced by one another in a way more effective than being influenced by parent, teachers and caregivers. [31] The intervention will also make use of media such as the internet and social networking website which form a large part of the lifestyle of today's children and adolescents. Along with use of social networks, the intervention will use TV advertisements and internet videos to communicate health message to the target audience, who spend a considerable amount of time watching TV and online videos. [32]
In addition to promoting healthy eating and exercise habits, the campaign will also make available fruits and vegetables at more affordable prices to schools who take part in the campaign as well as to families that have children and adolescents. It will involve education of parents and caregivers especially in the lower socio-economic families where healthy eating habits and physical activity are not a part of the household. Along with children, their parents and caregivers will be encouraged to adopt these health practices so that it will be easier for these children and adolescents to Eat Smart and Play Hard.

Critique 1: Psychological Reactance Generated Makes Campaign Ineffective
The ESPH Campaign involves getting children and adolescents to eat healthier and take part in more physical activity. The Campaign does this by telling children what healthy food are and that they must eat these foods. For example telling children to eat more fruits and vegetables, asking them not to drink sweetened drinks, not eat fried foods, etc. In order to improve physical activity i.e making children play hard, the campaign recommends restriction of screen time. This means that parents have to set restrictions for the amount of time spend in front of the TV, computer, video games, etc. [15]
The Psychological Reactance theory proposed by Brehm, states that if a person's behavioral freedom is reduced or threatened with reduction, the person will become motivationally aroused. This arousal would presumably be directed against any further loss of freedom, and it would also be directed towards re-establishment of whatever freedom has already been lost or threatened. This hypothetical state of motivational arousal is know as Psychological Reactance. [16,17] The variables affecting the degree of reactance include, strength of a threat, presence of a freedom, importance of the freedom, proportion of the freedom threatened, and implication for future threat . [18] The effects of this psychological reactance can adversely affect the ESPH campaign. When children and adolescents are told what they must and must not eat, their freedom to select the food of their choice is threatened. They can react to it by intentionally picking so-called the forbidden food. The success of a public health campaign in avoiding reactance, depends on its explicitness, dominance and reason. [19] The ESPH campaign does not explicitly explain to the target audience why they must eat healthier foods. One of the tools is replacing unhealthy foods in the cafeteria with healthier options, but in doing so, there is no consideration given to reasoning with the children and adolescents as to why this change has been brought about. This will result in increased reactance among the children and decrease the chances of changing health behavior. Similarly, with regards to the play hard part of the campaign, if children are made to exercise by enforcing screen time restrictions they will see it as a threat to their freedom. This will increase reactance and they will be prompted to do the exact opposite and not exercise in order to gain back control. [20]

