Challenging Dogma - Fall 2009

Thursday, December 17, 2009

A Critique of North Carolina's Fair Trade Anti-Obesity Campaign & A Proposed New Approach: The Live free Anti-Obesity Campaign - Kristen Giambusso

Obesity is a current and major health issue in the United States. There are a multitude of factors that contribute to the problem that is only getting worse. Public health professionals and agencies are flurrying to create ways to change the behaviors of the country’s people in an attempt to stunt the epidemic and move in the direction of a healthier nation. A great way to reach different populations is through state-sponsored campaigns that target a specific geographical audience. This is exactly what health professionals in North Carolina attempted to do when they launched the Fair Trade television campaign in 2007. North Carolina has one of the highest prevalence of obesity in the United States at 29% (1). Fair Trade is an anti-obesity media campaign launched, in response to the problem, by the Raleigh, North Carolina ad agency The Stone Agency for Blue Cross Blue Shield of North Carolina. The campaign consisted of four television spots portraying North Carolina residents engaging in healthy activities such as exercise and eating fruits and vegetables. It asks its viewers to “trade” things like a latte and a trip to the drive-thru for another day of life. It cannot be denied that these commercials are motivating and provide some practical suggestions for living healthier. However, from a social and behavioral science perspective, the campaign is lacking in a variety of ways. The first part of this paper will describe three main faults of this campaign and support those faults through the use of social and behavioral science theories, research and examples from various pieces of literature.

As the wave of obesity in the United States does not show signs of crashing anytime soon, it is important to research and utilize the existing social and behavioral science theories that work to effectively influence individuals and groups to change behaviors.
The second part of this paper will take into account the three main liabilities noted in the critique and offer a new approach to the anti-obesity campaign. The new approach will be supported by alternative social and behavioral science principles, concepts, and examples to validate the suggestions made.

Critique I: Health is for Sale and No One is Buying It

The first area where the Fair Trade campaign comes up short is in the product it is selling: health. Many of the theories that have historically been used in public health “assume that people value good health and will make the necessary changes to reduce behaviors associated with adverse outcomes of poor health.” (2) This assumption, so rooted in public health theory, leads to campaigns that have health as the main deliverable. There is a long-established approach of deciding what the people want or need, and then attempting to sell it. Marketing Theory offers an alternative approach that is prevalent in advertising for almost everything else besides health. Instead of deciding for the people, public health practitioners should conduct research to figure out what it is the people desire, and then base their intervention or campaign on those things (3). It is not that the people of North Carolina want to be obese or unhealthy, it is that, as social beings, they likely hold core values that are socially-based such as acceptance, control, power, and attractiveness to name a few. These are the types of values that advertisers use to sell clothing, sneakers, music, food, and a lengthy list of other products. The Fair Trade campaign’s promise is that if you trade away little things in your life and start exercising and eating healthy foods, the advantage will be more days and a longer life. In concept, this sounds like it should be a done deal. Why wouldn’t a person choose to give up a cheeseburger and gain a whole extra day of life? It is exactly that type of assumption of values that results in the failure of public health campaigns and, in this case, the ineffectiveness of North Carolina’s Fair Trade campaign.

Critique II: A Rational Look at Irrational Behavior

A second area where the Fair Trade campaign loses momentum is in its assumption that human behavior is rational. The idea of a “fair trade” is clever. The thought of trading in little things here in there for the promise of another day seems pretty fair indeed. However, the problem is that for someone to simply trade in their morning latte for another day that they will enjoy years in the future is not a decision people are likely to make rationally as they drive by their local Starbucks. It is likely that this campaign, with best intentions, has fallen victim to the Health Belief Model (HBM) approach to behavior change that is so ingrained in public health practice. The HBM assumes that people weigh perceived benefits and perceived barriers and, based on those weights, make a choice either to change or not change their behavior. The problem, however, it that people don’t always make decisions this way (4). Linda Thomas, who wrote a feminist critique of the HBM as it applies to nursing, stated in reference to the HBM, “The goal is to predict, explain and control behavior. The model allows for a complex phenomena to be deducted and explained in terms of its elemental parts.” (5). This quote lends support to the fact that the HBM can be useful for some behaviors, but not ones that are complex and deeply rooted in peoples’ lives such as those that contribute to obesity. Behavior is actually quite spontaneous, unplanned and determinant on many other factors like environment, social networks and core values other than health.

