Improving the Efficacy of Nutritional Improvements to the National School Lunch Program with Adolescent Students – Sara Woolcock

Obesity in the present day is not just a concern for adults. From 1999-2002, it was found that the prevalence of overweight children and adolescents was about 16%, largely due to obesogenic environments for both physical activity and dietary intake. (1) During their school years, children and adolescents are learning eating behaviors and knowledge that they will carry on into adulthood. (2) Considering that one half of kids and adolescents get at least one of their meals at school through the National School Lunch Program (NSLP), (3) programs have been put under a critical eye for its efficacy of promoting healthy food choices. Parents, legislators, and public health officials have cited the sales of low nutrient, energy-dense foods as a major environmental cause to childhood obesity. (2)

Improving the School Lunch Program at local schools is often logistically difficult for administrators and food service personnel. Public school districts work under very restricted budgets, and school food service employees have little monetary room to make healthful changes. While concerned parties want to work with administrators to make positive changes, administrators see many barriers to implementing healthy lunches in schools, including funding, students’ preferences for unhealthy foods, lack of communication between food service staff and teachers, and short lunch times. (4)

Recognizing that changes need to happen, school administrators have largely resorted to district-wide wellness policies to address the concerns of public health officials and parents while also working within their barriers to improve school lunches. Wellness policies try to improve the nutrition of foods served at schools, mostly through a la carte snack bars, and vending machines. Junk foods sold in these places are usually referred to as “competitive foods” because they limit the sales of whole lunches in school cafeterias. Studies have found a positive correlation between the number of competitive foods in school and the poor quality of students’ diets in middle schools. (5) In response to similar studies, many schools have limited sales of sodas during school hours, the sugar content of beverages sold during lunch, the offerings of competitive foods – such as brand-name chips, cookies, and snacks – a la carte (6), and the number of days fried foods can be sold. (7) Public health officials have applauded these changes as progress toward preventing obesity and chronic disease. (8) However, the effectiveness of the policies with the older students in the middle and high schools is questionable.

District-wide wellness policy often implement changes to the middle and high school students together with younger students in primary school without regard to the students’ differing beliefs, values, and behaviors. In general, adolescence is a life stage when young adults desire to build their independence and sense of autonomy. (9) While children in younger grades will accept school wellness policy changes, adolescents view these changes as a loss of their freedom. One health coordinator in a school in Massachusetts stated that in her district, “high school students were furious this year when French fry sales were limited to three days a week.’’ Administrators often attribute this outcry to their students’ preference for unhealthy foods, (4) while failing to recognize that this reaction is typical of students in their age group. Therefore, it is important for school food service officials to consider designing changes to the school lunch programs that specifically target adolescents in the middle and high schools.

Adolescents Do Not Perceive The Urgency Of A Healthful Diet

One major flaw of applying wellness policies to adolescents is that these policies are often rationalized as obesity and chronic disease prevention efforts. It is assumed that students should be willing to adopt a healthier diet because they are concerned about chronic disease. (10) This rationale is based on the Health Belief Model (HBM) of behavior change.

The basic principle of the HBM is that there are basic “beliefs” that motivate individuals to adopt new health behaviors. These beliefs are the perceived benefits of adopting a new behavior (i.e. the severity of chronic diseases related to unhealthful behaviors), and the perceived barriers to adopting a new behavior. (11) Using this model to modify the diet of adolescents is flawed because none of the beliefs in the HBM motivate adolescents to adopt healthy behaviors.