Intervention Defense 1: Using the Social Cognitive Theory/Social Network Theory to Combat Psychological Reactance.
One of the ways to overcome psychological reactance is to make the campaign message delivery as similar to the target audience as possible. This is less threatening to their freedom and they will willingly want to bring about the behavior change. Similarity increases the positive force towards compliance by increasing liking. [33,34] A good way to do this is to have a communicator who is as similar to the children and adolescents. Thus using peers to convey the message of healthy eating habits and increased physical activity will be more widely accepted by these children than a similar message by parents, caregivers, schools, etc. This can be done by building a model based on the Social Cognitive Theory which states that change is behavior is influenced by the environment, self-efficacy and modelling of observed behavior. [35]
In schools, a committee of students can be formed, who will communicate the message of eating healthy and increasing physical activity. The initial group of students can be selected based on general model social behavior, peer influence and leadership potential. This group of students can communicate the message directly to their fellow students and also communicate to the teachers and school management about what children and adolescents like to eat, the physical activities that they would enjoy taking part in, etc. The students can be involved with the school in deciding healthier options to replace junk foods in the cafeterias. This will help schools have foods that are healthy and more liked by children. Also knowing that their peers had a say in deciding the cafeteria menu will reduce reactance among the children and adolescents and they will be more willing to try these new healthier options. Also knowing that the more popular and influential kids eat healthy foods, will make many other children model similar behavior and this will encourage healthy eating habits.
In order to improve physical activity, a similar group of students can be used to help the educators come up with innovative and interesting activities that will be attractive to the students. Team activities can also be started using the selected students as leaders of different teams. There can be healthy competition which will encourage the students to engage in more physical activity without it being boring or seeming like a task. At home this can also be done by encouraging older siblings to first modify and adapt healthier eating habits by explaining to them the importance of these health behaviors. Being explicit and open about healthy eating habits will reduce reactance amongst the older children. [19] They should be told about the influence they have on their younger siblings and that they can act as helpers to the parents. This will evoke a sense of responsibility among the older sibling and will improve health behavior in younger siblings through modeling of sibling eating habits.
In addition to this, the Social Network theory can also be used to improve eating habits and physical activity among children and adolescents. Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. [37] This knowledge can be used for prevention of Childhood Obesity. According to the Social Network theory , the factor that most affects a person's behavior is the behavior of persons in their social network, such as family, extended family or non-kin -church or work groups, friends or neighbors who regularly socialize and clubs and sporting teams. [38] This can be done by positively using various social networking websites where children and adolescents are a part of. Groups can be formed on these sites that encourage healthy eating habits and increased physical activity. The campaign can be propagated as a movement, being a part of which, can be considered trendy or 'cool' by the target group. This can again be done by initially involving a select group of students and including them as part of the campaign. They can then spread the message to their network of friends via these websites and these friends will pass it on to others, thus creating a large movement which will spread through the social network. [39] This social network can then also be used to create and organize events that will encourage healthy eating habits and involve physical activities games, among others and targeted toward different age groups keeping in mind their interests and current trends. Various other online contests such as one for healthy innovative recipes that children and adolescents can come up with, games involving physical activity, etc can also be held. Thus social networks can be used to bring about health behavior change.

Critique 2: Use of An Animated Mascot/Spokesperson to Communicate Behavior Messages
The ESPH Campaign uses animated spokes-character, the Power Panther and his nephew Slurp, to communicate messages to children and adolescents and their care givers. The Campaign provides three scripts to help communicate these messages. [21] Eat Smart. Play Hard. With MyPyramid: It is a script for community events and introduces parents, kids and community groups to the Power Panther and the food guide pyramid. It provides an optional physical activity- Power up Moves.
Power Panther takes Eat Smart, Play Hard to Schools: This is an interactive session where school-age children are introduced to Power Panther who encourages them to embrace healthy eating and physical activity behaviors. Power Panther also conveys the importance of eating breakfast. Learn to Eat Smart, Play Hard with Power Panther: Interactive session where children and care givers are introduced to the campaign
Along with these scripts, there is also a Power Panther song encouraging children and adolescents to follow healthy eating habits and physical activity.
The target audience of this campaign is children and adolescents from 2 to 18 yrs of age. While use of an animated character as a spokesperson may be an effective means to communicate with younger children, it may have an adverse effect on adolescents. Adolescents do not like to be treated like children. They are at a stage when they begin to consider themselves close to being adults and prefer to addresses similarly. Often reckless and irresponsible behavior seen in teenagers is a way of declaring their adulthood. If they are treated as adults by caregivers, teachers, etc., they almost immediately rise to the challenge and can bring about effective behavior change. [22]
The ESPH campaign mainly uses tools such as activity sheets, bookmarks, comic stickers to encourage children to indulge in healthy behaviors. They also use brochures, posters and handouts. Though attractive to younger children, these tools may not be an age-appropriate method to communicate with adolescents. Adolescents are less likely to take these methods seriously and may in turn mock them or form spoofs to gain peer popularity. This deters the goal of the campaign. Also adolescents are at a stage where they tend to look up to their peers and gain recognition from them and are less likely to be influenced by a spokes-character like the Power Panther which they might consider too childish for them. [23] In order to gain prestige some teens use general sociability and good reputation while some others do it by being the class clown. [24] In attempting to be popular among peers these teens might resort to mocking the seemingly juvenile posters, stickers, etc.
This can result in others following similar behaviors due to peer influence and not taking the campaign and its message seriously. [25] For the campaign to be successful, it needs to be conveyed via a more effective vehicle that is likely to be effective for all of the target audience.