People also need adequate information to be able to make informed decisions (4). Without information, how are people to even begin to consider balancing out the perceived susceptibility, risk, benefits and barriers that the HBM outlines as the steps to making healthy decisions? The campaign assumes that everyone viewing it has equal information from which to make a rational decision about their behavior. Even if everyone did have equal information, the behaviors that the campaign suggests changing are ones that are generally made irrationally, and this careful balancing act does not take place before people either do or not do the behavior.

Critique III: Context, Ownership, and Why It’s So Hard to Say Goodbye

The third reason why the “Fair Trade” campaign unsuccessfully changes behavior is because the creators forgot about the two important aspects of context and ownership that contribute to the human inability to swap unhealthy choices for healthy ones. As discussed, this campaign is asking people to give up things like lattes, TV and fast food. While this is sending a motivating message of “trading in” these things for a healthier life, it is easier said than done.

The families, friends and individuals all look like they are having a great time engaging in exercise and healthy eating in places like parks, backyards, pools, quiet neighborhoods, and farms. What are missing from this picture are housing developments, city streets, convenience stores, and school cafeterias. The ads neglect to include all of those people living in North Carolina who can better relate to the latter set of environments than the former. It is important to take into account socioeconomic disparities to include people who do not have access to fresh foods, safe streets and parks to jog in, pools to swim in, and perhaps even families and friends to enjoy healthy activities with. Unfortunately, these are the people who need to receive the anti-obesity message the most.

To further explain why a health message might not reach someone of lower socioeconomic status, we need not look much further than Maslow’s Hierarchy of Needs. Maslow displays the needs of humans in a pyramid shape, starting at the bottom with the most basic needs like food and sleep, and climbs through the levels of need to the top where the maximum potential of a human being lies in self-actualization. It is not until a person achieves one level of need that they can move on to the next (6). Long-term health, what the Fair Trade campaign is selling, fits in way at the top of the pyramid. The campaign does not take this hierarchy of needs into account when it assumes that people have already reached each level and are at the very highest tier of need attainment. Some people, especially those of lower socioeconomic status, may not have even achieved the second level, which includes things like, employment, property and security. The next level up includes self-esteem and confidence, things that many people, especially youth, are unlikely to have achieved. These people are less prone to worry about long-term health when there are more immediate needs to be met.

Another way of viewing context as a means of affecting peoples’ decisions about healthy behaviors is with social networks. People do not go throughout their days making decisions based on their own personal beliefs about what they should and shouldn’t do. People are influenced by those around them such as friends and family (7). The New England Journal of Medicine included a study by Nicholas Christakis and James Fowler called “The Spread of Obesity in a Large Social Network over 32 Years”, which demonstrated that certain traits such as obesity tend to spread through social groups over time. This quantitative analysis confirmed that “The spread of obesity in social networks appears to be a factor in the obesity epidemic.” (7). If a person’s friends or families do not value healthy behaviors like eating well and exercising, it will be harder for that person to change their own unhealthy behaviors. A core value mentioned earlier, acceptance, is what will more likely determine a person’s behavior. Being a part of a social group is more important than long-term health to most people. Additionally, if there is no juxtaposing view to reveal that there is another way to be, people may not even perceive themselves as unhealthy in the first place. People viewing these ads could realize that their behaviors are not optimal for a long life, but unless their immediate and most valued social networks have this same realization, it is unlikely that they will break from the group and pursue health for themselves.

The Fair Trade campaign also forgot about the strength of ownership. After seeing the commercial, one might be inspired to give up their morning latte and start exercising. However, once the commercial is over, and they are up the next morning, tired and rushing to work, that grand feeling of motivation that seized them yesterday may be a distant memory. It is not only the fact that people cannot easily give up habits, it is also that we can’t stand loss. In his book, Predictably Irrational, Dan Ariely devotes a chapter to the “high price of ownership”. In this chapter he asserts that, “Much of our life story can be told by describing the ebb and flow of our particular possessions – what we get and what we give up.” (8). A warm paper cup of milk and espresso seems like something that could easily be given up, but it is in fact more than just the physical feel and taste of the object that people have a hard time letting go of. It is the act itself of going to the coffee shop, getting what you like, and having it as a component of your day. You identify with the brand, the shop, and perhaps the people who work in the shop. The latte is just one example of how much more is involved in giving something up than one might think. Ariely further comments on loss aversion when he says, “…we focus on what we may lose, rather than what we may gain.” (8) He uses the example of a sale of basketball tickets in at Duke University, where a lottery for the highly coveted tickets was held, and a subsequent experiment conducted to test the value of ownership. People who did not win and those who did win the tickets were called and questioned to see what monetary value they placed on the tickets. Sure enough, those who won the tickets valued them much higher than those who had not won. The reason for this is that we become so attached to what we have that it automatically becomes more valuable, even if it isn’t. The scenario of losing a latte and gaining more life seems like a no brainer. Most, if asked on the spot, would say they would prefer to live longer than to continue having high-calorie beverages. However, as Ariely suggests, we focus more on the loss than the gain (8). If this is the case for an immediate situation like the sale of basketball tickets, it is even more so for something like obtaining a longer life, which is in no way immediate.