The perceived threat of a disease is the weakest motivator of the HBM, (11) and in the case of adolescents, this belief has little to no effect on their behavior. Adolescents do not have little to any perception of the threat of chronic disease. Most adolescents are concerned with issues of immediacy, such as their performance and appearance. (10) Members of this age group often state that they have time to worry about a healthy diet when they are older. Studies measuring adolescents perceived benefits of a healthy diet have found that what truly motivates adolescents to eat healthy is their appearance, performance, having energy throughout the day, and their self-esteem. (12)

Researchers have also independently studied many of the perceived barriers to eating healthy with adolescents. Different groups of adolescent have often listed similar barriers that are outside their ability to control, including time/convenience of junk foods, peer reinforcement of unhealthy behavior, higher perceived palatability of junk food versus healthy foods, availability of healthy foods at home and at school and cost of healthy foods. (10,12) Interestingly, in one study that assessed adolescents’ knowledge of nutrition, researchers found that lack of knowledge is not a barrier preventing adolescents from adopting healthy eating behaviors. Participants in this study identified “balancing” their diet with “fruits, vegetables, meat, nuts, and milk” and adding a vitamin as ways to improve their diet. (10)

High school and middle school students have also been studied to find their perceived barriers to healthy eating in schools. Even adolescents identify that the quality of foods served in schools needs to improve. However, they suggest that just removing unhealthy choices will not get them to purchase a better lunch, and that they want healthy choices that are also palatable. (13,14) Based on these studies, policies that seek out nutrition education to remedy adolescents’ resistance to changes to school lunch programs will find that these efforts will have little efficacy with this age group, instead school food service officials should focus on improving the barriers that students identify as keeping them from purchasing a healthy lunch at school.

Adolescents View Changes to School Lunch as a Threat to Their Freedom

Studies in school food service operations have found that the more competitive foods sold in schools increases the likelihood that their students will have a poor diet. (15,16) School administrators and food service personnel’s first reaction to objections over the sales of competitive foods in school cafeterias is often a limitation on sales. Policies such as this have been implemented to limit the sale of sodas, chips, and fried foods. (17) However, these officials often do not consider that adolescents will view these restrictions as a loss of freedom and display psychological reactance.

Brehm conducted one of the first key studies describing psychological reactance. She studied children who were given two toys for play; one behind a barrier and another unrestricted, and she observed that many children desired to only play with a toy behind a barrier. (18) Studies of this phenomenon in the average adult consumer have found that even most adults react negatively to external pressures to force a behavior, causing an increased desirability for a restricted item or behavior. (19)

Health messages that try to direct behavior can also provoke psychological reactance, so while these messages may have good intentions for health promotion, the consumers of these messages often do not react well to restrictions in their behavior. Adolescents in particular, who are in a stage of life when they are building their independence, react much stronger to these threatening health messages than adults. (20)

School policies that limit junk food sales in middle and high schools usually also cause psychological reactance from students. Studies have found that restricting certain foods from children invoke psychological responses that result in increased desire and motivation to obtain that particular restricted food. (21) Research on the effect of wellness policies in middle schools has resulted in similar effects with students. In a study of wellness policy changes in a middle school in Houston, Texas, researchers found that after removing all snacks, potato chips, candy, sweet desserts, and sugar-sweetened beverages for sale in cafeterias and vending machines for one year there were significant declines in sales of such items. However, on further investigation, they found there was no significant change in dietary intake of these foods from baseline. Researchers speculated that despite these policy bans, students started bringing these foods in from home or obtaining them from vendors outside of school. (17) These results indicate that most students displayed reactance to the policy ban by increasing their intake of prohibited foods.

It is important for interventions in school lunch programs to be tested to see if they contain any factors that cause this psychological reactance. Studies of health messages have found that there are three factors that influence the degree of reactance: controlling language, lexical correctness, and restoration of freedom.

Controlling language is used in messaging that is very directive. This language often includes phrases with “must” and “should”. The most controlling and directive messages will get the most negative reactions and be least effective. (20) If school officials state that students “must” restrict their diet of fried foods to be healthy, it is likely that students will react by increasing their consumption of fried foods.

Lexical correctness is related to if a message conveys explicit or vague details. If a message contains more explicit detail, it will cause less reactance. (20) Usually bans on unhealthy foods in schools only cite vague reasons of obesity prevention, (17) which is not relevant or a motivator for adolescents.