Intervention Defense 2- Use of Advertising and Marketing Theory for Better Compliance.
An important cause of increased childhood obesity is in the increase in junk food TV commercials. [39 ] These commercials are based on the three main principles of the Advertising theory. They are:
Promise: Every advertisement makes a promise to a certain desirable outcome to the consumer if he/she buys the product
Support: Evidence that the product can support the promise
Core Values: There are a certain set of core values that have universal appeal.
Some of these are family, love, freedom, youth, rebelliousness, power and, acceptance. If an advertisement can appeal to these values in an individual, it is more likely than not to be successful.
These same principles can be used to create advertisements which encourage healthy eating habits and physical activities in children and adolescents.
Advertisements can use young celebrities who can communicate the Eat Smart, Play Hard message. These celebrities are usually looked up to by children and adolescents and have high model prestige. If they encourage a certain health behavior, more youth will want to model their behavior and indulge in healthy eating and exercise habits. The advertisements can be as simple as the celebrity choosing a fruit or a vegetable over a bag of chips. They can be targeted towards appealing to the core value of 'power' where children will believe that it is indeed in their hands to make a change about their own behavior and whether or not they choose a healthy lifestyle is up to them. This will also minimize psychological reactance and bring about voluntary change in health behavior.
In addition to using celebrities, children and adolescents from the same age group as the target audience can be used to create advertisements that promise a healthy life style. For example, an advertisement can show a group of teens, including a mix of different type of kids that most children can identify with. These teens can be shown to make simple choices such as picking health food at the cafeteria, choosing to bike to school or even the mall as opposed to being dropped off, choosing to play a group sport as opposed to a video game and doing so with a lot of ease and enthusiasm. Each of the advertisements can have the catch phrase 'I/We Choose', followed by different endings such as 'eat healthy', 'stay fit', 'go green'. These will appeal to a number of core values such as freedom, power, rebelliousness, acceptance just by demonstrating that children and adolescents have the power 'to choose' the right health behavior. Media, in the form of, attractive visuals and catchy music can be used to appeal to these youth along with using the factor of peer influence. [31] This will create a public health brand that will seek to change eating and physical activity habits.
Social Marketing employs commercial marketing principles and tactics to influence voluntary human behavior for societal benefit rather than commercial profit. [42] According to this marketing theory, there is a need to research what consumers want and modify the campaign so that the product trying to be sold fulfills those wants. These ads will market 'Fun and Freedom' in order to promote good health. The advertisements will make the promise of a healthy yet fun and interesting lifestyle appealing to various core values in youth. In order to follow up and provide support to this promise, we can have healthier options in cafeterias, more time allocated to physical activities in schools, providing parking for bikes at schools, malls etc. In addition to having advertisements on TV, the videos can also be posted online. The internet is one of the major sources of entertainment and learning for today's youth. Children and adolescents spend a good amount of time surfing the internet. [42] Thus putting these videos online can increase their viewership in children and adolescents.
The internet can also be used to create various competitions under the 'We Choose' campaign where children can send in videos and photographs of their friends and peers and how they chose to make a healthier food or exercise choose. This can be done through social networking sites as well as online videos announcing these competitions. Winners will be chosen from each category on a monthly basis and winning videos and photos can be posted online and at the end of 6 months one chosen video can be used as a part of a TV advertisement. This will create healthy competition as well as provide an opportunity to do something creative, all while keeping the ultimate goal of healthy eating and exercise habits.

