Jonathan L. Blitstein

Shame or subsidy revisited: social mobilization for sanitation in Orissa, India

OBJECTIVEnTo determine the effectiveness of a sanitation campaign that combines shaming (i.e. emotional motivators) with subsidies for poor households in rural Orissa, an Indian state with a disproportionately high share of Indias child mortality.nnnMETHODSnUsing a cluster-randomized design, we selected 20 treatment and 20 control villages in the coastal district of Bhadrak, rural Orissa, for a total sample of 1050 households. We collected sanitation and health data before and after a community-led sanitation project, and we used a difference-in-difference estimator to determine the extent to which the campaign influenced the number of households building and using a latrine.nnnFINDINGSnLatrine ownership did not increase in control villages, but in treatment villages it rose from 6% to 32% in the overall sample, from 5% to 36% in households below the poverty line (eligible for a government subsidy) and from 7% to 26% in households above the poverty line (not eligible for a government subsidy).nnnCONCLUSIONnSubsidies can overcome serious budget constraints but are not necessary to spur action, for shaming can be very effective by harnessing the power of social pressure and peer monitoring. Through a combination of shaming and subsidies, social marketing can improve sanitation worldwide.

Predictors of Violent Behavior in an Early Adolescent Cohort: Similarities and Differences Across Genders

The authors assessed a cohort of 2,335 students from the Minneapolis, Minnesota, area to identify predictors of violent behavior and to determine whether the predictors varied by gender. The sample was 76% White; boys and girls were equally represented. The majority lived with two parents. A measure of violent behavior collected at the end of the eighth-grade year (2000) was entered into Poisson regression against baseline data collected at the beginning of the seventh-grade year (1998). Predictors of violent behavior influencing both boys and girls included depressive symptoms, perceived invulnerability to negative future events, paternal nonauthoritative behavior, and drinking alcohol. Additional predictors of violent behavior specific to girls included both risk and protective factors.

Perceptions of the food shopping environment are associated with greater consumption of fruits and vegetables.

OBJECTIVEnThe present study examined whether characteristics such as quality, selection and convenience are associated with dietary intake of fruits and vegetables independent of perceived costs in an inner-city, low-income population.nnnDESIGNnSecondary analysis of baseline data from a social marketing intervention designed to change household dietary practices among parents of 3- to 7-year-old children.nnnSETTINGnA community sample drawn from six low-income, primarily minority neighbourhoods in Chicago, IL, USA.nnnSUBJECTSnFrom the parent study, 526 respondents completed the baseline survey and were eligible for inclusion. Of this number, 495 provided complete data on sociodemographic characteristics, fruit and vegetable consumption, perceptions of the shopping environment, perceived costs of fruits and vegetables, and food shopping habits.nnnRESULTSnLogistic regression analysis showed that more positive perceptions of the food shopping environment were associated with greater consumption of fruits and vegetables. There was an increase of approximately twofold in the likelihood of consuming three or more fruits and vegetables daily per level of satisfaction ascribed to the shopping environment. This association was independent of perceived cost, store type and sociodemographic characteristics.nnnCONCLUSIONSnOur data show that among a generally minority and low-income population, quality, selection and convenience are important determinants of fruit and vegetable consumption. Nutrition promotion campaigns that aim to alter the built environment by increasing access to fruits and vegetables should recognize that simply increasing availability may not yield beneficial change when characteristics of the shopping context are ignored.

Systematic Review of Public Health Branding

Brands build relationships between consumers and products, services, or lifestyles by providing beneficial exchanges and adding value to their objects. Brands can be measured through associations that consumers hold for products and services. Public health brands are the associations that individuals hold for health behaviors, or lifestyles that embody multiple health behaviors. We systematically reviewed the literature on public health brands; developed a methodology for describing branded health messages and campaigns; and examined specific branding strategies across a range of topic areas, campaigns, and global settings. We searched the literature for published studies on public health branding available through all relevant, major online publication databases. Public health branding was operationalized as any manuscripts in the health, social science, and business literature on branding or brands in health promotion marketing. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 154 articles and reviewed a final set of 37, 10 from Africa, Australia, and Europe. Branded health campaigns spanned most of the major domains of public health and numerous communication strategies and evaluation methodologies. Most studies provided clear information on planning, development, and evaluation of the branding effort, while some provided minimal information. Branded health messages typically are theory based, and there is a body of evidence on their behavior change effectiveness, especially in nutrition, tobacco control, and HIV/AIDS. More rigorous research is needed, however, on how branded health messages impact specific populations and behaviors.