Restoration of freedom is when a message ameliorates reactance and gives the receiver the ability to self-determine their fate. If this technique is used in a message, reactance will be minimal. (20) Restoration of freedoms are often ignored in messages to adolescents, because it is a long prevailing thought that adolescents lack maturity to make healthy choices. (22) In order for school lunch interventions to be effective with adolescents, messaging to middle and high school students need to consider these three factors of psychological reactance, especially the often-ignored restoration of freedom, to ensure these changes are not threatening freedom.

Marketing To Adolescents Is Underutilized in School Lunch Programs

Marketing is a useful tool that school lunch programs can use to “sell” healthy changes to adolescents. It is often underutilized, but officials could use marketing to address students’ concerns about the barriers they perceive to eating healthy and offer messages that restore students’ freedom to choose.

Advertising and marketing are two strategies that are constantly being used by companies to successfully sell their products to adolescents. Successful marketing campaigns demonstrate how different products can resonate with consumers “desires, values, and behaviors.” These campaigns must have three components: a core message, appeals to target audiences’ beliefs and values, and utilize appealing images and music to support their message. (22)

Market research can be a valuable tool to determine how to effectively craft the three components into a campaign that will identify with adolescents. (23) Market research is important so that campaign creators know the audience of their campaigns. Understanding, “ how [adolescents] feel, what they care about and what motivates them” can direct the messaging of an effective marketing campaign. Strategies such as purchasing observations and focus groups are both successful tools for market research in adolescents. (22)

When making changes to school lunch programs, most school administrators or food service personnel do not create a core message for their efforts. The message that usually reaches students is that it is for preventing obesity and chronic disease. (10) This core message assumes that the threat of disease as per the Health Belief Model is effective in motivating adolescents. It may also elicit psychological reactance because students perceive that choices are being taken away from them. Market research with adolescents on their opinion of school lunch has found that students mostly are concerned with the taste and convenience of foods sold in cafeterias. (22) Focusing a core message that addresses these concerns will most effectively resonate with adolescents.

Most adolescents share some very similar values and beliefs related to their age group. Adolescents strongly believe in freedom because they are developing their autonomy and independence. Marketing strategies that appeal to these values can also work to restore the freedom of their target audience. Marketing messages that give students more choices would be effective in assuaging any treats to freedom and would appeal to adolescents’ core values.

Advertising techniques and channels also have a great impact on how adolescents respond to messages. (23) Adolescents like to see advertisements that are especially innovative and use their peers as content creators. (24) Today’s adolescents are part of generation Z, or digital natives. They have the most comfort connecting online and prefer media that simple and interactive. (25) Marketing through social media is a valuable tool to reaching these consumers because they can interact with favorite brands. (26) Effective marketing strategies in schools will utilize these concepts to reach out to adolescents.

One such intervention that attempted to use media to market fresh fruits and vegetables to students was the Gimme Five campaign. It sought to address barriers that students identified as reducing their consumption of these foods: inconsistent taste, availability, and lack of variety, notably similar barriers that students have identified with eating healthy lunches at school. The campaign used media such as posters and PSAs broadcasted in the mornings to reach out to students in 12 high schools in New Orleans, Louisiana. Researchers simultaneously increased the number of fruits and vegetables available during lunch. (27) The messages used in the campaign were positive and focused on motivators of good nutrition that are effective with teenagers: appeals to performance, energy, and appearance. (22) Other than the PSAs, which students associated with administrator communications, the media component of the campaign was successful. About 85-97% of students rated the media outreach component as “thumbs up.” Researchers hypothesized this success was largely due to their targeting approach to appeal to the priorities and values of adolescents. (22)

These types of campaigns are rarely used in conjunction with school lunch programs yet have been measured to have a great impact on students’ perceptions of nutrition programs. Marketing is a valuable tool to frame changes to school lunch programs and policies in a way that is non-threatening to adolescents. Effective campaigns can address adolescents’ concerns with healthy eating and appeal to their own values through marketing channels most familiar to them.

