Parents Can’t Do 'We Can!': A Critique and Redesign of 'We Can!' Program
In the past decade, overweight and obesity have arguably become the primary childhood health problem in the United States. According to the results of National Health and Nutrition Examination Survey (NHANES), prevalence of overweight increased from 7.2 to 13.9% among 2-5 year olds and from 11 to 19% among 6-11 year olds between 1988-94 and 2003-2004 (1). The most recent NHANES (2003-2006) indicate that on average 16.3% of children ages 2-19 years are overweight, and an additional 15.6% are considered at risk of becoming overweight (2).
Overweight in childhood can add up to health problems, often for one’s whole life. As with adults, obesity in childhood causes hypertension, dyslipidaemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction, and hyperinsulinaemia (3). Particularly, type II diabetes is increasingly being seen in children and adolescents, particularly among minority communities. Moreover, the 2005-2006 NHANES data show that about 16 percent of these youth have pre-diabetes. In a recent national study, 58 percent of children diagnosed with type II diabetes were overweight (2).
Studies indicate that lack of physical activity, excessive television watching (4), and diet pattern are three of major contributing factors to childhood overweight. To fight against those causes, on June 1st 2005, National Heart, Lung and Blood Institute (NHLBI) of National Institutes of Health (NIH), in collaboration with other three NIH institutes, launched a science-based national education program – Ways to Enhance Children’s Activity & Nutrition (We Can!). We Can! program brings together what have been learned from years of NIH-funded research into practical resources (e.g. toolkits, instructions, tips etc.) for communities and parents to fight childhood obesity among ages 8-13. It focuses on three key behaviors that families can adopt together to maintain children’s healthy weight: improving eating habits, increasing physical activity and reducing recreational “screen time”—time spent watching TV or playing video or computer games. We Can! program forms partnership with local communities, NGOs and corporations nationwide to let them help disseminate the message to employees, consumers and residents, hoping to increase the program’s exposure. Parents are the final recipients of the message and the major executors who actually promote healthy life style to their kids.
This paper focuses on the We Can! program. The following section cast doubt on the effectiveness of the program by presenting three drawbacks using social and behavioral science theories. The third section proposes and provides support for some improvements of the program mainly based on social norms theory, which specifically targets the three weaknesses mentioned in the previous section.
Critique of NHLBI’s We Can! Program
This section argues that the effectiveness of We Can! program is weakened by three main reasons. First, it overestimates the role of parents and community in shaping children’s health behavior. Second, it assumes parents’ behavior to help transform children’s lifestyle is rational and controllable by themselves. Third, it fails to use basic principles of advertising and marketing theory to attract and influence more people.
I. We Can! Program Overestimates the Role of Parents and Community in Shaping Children’s Healthy Lifestyle.
In We Can! program, all the materials are for parents and other adults in the community, such as school teacher, caregiver and community leaders. The only three activities that sound like designed for kids, CATCH Kids Club After School Program (the Child and Adolescent Trial for Cardiovascular Health, geared toward grades K-5); SMART (Student Media Awareness to Reduce Television, targeted for grades 3-4) and Media-Smart Youth (geared towards ages 11-13), are actually curricula for didactic purpose. In consequence, the program may not attain the best result since it overestimates the role of adults in shaping children’s healthy lifestyle.
First, Parents’, caregivers’ and teachers’ instruction or order may have limited influence on children ages 8-13. According to the Psychological Reactance Theory, people tend to disobey order or even act in an opposite way in response to threats to perceived behavioral freedom (5). Freedom here is not an abstract consideration, but rather a feeling associated with real behaviors. For a behavior to be free, the individual must have the relevant physical and psychological abilities to partake in it, and must know they can engage in it at the moment or in the near future (5). As we can see, crunching snacks, drinking soda, watching TV and playing video games perfectly satisfy the definition of free behavior, and it might be the most important free behavior in their spare time perceived by many children. One rule of Reactance Theory is the more important a free behavior is to a certain individual the greater the magnitude of the reactance. Therefore, those unhealthy behaviors of children might be very difficult to reduce or eliminate by parents, caregivers or teachers.