Critique 3: Reliance on the Theory of Reasoned Action Fails the Campaign at a Community Level
Like a lot of other public health interventions, the ESPH Campaign relies on the Theory of Reasoned Action. According to this theory, a person's behavior depends on [43]:
Attitude: A persons belief about what will happen if he or she performs the behavior and a person's judgment about whether the expected outcome is good or bad.
Subjective Norms: A person's belief's about what other people in his or her social group will think about the behavior and a person's motivation to conform to these perceived norms.
Behavioral intention: A person's intention to perform behavior.
This theory however has its weaknesses. To begin with, it is an individual level model, which assumes that intention leads to behavior which may not be true. It also uses social norms as a determinant for behavior change. However social norms are not universal and defer based on culture, society, etc.
The ESPH campaign involves use of charts, posters, worksheets etc to explain to children and adolescents the importance of healthy eating and physical activity. Through the use of its spokes-character it encourages adoption of such health behaviors. However, the theory makes an assumption that if children know the health benefits of healthy eating and exercise they will want to change their habits and this in turn will prevent obesity and bring good health. However there are various other factors that may be barriers to adoption of healthy behaviors even if children and adolescents intend to do so. One of the ways the campaign plans to promote healthy eating is providing healthier options in the cafeterias. However it does not take into account the fact that often these healthier foods such as fruits, vegetable or salads are more expensive than the unhealthy options, such as a bag of chips or French fries. [44] Though some children may be able to afford these more expensive food items, there are many that may not be able to do so and therefore their intention to eat healthy may not actually turn into reality.
Another problem would be eating habits of children after school. Many children come from families that do not themselves practice health eating and exercise habits at home. For these children the unhealthy habits are a part of their lifestyle and they view them as norms. Since they think this is normal behavior, it is harder to them to bring about a change in their behavior. Also often children and adolescents come from poorer families who cannot afford to buy healthier foods. There are also children whose parents themselves are not aware of the changes that can be brought about with addition and healthy food and exercise behaviors and unhealthy habits for such children is often learned behavior. The Campaign however assumes that parents would actively take part in bringing about change to their households with the use of tools provided through the campaign. The campaign does not take into account these norms that affect the child's behavior and does not involve active education of parents and caregivers.

Intervention Defense 3: Overcoming Assumptions of the Theory of Reasoned Action.
In order to enable children and adolescents to adopt healthy behaviors, the campaign will provide affordable healthy foods. The Campaign will match prices of foods such as fruits, vegetables, salads, etc to those of unhealthier options like fried and fatty foods. This will enable children to make a choice without having to worry about the costs involved in choosing healthy foods. This can be done by partnering with produce companies and buying in bulk so that affordability of these foods can be maintained. In addition to this, the healthier foods can be displayed more attractively and accessibly so that young people who have the intention to change their health behaviors will get a push forward in the direction towards making that healthy choice.
Another barrier to adoption of healthy eating and exercise habits is the after school environment of kids which differs from person to person. The Campaign will undertake education of parents and caregivers by conducting community level programs and workshops. In these workshops the parents and caregiver will be taught about the ill effects of obesity during childhood and its affects on future life as adults. Benefits of healthy eating habits and regular physical activity will be explained to them and they will be given various methods to help bring about this health change in their wards. They will be given various easy healthy recipe options and encouraged to incorporate these into their diet. They will also be told not to ask a certain behavior of their children in order to avoid reactance but instead to provide healthy options to the children and encourage them to make the right choice. For families who come from lower socio economic backgrounds, healthy foods such as fruits and vegetables will be provided at subsidized rates within the community and incentives will be provided to families that adopt healthier eating habits.
To encourage regular physical activities, parents and caregivers themselves will be encouraged to take part in such activities and use some such fun physical activity as a good bonding experience for the entire family. Adults will be encouraged to adopt healthier lifestyles and lead by example by cutting down on screen time themselves. This will help create an environment which will prompt children to take up more physical activity. [45] Parents will also be educated to encourage their children to walk and use bicycles to go to school and other accessible places rather than dropping them there. The campaign will organize community events where families can take part in activities such as races and other games involving physical activity, workshops for parents and kids to learn simple and healthy recipes, etc. These will help bring about effective health change in children and adolescents.