Address Adolescent-Identified Barriers to Healthful Eating

Considering barriers that adolescents identify as important are much more effective than barriers that are most often considered, including knowledge and a lack of urgency about health. The most important barriers that students identify to eating healthy are time, taste, price, and the availability of healthy foods. (10,12) Even in schools that offer healthy options, barriers that prevent adolescents from purchasing these options are the lack of quality and variety. (14)

School food service directors need to create and serve healthy options that are of equal or greater quality to their usual product quality standards. This will improve the appeal of these options to their adolescent customers. However, these food options also need to have other characteristics that are important to adolescents. Most importantly, they should taste good, and be equal or greater in acceptable flavor and texture when compared to other options. These options should also be convenient to eat and prepare, addressing students’ concerns over time. (14) Optimally healthy products should be of equal or lesser price so as to not lessen their appeal for economic reasons.

Some of these acceptable healthy options available to food service operations include whole hand-fruit, such as apples, pears, and oranges. These fruits are easy to carry in students’ hands and eaten “on the go”. They are also much less expensive than prepared fruit slices. Putting hand-fruit in large, attractive fruit bowls even has the potential to double fruit sales. (29) Other options are salad bars with a variety of colorful vegetables, or vegetables like carrots, celery, and bell peppers cut into convenient-to-eat strips with healthy dipping sauces. All these products can be taste tested with students to see if they meet acceptability and if customers are likely to purchase them.

Provide a Variety of Options to Restore Adolescents’ Freedom to Choose

Adolescents are concerned with the lack of variety in their school cafeterias, (14) so when bans on the sales of particular foods are enacted, middle and high school students usually respond with reactance. However, variety can be employed in another way to increase sales healthy options in school cafeterias. A study in a university cafeteria found that they were able to significantly increase sales of fruits and vegetables when the variety of options of these foods were doubled and price was reduced. (29)

Sales of healthier options in middle and high school cafeterias could be promoted by offering a larger selection of choices for students to choose. Middle school cafeterias in California and Texas were studied after implementing changes in their cafeteria. These changes did not include any bans but instead increased the variety of fruits, vegetables, and decreased the portion sizes of high calorie snacks and drinks available to students. Researchers found that surveyed students rated changes as positive and favorable. (30)

School food service operations can offer more than two or three different options of fruit and vegetables available to students for sale. Even though these are both healthy options, giving students the ability to choose between the two restores their freedom to make their own choices. Less healthy options can also be modified and included in the variety to guide students to making healthier choices. For example, decreasing the portion sizes of French fries while also offering sweet potato fries gives students the option to choose while also offering better nutrition. Varieties of cooking techniques, such as pressure frying, baking and grilling, can also be explored to give students more healthful options to choose from.

Employ Marketing Techniques to Sell Changes to Students

The key to successfully implementing the changes to the quality, types, and variety of healthy foods offered in middle and high schools is successfully marketing these changes in a way that resonates with adolescents. Effective marketing can go a long way to getting students on board with any changes that food service officials and administrators want to make. However, in order to have an effective marketing plan, officials must consider using market research, core messages and values, and appropriate communication techniques.

Market research is essential for accurately targeting a marketing campaign to a particular group of adolescents. Each food service operation should conduct market research on their unique group of students to truly understand what unique motivates students at their school. Focus groups are effective ways of getting adolescents’ input on a marketing plan, and also making the students feel involved in changes at their school. Well-directed focus groups can reveal what students are interested in, what is important to them, and what motivates them to purchase foods. (22)

Market research can help guide campaign designers to goals and core messages that would appeal to adolescents in a marketing strategy. Changes made to make school lunch programs healthier should be marketed as a way to give students better quality, taste and variety rather than for health concerns. (22) Messages that emphasize choice can appeal to adolescents’ value of freedom and independence. Also, justifying changes with evidence that supports adolescents’ reasons for eating healthy: such as energy, performance, and appearance, gives students reasoning for changes that is relevant to their motivations and goals.