Nutrition-Education Program Improves Preschoolers' At-Home Diet: A Group Randomized Trial

OBJECTIVEnThis study evaluated whether a nutrition-education program in child-care centers improved childrens at-home daily consumption of fruits and vegetables, at-home use of low-fat/fat-free milk, and other at-home dietary behaviors.nnnMATERIALS AND METHODSnTwenty-four child-care centers serving low-income families were matched by region, type, and size, and then randomly assigned to either an intervention or control condition. In the 12 intervention centers, registered dietitian nutritionists provided nutrition education to children and parents separately during a 6- to 10-week period. They also held two training sessions for center staff, to educate them on healthy eating and physical activity policies at the centers, and distributed weekly parent newsletters that included activities and recipes. Parents (n=1,143) completed a mail or telephone survey at baseline and follow-up to report information on their childs fruit, vegetable, and milk consumption and other dietary behaviors at home. This study used general and generalized linear mixed models to evaluate program impacts, while accounting for the clustering of children within centers. This study included child age, child sex, household size, respondent race/ethnicity, respondent age, and respondent sex as covariates.nnnRESULTSnThe program had a substantial impact on childrens at-home daily consumption of vegetables and use of low-fat/fat-free milk. This study also found a significant increase in the frequency of child-initiated vegetable snacking, which might have contributed to the significant increase in vegetable consumption. The program did not have a significant impact on fruit consumption or parental offerings of fruits and vegetables, child-initiated fruit snacking, or child fruit consumption.nnnCONCLUSIONSnThis intervention in child-care settings that emphasized children, parents, and teachers significantly increased at-home vegetable and low-fat/fat-free milk consumption among low-income preschoolers.

Increasing the Degrees of Freedom in Existing Group Randomized Trials The df* Approach

This study describes a method for incorporating external estimates of intraclass correlation to improve the precision for the analysis of an existing group-randomized trial. The authors use a random-effects meta-analytic approach to pool the information across studies, which takes into account any interstudy heterogeneity that may exist. This approach can be used in several different situations to estimate the degrees of freedom available for an adjusted test of the intervention effect in a study where the challenges of group-randomized trials were not fully considered when the study was planned. The authors discuss the limitations of this approach and the circumstances in which it is likely to be helpful.

Efficacy of Abstinence Promotion Media Messages: Findings from an Online Randomized Trial

OBJECTIVEnWe conducted an online randomized experiment to evaluate the efficacy of messages from the Parents Speak Up National Campaign (PSUNC) to promote parent-child communication about sex.nnnMETHODSnWe randomly assigned a national sample of 1,969 mothers and fathers to treatment (PSUNC exposure) and control (no exposure) conditions. Mothers were further randomized into treatment and booster (additional messages) conditions to evaluate dose-response effects. Participants were surveyed at baseline, 4 weeks postexposure, and 6 months postexposure. We used multivariable logistic regression procedures in our analysis.nnnRESULTSnTreatment fathers were more likely than control fathers to initiate conversations about sex at 4 weeks, and treatment fathers and mothers were more likely than controls at 6 months to recommend that their children wait to have sex. Treatment fathers and mothers were far more likely than controls to use the campaign Web site. There was a dose-response effect for mothers Web site use.nnnCONCLUSIONSnUsing new media methods, this study shows that PSUNC messages are efficacious in promoting parent-child communication about sex and abstinence. Future research should evaluate mechanisms and effectiveness in natural settings.