Current interventions for prevention of Childhood obesity include the Eat Smart, Play Hard Campaign which is targeted at children and adolescents between 2-19yrs of age. It makes use of tools such as worksheets, charts, posters, spokes-character, etc to encourage children and adolescents to adopt healthy eating habits and physical activity. This campaign however, does not take into the account the psychological reactance that it cause in youth, does not use enough and appropriate mass media to propagate its message and does not take into account the various barriers to adoption of the suggested health behaviors.
The new campaign that this paper proposes, plans to overcome the drawbacks to the ESPH Campaign to create an improved childhood obesity prevention program. The new campaign makes use of celebrities and peers to communicate the health messages in order to minimize reactance. It makes use of the power of social networks in influencing youth and uses them to bring about behavior change. It uses TV and online advertisements which appeal to core values of the youth and gives them the power to choose to adopt the target health behavior thus prompting informed change and promoting the adoption of a healthier lifestyle. The campaign also makes an effort to overcome economic and social barriers that may limit children from eating healthy and taking up more exercises. It does this through parent and caregiver education and provision of healthy foods at subsidized rates to participating schools and families with children and adolescents.
Child Obesity is one of the leading public health problems in the US today. It has serious short-term consequences such as increased risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and type 2 diabetes as a youth [46]and long term consequences such as increased risk of diabetes, high blood pressure, high cholesterol, asthma, arthritis, and a general poor health status. [47] Prevention of Childhood obesity should therefore be a public health priority. The new campaign proposed, aims to prevent childhood obesity by a using more effective vehicles to promote health behavior change and if well implemented will help bring the obesity epidemic under control.

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A Critique of the New York City Department of Health and Mental Hygiene Pouring on the Pounds Campaign - Lauren DeBerry

During the past 20 years there has been a dramatic increase in obesity in the United States (1). More than one third of U.S. adults, more than 72 million, people and 17% of U.S. children are obese. From 1980 through 2008, obesity rates for adults have doubled and rates for children have tripled (2). If current trends continue, it is estimated that 75% of Americans will be overweight or obese by 2015 (3). The prevalence of obesity is a serious public health concern because of its health and economic consequences (4,5). Obesity is a major risk factor for cardiovascular disease, certain types of cancer, type 2 diabetes, and lifetime morbidity (4). The medical care costs of obesity in the United States are increasing with the increase rate of obesity. In 2008 dollars, these costs totaled about $147 billion a large share of which is being paid for by Medicare and Medicaid (5). The Center for Disease Control and Prevention (CDC) states that obesity results from an energy imbalance. This involves consuming too many calories and not getting enough physical activity (6). According to government surveys, the number one source of calories in the American diet is sugar-sweetened beverages, representing 7 percent of the average person’s caloric intake and up to 10 percent for children and teenagers. These calories are worse than useless because they are empty, and contribute to a daily total that is already too high (7,8,9). In 2009, the New York City Department of Health and Mental Hygiene implemented the Pouring on the Pounds campaign in order to highlight the health impact of sweetened drinks (10).

Pouring on the Pounds
New York City is comprised of five counties, Bronx, Kings, New York, Queens, and Richmond (11). The 2008 age adjusted estimates of the percentage of adults who ware obese in these counties were 28.3%, 24.2%, 16.1%, 23.5% and 24.6% (3). In an effort to highlight the health impact of sweetened drinks and address this increasing rates of obesity, the New York City Department of Health and Mental Hygiene asked New Yorkers “Are you pouring on the pounds?” The agency’s public-awareness campaign was comprised of posters in the subway system and a multilingual Health Bulletins and public service announcements. Sugary drink consumption was chosen as the area of focus for this campaign because research has shown that more than 2 million New Yorkers drink at least one sugar-sweetened beverage a day, adding as many as 250 empty calories to their diets, which puts the human body at increased risk for a multitude of diseases (5). The campaign urges people to drink lower-calorie alternatives or limit their portions. The campaign attempted to disgust and shock people into changing their consumption of sugar-sweetened beverages to water, seltzer, unsweetened tea or low-fat milk instead (11).
The pouring on the pounds campaign is deeply rooted in the health belief model. The health belief model stipulates that a person's health-related behavior depends on the person's perception of four critical areas: the severity of a potential illness, the person's susceptibility to that illness, the benefits of taking a preventive action, and the barriers to taking that action (12). The New York City Department of Health and Mental Hygiene expected to change New Yorker’s drinking habits by simply educating the public on their susceptibility to obesity and the severity of obesity. Although this was a good starting point in developing the campaign they missed the mark on a few important issues; the campaign did not fully express the benefits and barriers/cost of removing the benefits of removing sugar sweetened beverages from your diet, the campaign ignores advertising theory, and the campaign does not account for behavior influenced by context.