This generation of adolescents grew up in the digital age, and they are mostly exposed to marketing messages through online channels. Social media and websites can be a familiar way for adolescents to communicate. (25) One benefit of campaigns using social media is that designers can elicit instantaneous feedback from students on each day’s menu offerings. School food service personnel that communicate with students through social media can make students feel like their opinions are important, which is very important to adolescent consumers. (25)

Campaign messaging can utilize print, video and audio media that are popular and resonate with adolescents. Adolescents today enjoy interactive media and media that allow them to be content creators, (24) as seen with such websites as YouTube, which allows users to submit their own videos to a personal profile. Video, art, and music contests about the campaign can be another channel to make students feel like they are a part of the changes being made.

In conclusion, making healthful changes to school lunch programs can be more challenging with adolescents, but there are several different ways these changes can be presented and marketed to students so they are more acceptable. It may seem like a daunting task, but presenting changes to school lunches in a way that is non-threatening to middle and high school student can have big payoffs. There is the obvious benefit of preventing obesity and chronic disease. However, these changes also have the potential to increase student participation in the school lunch program, which can have profound implications on budgets and finances. The key to success is working with adolescents’ concerns, and making changes with the students as a guide.

References

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Thinking First Before Using “ThinkFirst for Teens” – Malindi Thompson

INTRODUCTION

Head and spinal cord injury bears a substantial burden on society, especially among certain higher-risk populations (1). Most head and spinal cord injury-related morbidities are the result of motor vehicle and traffic-related accidents, in which injury may have been avoided had safer driving behaviors and proper precautionary measures been taken beforehand (2). This paper will address the important potential impact that injury prevention programs have in preventing head and spinal cord injury among populations who are affected most. However, in addressing a health issue that relies heavily on the behavior and actions of individuals within a population, complexities arise which mediate the effectiveness of prevention programs. Carefully examining health behavior theory is necessary in order to effectively target health choices in the context of a person's environment, and meeting the public health goal of making safer behaviors also the easier behaviors to achieve. Critical evaluation of ThinkFirst for Teens (TFFT), a program of the National Injury Prevention Foundation, will demonstrate that often prevention programs overlook fundamental behavioral influences and create assumptions to explain certain risk-taking behaviors. This review will identify weaknesses to TFFT, as well as suggest alternative approaches that may provide stronger influence for adolescents to make safer driving decisions before injury occurs.

HEALTH PROBLEM: Head and spinal cord injury among adolescents

Motor vehicle crashes cause over one out of three deaths among teenagers in the U.S., the leading cause of death for this age group (1). Additionally, millions of drivers and passengers are treated each year for injury as a result of motor vehicle crashes, most of which are teenagers and young adults (3). Nearly half of all traumatic head and spinal cord injuries are caused by motor vehicle accidents, 50-70% of patients between the ages of 15 and 35 years old (4). Among all age groups, males are approximately 1.4 times more likely than females to sustain a traumatic brain injury (5); teenage males are nearly twice as likely to die of a motor vehicle accident than teenage females (1). The economic burden of lifetime costs of fatal and nonfatal head and spinal cord injuries in medical care, treatment, rehabilitation, and lost work productivity costs accumulates to an estimated $99 billion annually in the U.S. (6).

Many current injury prevention programs aim to increase driver and passenger safety by addressing risky driving behaviors widespread among adolescents. Active approaches to reduce head and spinal cord injuries are promoting the consistent use of safety belts and increasing driver safety. Seat belts are the most effective intervention for protecting motor vehicle occupants, reducing the risk of serious injuries from motor vehicle crashes by approximately half (7). However, teenagers, especially males, are least likely to wear seat belts (8). Other safety measures include leaving adequate headway between vehicles, not speeding, and not driving while intoxicated (2).