Conclusion of Critique

To summarize, there are three main limitations to the Fair Trade campaign that culminate in its overall ineffective approach to changing health behavior. The campaign is selling health. Although it is true that most people want to be healthy, health as the product is not strong enough to actually change behavior. The campaign presumed that the behavior of people in North Carolina is rational, and that they would consciously make the decision to trade a trip to the drive-thru or an hour of television in for some extra days of life realized decades in the future. Lastly, the campaign disregarded how difficult it is for people to give things up. The main reasons noted in this case are differing socioeconomic status and access, social influences, and loss aversion. The campaign produced four different, but almost identical television spots that failed to account for these barriers. The next part of this paper will propose a new approach to the Fair Trade media campaign that will take these limitations into account and deliver a more effective anti-obesity message to North Carolina citizens.

It is through analyzing the weaknesses of the Fair Trade campaign that a new approach to the obesity epidemic can be crafted. The following is a description of a new campaign that will be used in North Carolina. This new campaign will produce four ads, all with the same aim as the Fair Trade ads, to encourage healthier living and reduce obesity in the state. However, the new ads will employ methods that account for the faults rendering the current campaign ineffective.

A New Approach: The Live Free Campaign

The proposed approach is an overhaul of the current advertisement strategy that will contain three main components challenging the faults of the Fair Trade Campaign. The initial step will be to organize a team of public health and social science professionals to conduct research in the state. These researchers will visit towns and cities in North Carolina, speak to the people living there and experience their various lifestyles to get a sense of their pervading values. Upon returning from the field, this qualitative data will be used to construct an anti-obesity television campaign that speaks to the values learned in the field research. The first key difference from the Fair Trade campaign will be that each ad of the new campaign will be carefully aimed at a different population within the state: people living in suburbs or on farms, people living in urban areas, young people ages 13 through 25, and adults and seniors. As each of these groups hold different core values, the ads will offer values that speak to each group, with some overlapping themes among the four groups. For example, the ads targeted at the youth group (13 – 25 year-olds) will utilize a common-enemy effect, bringing this group together to challenge the fast food industry in the United States.
In order to veer away from using models such as the Health Belief Model, which assume rational behavior (4), the ads will assume that behavior is irrational and employ an alternative model that supports this. This is the second key distinction between the old and new campaigns. The ads will again tailor to each group by including local opinion leaders that appeal to that audience. For example, the ad targeted at the youth group will include Duke University basketball players. These opinion leaders are people that are similar to this audience – young, free and independent– but simultaneously embodying a role model status that young people naturally look up to and aspire to be like. The opinion leaders will successfully rally young people to adopt certain behaviors by portraying healthy living as a social movement or norm, enticing them to become a part of the group and to “Live Free”. The same methods of value-matching and the use of opinion leaders will be used for the other three targeted groups, but with varying approaches so as to appropriately tailor the message to each audience. The third important feature that will differentiate the new campaign is that it will not ask the audience to give anything specific up, and will imply that they will only gain from being a part of the movement towards a healthier lifestyle.

Supporting Argument I: Giving the People What They Really Want

Despite what it seems people should value such as health and longevity, we hold values that reach the core of what makes a human being, as part of a society, feel good in the present moment. By conducting adequate research, it is possible to find out what values the message should sell in place of health for different types of people (9). This is common practice in other, traditionally commercial, industries.

The Truth Campaign is an example of a set of ads aimed at a specific group, young people, to sway them from taking up smoking. The Truth Campaign draws upon the core values of youths such as rebellion, freedom, and independence and unites them to stand against a common enemy: the tobacco industry (11).