Benefits and Barriers
As previously discussed, The New York City Department of Health and Mental Hygiene Pouring on the Pounds campaign focused on one’s susceptibility to and the severity of obesity. The campaign’s signature image was a bottle of soda, “sports”drink or sweetened iced tea turns to a blob of fat as it reaches the glass. They also showed images of the amount of sugar in sugar sweetened beverages, an obese person in a wheelchair, a man in cardiac arrest, and a foot mangled by diabetes (10, 13). If the NYCDHMH was following The Health Belief Model these images were necessary, however, images of the perceived costs/barriers and benefits should have been included as well (12).
The most important barriers to address when attempting to switch someone from sugar sweetened beverages to healthier alternatives are the ability of the alternative choices and the social and finical cost of the switch. The campaign never shows a person making the healthy choice and therefore never highlights the ease to making said choice. If a person does not regularly consume water, seltzer unsweetened tea or milk they may be unaware of its wide availability. Most stores, restaurants and vending machines that sell sugar sweetened beverages also sell the alternatives suggest although the option my not be as clearly advertised (example vending machines that list water as the lowest option).
The campaign dose not address the financial cost of switching from sugar sweetened beverages to healthier options. Since the beginning of the recession the media is constantly discussing the increased cost of living. One of the many way they express this is with stories about the increase cost of milk, one of the suggested healthy drinks in the campaign (14,15,16,17). If the campaign want to succeed in switching New Yorker to healthy drinks they must express its effect on the on the consumers wallet.
Another flaw in the campaign is it does not the social cost of removing sugar sweetened beverages from one’s diet. Sugar sweetened beverages are embedded traditions In the United States. Manufacturers of sugar sweetened beverages have associated themselves with everything from sporting events to Christmas (18,19). This makes the perceived cost breaking life long habits and violating social norms. Although the campaign aims at changing life-long habits, if fails to connect healthy habits to the activities usually associated with sugar sweetened beverages in order to display the new habit will not conflict with social norms.
Pouring on the pounds never expresses the benefits of switching sugar sweetened beverages for healthier options. The campaign mention the avoidance of weight gain obesity and diabetes but never mentions how switching can change one’s life (10,11,13). The campaign never mentions that removing one can of soda a day can result in losing 10 pounds a year (19). The ads also fail to mention the many health and beauty benefits of drinking water and milk. By omitting these benefits The New York City Department of Health and Mental Hygiene misses out on providing an enticing promise to their audience.

Advertising Theory
The manufactures of sugar sweetened beverages have used advertising and marketing theory to sell their products for years. The New York City Department of Health and Mental Hygiene wants its campaign to compete with them therefore they should use advertising and marketing theory as well. The Pouring on the Pounds campaign does a good job with branding. The campaign used its catchphrase “Are you pouring on the pounds?” and its signature image on most of their materials making the campaign recognizable to the viewer. The campaign also used the diffusion of innovations theory well by having their videos on the Internet enabling them to go viral, but it can be found lacking many other important elements of advertising theory (10,20). The campaign fails to use core values to create universal appeal and lacks a promise.
The core values that work for persuading the American public are: family, love, success, hard work, freedom, fairness, belonging, attractiveness, sex, youth, rebelliousness, and power. Companies like Coca Cola and Pepsi have used theses values time and again to sell their sell their product (21-26). Some of the common core values used in sugar sweetened beverages advertisements are belonging, attractiveness, sex, and youth. The Pouring on the Pounds campaign does not use one of these values in fact they show images of young attractive people drinking the very drinks they are trying to discourage people from drinking (13). If the campaign utilized the core values they would have a more convincing argument and would likely reach more people.
According to David Ogilvy, a prominent copy writer from the 1960s, the key to a successful advertising campaign is its promise (20). The promise is made by the messenger about the idea they are selling. The audience is driven by the promise. Strong promises usually include one or more of the core values of the audience. The stronger the promise the more effective the effective the campaign (20,27). Considering the Pouring on the Pounds campaign was trying to compete with sugar sweetened beverages advertising campaigns it is a surprise they choose to not include a promise in their posters and video. NYCDHMH could have promised New Yorkers happiness, belonging, attractiveness, sex, youth or love among many other things to encourage people to drink healthier beverages. The pouring on the pounds campaign has an advantage over the sugar sweetened beverages makers in that their promise can be backed up with real proof, another key part of advertising theory. The NYCDHMH already has scientific studies at their disposable showing the health and beauty benefits of increased water consumption and decreased sugary drink consumption.