CURRENT APPROACH: “Use your mind to protect your body” (9)

ThinkFirst for Teens (TFFT) is an educational injury prevention program that is nationally and internationally recognized as a leader in injury prevention through education, research, and policy (10). The program's goal is to decrease the prevalence of preventable head and spinal cord injury among teens by reducing associated high-risk behaviors, and encouraging safer choices toward safety belt usage and safe driving behavior (9,10,11). The program, which focuses on good decision making skills and the consequences of risk taking, aims to reduce risk-taking among youth by educating middle and high school students on the dangers of risk taking and increasing their understanding of their risk of possibly fatal injury from motor vehicle accident (11).

TFFT is implemented in a middle/high-school assembly environment, and consists of a short video, lecture, guest speaker, and discussion (10,11). The video shows clips of youth who have been affected by a head or spinal cord injury: details about how the injury occurred, how the injury has permanently changed their life, and how it could have been prevented. The guest speaker, a young person who has sustained a head or spinal cord injury, gives a personal testimony about their experiences and challenges since the accident. Together, the program elements present real people who have lived to tell their real experiences. Consistent throughout each program component, emphasis is placed on the devastating and irreversible consequences that may occur as a result of a brain or spinal cord injury, and how, through risk-reduction, these consequences may be avoided (10).

Despite positive reviews on ThinkFirst's national website, several evaluation studies have produced results which question the effectiveness of TFFT in actually changing behaviors among adolescents exposed to the program. One evaluation of TFFT by Wright et al. (1995) found no significant changes in attitude scores between pre- and post-test assessments in schools that had implemented TFFT (12). Results showed a significant increase in knowledge among middle school students, but not high school students, and no significant impact was observed for seat belt use among all age groups (12). The evaluation further measured that self-reported behavior had significantly changed in the direction toward unsafe behavior after intervention, rather than safer behavior, for eight out of nine schools in the study (12). Similar findings from an evaluation of TFFT in Oregon reinforce the conclusion that students exposed show changes in knowledge, but no change in self-reported seat belt use (13).

Based on the findings of these evaluation studies, TFFT's program effectiveness may be legitimately questioned. Several arguments arise, which provide possible explanations as to why the program is flawed, according to the previous studies. Foremost, TFFT is based on the Health Belief Model (HBM) (11). The HBM theorizes that a person's value and expectancy beliefs guide their behavior (14). TFFT rests on the idea that increasing student knowledge of the serious effects of brain and spinal cord injuries and actual likelihood of sustaining such an injury will induce behavioral change toward less risky driving-related activities. Review of behavioral literature supports a challenge to this theory, arguing that the HBM is not an effective strategy for injury prevention among youth (14).

Relying on assumptions of human behavior such as those associated with the HBM and similar behavioral health theories (Theory of Reasoned Action and Theory of Planned Behavior) creates barriers to the effectiveness of health programs such as the TFFT. Three main critiques of TFFT will identify larger themes that often persist in other health behavior programs: 1) TFFT is individually-focused; 2) TFFT assumes that adolescents think and act rationally; and 3) TFFT uses ineffective motivators to produce behavior change.

RECOMMENDATION: Modify approaches

Elements that are required for a health program to be successful include comprehensiveness, social and cultural-sensitivity, appropriate timing, incorporation of varied techniques, having a sufficient dosage, ensuring positive relationships with its patients, and using theory-driven methods (15). Overall, TFFT has good intentions and meets most programmatic standards, but has a weak approach. TFFT lacks appropriate theories that explain adolescent behavior and their decision-making processes. Modifying the approaches used by TFFT to overcome challenges of injury prevention among adolescents through behavioral change may be done in three ways: 1) Use a social-ecological model; 2) Recognize that knowledge alone will not produce behavior change; and 3) Evaluate what motivates adolescents to influence behavior. Strategically incorporating these recommendations into a new head and spinal cord injury prevention program for youth, based off of TFFT, will likely result in a much more effective intervention.