Aside from commercial products, we can draw upon other examples using research to find out what people value and using that research to shape a successful campaign. In “Marketing Public Health – An Opportunity for the Public Health Practitioner”, this approach is explained through the example of The Coalition for Health Insurance Choices’ use of extensive research to figure out what voters wanted and then using the results to launch a counter-campaign against President Bill Clinton’s health care reform proposal. “Using careful, formative research, the coalition framed Clinton’s health reform proposal in a way that conflicted with the core values of American voters, generating subsequent opposition to the proposal.” (3).

By abandoning the old public health practice of telling people would they should want and using statistics as support, Live Free will find out what people want and position the product in such a way that those things, supported by symbols and images, reach the targeted population.

Support Part II: Deciding to See How People Really Decide

It is easier to create a campaign based on the assumption that human behavior is rational. Old models like the Health Belief Model, although useful in predicting behavior in some very basic situations, is not a practical model for inspiring people to change to a healthier lifestyle. To do this, we can look to newer theories that account for the way people really make decisions: irrationally and in groups (4). The Diffusion of Innovations Theory is a great model that can be used to reach different populations in North Carolina. The theory operates on a group level and assumes that behavior is unplanned. Sociologist Everett Rogers says, “Diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system.” (11).

The goal of the ads will be to turn healthy living into a social norm. The opinion leaders will be crucial to the approach. In Diffusion of Innovation in Health Care, the authors note that “Opinion leaders have been a key vector of diffusion for many medical and information technologies, and a large amount of effort is dedicated to identifying, informing, and convincing them to become early adopters.” (11). The opinion leaders, as symbols of the values each audience holds, will portray the healthy lifestyle as something that many people are already trying to accomplish and work at. This contrasts the Fair Trade campaign, which shares grim statistics describing the lives taken annually by obesity in the state and then asks people to trade in parts of their lives to avoid becoming one of these numbers. In the book Nudge, authors Cass Sunstein and Richard Thaler write about socializing behaviors. The authors note, “Alert to the possibility of changing behavior by emphasizing the statistical reality, many public officials have tried to nudge people into better directions.” (12). They go on to explain how Montana used this statistical reality to point out that most of Montana teens actually do not smoke. By creating this new perspective, the campaign successfully changed the misperceived norm that most teens do smoke to the norm that most teens in fact do not smoke (12). Teens will automatically want to do what they know most others like them are doing. This same strategy can be used in the case of driving down the prevalence of obesity.

Support III: Giving People New Ways to Drop Old Habits

As mentioned in the critique of Fair Trade, long-term health is at the top of Maslow’s pyramid of human needs. It is not until a person satisfies one tier of need that they can move onto the next. The Live Free Campaign will take into account that some people are on varying levels of the hierarchy. By aiming at lower needs such as acceptance and independence, which the ads will do, it is more likely that they will reach those who are at the lower level of needs.

Social networks are important to take into consideration when trying to sway behaviors in one direction or the other. Just as social networks can work in negative ways such as spreading obesity among groups of people; they can work in positive ways as well. The New England Journal of Medicine study referenced earlier that looked for weight gain associations in social networks noted that, “Network phenomena might be exploited to spread positive health behaviors, in part because people’s perceptions of their own risk of illness may depend on the people around them.” (7). The study then goes on to suggest that public health campaigns may see greater success because “people are connected, and so their health is connected.” (7). By creating the sense that living healthy is more of a social movement and less of an individual choice, it is more likely that people will feel stronger about changing their behaviors.

Ownership is a difficult force to battle for a public health professional, whose goal is to pry the super-sized sodas of the peoples’ hands. Dan Ariely states that “there is no known cure for the ills of ownership” as it is “woven into our lives” (8) The Live Free Campaign is not asking people to give things up, but rather sending a general message of healthy living as a movement. Worrying about getting people to give up things like lattes and French fries will not be a problem. It is unrealistic to suggest that people give these things up. A strong behavior-changing message can still be sent without explicitly telling people what they must and must not do.


In conclusion, The Live Free campaign will offer a new approach to influencing healthy behavior. Live Free ads will use opinion leaders, chosen for each target audience, to act as change agents for a new social movement towards healthier living, one that is based on social values and unplanned behavior. By taking into account the differences across the state’s population and avoiding taking things away from people, the campaign will evoke a better reaction from viewers, and encourage them to join the movement for a healthier life and achieve the right to Live Free.


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