Impact of a parent-child sexual communication campaign: results from a controlled efficacy trial of parents

BackgroundPrior research supports the notion that parents have the ability to influence their childrens decisions regarding sexual behavior. Yet parent-based approaches to curbing teen pregnancy and STDs have been relatively unexplored. The Parents Speak Up National Campaign (PSUNC) is a multimedia campaign that attempts to fill this void by targeting parents of teens to encourage parent-child communication about waiting to have sex. The campaign follows a theoretical framework that identifies cognitions that are targeted in campaign messages and theorized to influence parent-child communication. While a previous experimental study showed PSUNC messages to be effective in increasing parent-child communication, it did not address how these effects manifest through the PSUNC theoretical framework. The current study examines the PSUNC theoretical framework by 1) estimating the impact of PSUNC on specific cognitions identified in the theoretical framework and 2) examining whether those cognitions are indeed associated with parent-child communicationMethodsOur study consists of a randomized efficacy trial of PSUNC messages under controlled conditions. A sample of 1,969 parents was randomly assigned to treatment (PSUNC exposure) and control (no exposure) conditions. Parents were surveyed at baseline, 4 weeks, 6 months, 12 months, and 18 months post-baseline. Linear regression procedures were used in our analyses. Outcome variables included self-efficacy to communicate with child, long-term outcome expectations that communication would be successful, and norms on appropriate age for sexual initiation. We first estimated multivariable models to test whether these cognitive variables predict parent-child communication longitudinally. Longitudinal change in each cognitive variable was then estimated as a function of treatment condition, controlling for baseline individual characteristics.ResultsNorms related to appropriate age for sexual initiation and outcome expectations that communication would be successful were predictive of parent-child communication among both mothers and fathers. Treatment condition mothers exhibited larger changes than control mothers in both of these cognitive variables. Fathers exhibited no exposure effects.ConclusionsResults suggest that within a controlled setting, the wait until older norm and long-term outcome expectations were appropriate cognitions to target and the PSUNC media materials were successful in impacting them, particularly among mothers. This study highlights the importance of theoretical frameworks for parent-focused campaigns that identify appropriate behavioral precursors that are both predictive of a campaigns distal behavioral outcome and sensitive to campaign messages.

Prevention Effects of an Anti-Tobacco Brand on Adolescent Smoking Initiation:

Health marketing mass media campaigns have been shown to be effective in changing health behavior and behavioral mediators. Tobacco countermarketing mass media campaigns have been effective in reducing smoking initiation and progression to established smoking. Targeted message strategies used by countermarketing campaigns influence specific attitudes and beliefs about smoking. Such strategies have been used to build public health brands modeled on commercial branding strategies, and previous research has shown that adolescent affiliation with anti-tobacco brands is associated with reduced smoking uptake. The current study was a prospective test to determine whether brand equity can serve as a protective factor to prevent youth from initiating smoking. This article reports on a longitudinal study of exposure to the Ohio Tobacco Use Prevention and Control Foundations stand campaign and affiliation with the stand brand. Youth aged 11–17 were surveyed at baseline and their exposure to brand affiliation as measured by a validated multidimensional brand equity scale, smoking behavior, and other attitudinal, behavioral and sociodemographic characteristics were measured. Youth with higher brand equity in the stand campaign exhibited lower levels of smoking initiation at the first 8-month follow-up. Somewhat reduced, but significant, prevention effects were also observed at a second 20-month follow-up. The brand leadership/popularity subscale had the strongest prevention effect. Descriptive social norms embodied in the individual items within this subscale may be the most important targets for social marketers employing a branding strategy. These results may be applicable to health behavior change communications aimed at other risk behaviors.

Systematic review of health branding: growth of a promising practice

ABSTRACTBrands are marketing tools that create mental representations in the minds of consumers about products, services, and organizations. Brands create schema that help consumers decide whether to initiate or continue use of a product or service. Health branding determines behavioral choice by building consumer relationships and identification with health behaviors and their benefits. Health branding can be measured by the associations individuals form with health behaviors. In 2008, Evans and colleagues systematically reviewed the literature on health brands, reported on branded health messages and campaigns worldwide, and examined specific branding strategies in multiple subject areas. This paper extends that review. We replicated the comprehensive online literature search strategy from 2008. We screened a total of 311 articles and included 130 for full-text review. This included both articles from the 2008 review and new articles. After excluding those new articles that did not meet full-text inclusion criteria, we reviewed 69 in total. Of these, 32 were new articles since the 2008 review. Branded health campaigns cover most major domains of public health and appear worldwide. Since 2008, we observed improvement in evaluation, application of theory, and description of campaign strategies in published work. We recommend enhanced education of public health practitioners and researchers on the use and evaluation of branding.