CRITIQUE 1: ThinkFirst for Teens is individually focused

The HBM, the theory that TFFT is based on, is individually focused and does not address interpersonal, social, or overall contextual factors surrounding behavior (14). TFFT aims to change beliefs each teenager has toward his or her own susceptibility to injury from vehicle crash, so that in the future when placed in a risky situation, the teen will make the right decision and “think first” before acting. By framing the issue so that the decision to be safe or not is up to the teenager alone limits the program’s scope of influence to only intrapersonal mediators, such as knowledge. Because people actually behave and react within the context of their broader socio-cultural environment, TFFT ignores many powerful external influences which may affect the program’s ultimate effectiveness (16).

Research supports the theory that contextual social factors strongly influence adolescents’ likelihood of engaging in high-risk behaviors. In general, teens are more likely than older drivers to drive recklessly (speeding and allowing shorter headways), but in the presence of other passengers this behavior is shifted (17). Peer influences, whether intentional or unintentional, act as either risk or protective factors toward driving behavior, depending on the way that the driver perceives that the passenger views the driving behavior as desirable or expected (17). In the presence of a male teenage passenger, teen drivers typically engage in more risky driving than the general traffic; in the presence of a female, teens drive more carefully by allowing greater headway in-between cars (17). Across all teenagers of both genders, safety belt use has been found to decrease as the number of passengers increases (18).

Lastly, assuming that behavior is determined by only individual beliefs and values implies that decision making is a static process which occurs, under any circumstance, as a simple “right” or “wrong” decision. In reality, not all situations that adolescents find themselves in contribute equally to the likelihood of risky driving (19). Strong emotional responses to certain stimuli may make the application of concrete decision-making and good driving skills extremely difficult when caught in the moment.

HOW TO STRENGTHEN 1: Use a social-ecological approach

Social-ecological models of behavior are comprehensive behavioral theories that emphasize the interactions between individuals and their family, organizations, communities, and society as a whole in understanding the multiple levels of influence of a health behavior (14). Evidence supports the concept that in order for health programs to be successful in helping people adopt, change, and maintain a positive behavior, programs must be multifaceted and address socio-structural determinants of health as well as personal determinants (16,20). Adolescents are highly influential, particularly to strong social influences from peer groups, and behave in ways that they perceive to be expected by their peers, based on social norms that they are exposed to in their external environment (21,22). Incorporating social influences into injury prevention theory addresses not only teenagers’ perceptions of their own driving skills and risks which contribute to their behavior, but equally addressing the importance of the perceptions they have toward passengers they ride with.

Patterns of adolescent risk behaviors reinforce the theory that ecological models are useful in systematically targeting group-level trends of behavior. Teens that have been exposed to one risky driving behavior have likely been exposed to others (23). Approaching risky-driving behavior from a group-level perspective may provide a more useful method of targeting the health problem of head and spinal cord injury than from an individual-level perspective.

CRITIQUE 2: Thinking first is not rational

The premise of ThinkFirst for Teens is that by teaching teens to rationally “think first” before engaging in risky behavior, they will be able to avoid serious harm. This mentality in itself is not rational. People in general, even those equipped with rational decision-making skills, often act irrationally (24). Adolescents face many environmental and developmental hurdles that affect the activities they decide to engage in on a daily basis, but no solid evidence is found which supports the suspicion that adolescents are at a particular cognitive disadvantage in understanding the risk and consequences of risk taking behavior, compared to adults (25). Therefore, rather than view irrational behavior as a flaw of adolescent mentality, irrationality must be recognized as a common human characteristic. Injury prevention programs that rely only on decisions made from a well-reasoned weighing of positive and negative outcomes, such as TFFT, will encounter difficulties due to a limited scope of behavioral explanation (26).