Behavior in Context
NYCDHMH assumes with its Pouring on the Pounds campaign that behavior is planned and rational. The campaign expects that by viewing their ads, people will be disgusted or shocked and decide to eliminate or reduce sugar sweetened beverages from their diet. This idea may work for people in who are consuming beverages when they are not thirsty or hungry but will not be as effective for those who are. During exposure to the ad, people might discard their beverages or avoid drinking sugar sweetened beverages for a few hours but what happens when that person develops the desire to quench their thirst (28,29)? The campaign disregards the concept that human behavior is dynamic and that it is influenced by context (28,29). Many things including hunger, thirst, and sexual desire can induce a hot state. In a hot state people’s behavior is instinctive unreasoning and irrational (28,29).
Research has shown, instinctive factors can change desires rapidly as they are affected by changing internal and external stimuli (28). For example, a person can see the Pouring on the Pounds ad in the subway on their way to work and decide to stop drinking sugar sweetened beverages. Later on their lunch break when they are hungry and thirsty, the person goes to a deli to get lunch. Seeing the vast variety of drinks offered as well as enticing images, they may forget their desire to remove sugar sweetened beverages from their diet. Exposure to images and menu options at the store or restaurant will now influence their purchasing behavior. This concept suggests that the environmental context has a greater impact on eating and drinking habits. The Pouring on the Pounds campaign would have a greater impact on viewers if they sought to intervene when the viewer is in the hot state.

Improving Pouring in the Pounds
Although the pouring on the pounds campaign had a few flaws it would be advantageous for the New York City Department of Health and Mental Hygiene to address those flaws rather than develop a new campaign. Because the brand messaging was well developed, it would be helpful to consumers to identify the campaign to keep the tag line.
In addition to the posters and videos the campaign already used, the campaign should develop a new series of videos that the highlight the benefits of reducing consumption of sugar sweeten beverages . The first video show a man in the convenience store reaching for a water or other unsweetened drink in slow motion. As the man gets closer to the water, you see him becoming slimmer illustrating the weight loss achievable if you do not drink sugar sweetened beverages. As the video is running a voice will be heard saying “Removing sugary drinks can result in 10 pounds weight loss.”Then the tag line will appear as well as a prompt to friend the campaign on Facebook. The second video will be set in an office. It can show three co-workers in the break room getting ready for lunch. Two of them, a thin and attractive man and women, will have reusable bottles of water one filling his up with the cooler. The third work, chubby, will be digging around in his pockets for money before asking the others for a dollar to buy a soda. As the women reaches into her purse she will smile say “It’s a good thing I’m saving so much money bring my own water to work. You should try it. ”and laughs. The soda drinker takes the money and says “Thanks boss” The next screen will show the average savings you can make by switching from sugary beverages to unsweetened beverages. Then the tag line will appear as well as a prompt to friend the campaign on Facebook. The next video could show a groups of happy fit young adults wearing matching team uniforms carrying a large trophy grabbing water and milk from the cooler pushing aside the sports drinks and sodas. As the camera pans out, you see the losing team drinking sports drinks. The announcer will say another benefit of drinking unsweetened beverages “Drinking low fat milk can help you build strong bones and keep you lean.” Then the tag line will appear as well as a prompt to friend the campaign on Facebook. The final video will show a young women walking along the refrigerated aisle in a bodega. She continual walks past cooler after cooler of soda and fruit punch. Finally she reaches the cooler with the water and as she reaches for a bottle her hand brushes against another had. She looks up for find a handsome man holding a bottle of water. He smiles a knowing smile at her and they begin to talk. The announce will say “Replacing soda with water can help you stay hydrated and you complexion looking young.” Then the tag line will appear as well as a prompt to friend the campaign on Facebook.
In conjunction to the new videos there will be a Facebook campaign. Facebook is important to the campaign because of it make the messenger seem more like the viewer and allows for grater access. Using Facebook allows the campaign to provide a community for people to discuss ideas and information about the campaign and its ideas. The campaign can use Facebook send out facts and reminders about sugar sweetened beverages and advertise events relating to the campaign. Facebook is unique in that it can provide an online community setting even for those who do not have regular access to computers. African-Americans and English-speaking Latinos are among the most active users of the mobile web (30). These ethnic backgrounds also have disproportionate rates of obesity. By utilizing Facebook the campaign can reach more people than by using the government run website as Facebook had applications for most mobile phones.
One of the events that will be advertised on facebook will the the trade in your sugar events. The campaign will go to both busy tourist locations and areas populated by office workers. Here they will have young happy attractive people in Pouring on the Pounds t-shirts asking people to trade in their sugar sweetened beverages for recommended drinks or reusable water bottles labeled with the Pouring on the Pounds tag line on one side and a fact about sugar sweetened beverages on the other. Some of these can be done as flash mob style surprising unsuspecting workers during their lunch break while others will be advertised on the facebook page. If they events are successful they could be filmed and aired in the vein of the truth campaign advertisements (31) .
The final improvement to the campaign would be the placement and content of the print advertisements. The NYCDHMH chose to run the ads in the subway system where people are not allowed to eat. They should place the in locations where people would be likely to see them as they were one their way to eat such as billboards close to fast food restaurants or posters in delis. The Pouring on the Pounds campaign should also run its commercials during eating hours so people at home can be reached in the hot state as well.

Defense of the improved Pouring on the Pounds
Each of these improvements address the what was missing in the campaign. The new commercials clearly discuss the benefits of the behavior change and each video can address the many different benefits both health the beauty of switching from drinking sugar sweetened beverages to unsweetened beverages. The advertisements also subtly show and dispel the perceived barriers to the switching from drinking sugar sweetened to unsweetened drinks. By showing people saving by money by not drinking sugar sweetened beverages and by showing that in stores filled with sugar sweetened beverages you can still find healthy options as in the second and fourth videos, The barriers are proven wrong with out specifically calling the barriers to the mind of the viewer and turning them off to the message.
Each commercial uses advertising theory. The commercial promises the viewer attractiveness. The second commercial promises wealth and belonging while also highlighting the core value of power since the boss is drinking water she brought from home. The commercial with the team uses the core values of happiness youth attractiveness and success. The promise of being a winner should compel the viewer to change their behavior. The final commercial employs the core values of youth, attractiveness, love and sex to show the viewer that replacing sugar sweetened beverages from their diet can be beneficial to their life. As the campaign continues the NYCDHMH can add new commercials to that highlight other key core values keeping the campaign in touch with New Yorkers’values and targeting new demographics.
The use of Facebook, in addition to providing increased access, creates a community. This will tap into the viewers’core value of belonging as well. Using facebook correctly can also keep followers informed on the issue as well as provide reminders of the need for behavior change.
Finally by placing the strategically placing advertisements in and around places of consumption the new campaign can reach viewer in the hot state where they are more less rational and forget previous messages to attempt to enact behavior change. The new Pouring on the Pounds Campaign also reaches people in the hot state by asking them to trade in their beverages during their lunch breaks.
The New Pouring on the Pounds campaign should be successful. If The New York City Department of Health and Mental Hygiene took advantage of its many different resources and employed the use of different behavior change theories they will be successful in any campaign they attempt.

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