A weakness of traditional theory that emphasizes rational decision processes is that rational behavior often is missing the important behavioral element of emotion. Emotions, whether positive or negative, directly affect attitudes, values, beliefs, coping mechanisms, and the ultimately the behaviors that produce a health outcome (14). Emotional involvement is a strong contextual influencer of how an individual responds to a given situation, and may be effectively utilized to further promote adolescent behavior after a health program’s educational component proves insufficient (27).

A second challenge of thinking that adolescents will always make safe and rational choices after increasing knowledge and risk-awareness is that gaps may persist between increased knowledge, intention, and behavior change. Consistent with the findings of the Wright et al. (1995) evaluation previously mentioned, increased favorable attitudes and behavioral intentions as a result of a risk-prevention program do not always translate into actual behavioral change (28).

HOW TO STRENGTHEN 2: Knowledge is not enough

Broadening TFFT’s mechanism of influence to encompass intrapersonal emotions and habitual modes of thinking will produce lasting and internalized behavioral outcomes (29). Rather than influencing behavior by increasing knowledge and awareness of injury, a new approach must capitalize on emotional and contextual factors common to teen drivers. Emotional engagement in a non-threatening manner will ensure that improvements in beliefs, attitudes, and intentions then lead to actual behavioral change. Successes of other youth prevention programs, such as anti-tobacco campaigns, may be attributable to the creative ways in which health-effects information is presented that emotionally engages and mobilizes viewers (30).

CRITIQUE 3: ThinkFirst for Teens uses ineffective motivations

A final critique of TFFT’s approach is that the mechanism of motivation which is thought to produce a positive reaction may be inappropriate for youth. The video and guest lecture in all TFFT school assemblies uses scare tactics to emphasize what could happen to teens if they continue to choose risky diving behaviors (i.e. Paralysis due to head or spinal cord injury). Terror management creates a negative reaction to the behavior that causes an unwanted outcome, and in theory it is the role of this aroused fear that activates behavioral change (31). This threatening strategy is usually ineffective at reducing risk-taking behaviors, except among audiences who are unaware of the problem and its associated behaviors (31,32). Lack of knowledge of motor vehicle accidents is typically not an issue among adolescents of driving-age.

Although the benefits to utilizing emotions to produce an intrinsic response were discussed previously, this method must be approached cautiously. Health messages that are overly aggressive and threatening, communicated through personal testimonies and graphic depictions of negative health effects, may cause an over-reaction among adolescent viewers and result in more risky behavior (30). This over-reaction is demonstrated through the Wright et al. (1995) evaluation of TFFT, which showed changes in self-reported behavior among exposed adolescents toward the direction of increased risk-taking (12).

HOW TO STRENGTHEN 3: Frame risky behavior differently

Rather than framing the problem of risky driving behavior as a character flaw shared by most adolescents, intervention strategies should counteract negative outlooks. Blaming adolescents for the reckless behaviors that they engage in, such as risky driving, will produce negative labels. Instead, highlight adolescence as a period of growth and development, and identify true motivators as positive gains. Behavioral persuasion that is communicated through gain-framed appeals is found to be statistically significantly more persuasive than loss-framed appeals (33). Emphasizing positive goals is a recognized strategy for simultaneously optimizing health and counteracting negativity, which works well in the context of injury prevention among youth (29).

CONCLUSION

To summarize, ThinkFirst for Teens is a well established educational injury prevention program aimed at reducing head and spinal cord injury among adolescents by building on health decision-making skills and reducing risky behaviors. However, many challenges arise in the implementation of a program based on the Health Belief Model due to individual, rational and negatively focused motivations, which often prove to be ineffective. This report addressed weaknesses of the ThinkFirst for Teens program and proposed recommendations to broaden its approaches toward successful behavioral change. Incorporating a social-ecological model that includes external influences, in addition to knowledge-based change, and framing the issue in a manner that highlights positive gain will more effectively persuade adolescents to alter their risky-driving behaviors.

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