Second, We Can! program overlooks the power of peers in behavior formation process of children. Researches have indicated that peer behavior is a strong indicator of individual behavior during school age. One study deemed peer drug use as universally labeled the factor most likely to influence current drug use (6). It has also been shown that peer influence is especially instrumental in initiation and continuation of smoking marijuana (7). Although the above studies are regarding drug use among older kids, similar peer effect may also exist among 8-13 years old children on eating diet, less TV and games, and more exercise. It is hard to imagine one child could play balls on court along while most of his friends are playing and talking about PSP games around the corner. In addition, peer effect can be explained by Reactance Theory as well. Study has shown that similarity of the communicator and the audience can reduce reactance of the audience by increasing compliance and by reducing resistance (8). Hence, a program directly targets children, if designed properly, might be more effective because the message might be more acceptable among peers.
Third, many parents are not able to act like a role model in front of their kids, since they can’t give up junk food and soda and shorten screen time themselves. Social learning theory stresses that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. Since parents’ instructions may have some limitations due to reactance of children, it might be better to exemplify it rather than to tell their kids what they should do. However, if it is so simple for adults to change their life style, there won’t be an epidemic of obesity any more. A recent study collected data from 1988 to 2006 and tried to find trend of adherence to healthy life style habits in US adults. The results are disappointing. They find that over the 18 years, the percent of adults aged 40-74 years with physical activity 12 times a month or more has decreased from 53% to 43%; and eating 5 or more fruits and vegetables a day has decreased from 42% to 26%. Both of the results are statistically significant (9).
II. We Can! Program Assumes Parents’ Behavior is Rational and Controllable by Themselves.
We Can! program is based on the Health Believe Model (HBM). HBM is the oldest of the individual behavioral theories used in public health and have been proved having some limitations in changing health behaviors (10, 11). It indicates that human behavior is mainly determined by the balance between person’s perceived benefits and perceived barriers of taking an action (here, helping foster children’s healthy lifestyle). Perceived benefit is a function of two other variables – perceived susceptibility and perceived severity of the undesirable problems that taking the action could prevent (10). In this case, they are the risk of becoming obese and having other complications in children’s life and severity of those diseases, respectively.
However, the variables in the model may be distorted by some irrational factors. For instance, perceived susceptibility might be largely underestimated by parents due to optimistic bias – the phenomenon that people believe negative events are less likely to happen to them than to others (12). This is particularly true when their children’s BMI is among normal range. Parents tend to disregard the fact that much more people become overweight or obese when they are getting older without having a healthy lifestyle established during childhood. In 2008, 67 percent of U.S. adults are overweight, and 34 percent of them are obese (13). These numbers are strikingly higher than the ones of children. Moreover, optimistic bias may be augmented due to person’s belief that the event (i.e. his/her children will become overweight) is controllable (12). As parents are likely to believe that it is easy for them to change children’s behavior after they become overweight by simply not buying them snacks and forcing them to exercise, they may be reluctant to put much effort in prevention.
Admittedly, the major achievement of We Can! program that makes it stand out among many other anti-obese programs is it realizes that even assuming people do form an intention to take an action, they may still fail to do so because of lack of self-efficacy. Therefore, the program not only informs parents the harmfulness of childhood obesity but also focuses on providing tools and skills to help parents build their self-efficacy. It teaches parents basic knowledge such as what is normal body weight range of children and how to calculate BMI, and it offers tips on how to shop food smartly and how to keep their children physically active. In general, the program resembles an instruction book that contains everything you need to know to maintain healthy weight of your children.
Nevertheless, the program is less likely to have a significant impact because it still based on a flawed assumption that people’s behavior is rational and controllable by themselves: if they want and are capable to do it, they will do it. It asserts that people’s behavior is taken in a vacuum thus fails to consider other external social and environmental factors that may influence people’s decision. For example, parents living in poorer community or suburban area may be willing to let their children have healthy diet and adequate physical activity and they have already known how to do it from We Can! program, but they still feel hard to achieve the goal since they lack accessibility to sport facilities, can’t afford fresh organic fruits and vegetables, or have irregular shift of their job.
Unlike the assumption made by We Can! program, which largely depends on the HBM, human behavior, especially health behavior, is irrational and sometimes uncontrollable by each individual. It is unrealistic to expect parents could change their children’s life style by simply providing them with information and skills.
III. We Can! Program Does Not Incorporate Basic Principles of Advertising and Marketing Theory
To disseminate We Can! messages and convince more people and family join this movement, the program builds partnership with local communities, NGOs and corporations. With the resources and influence of the four NIH institutes, We Can! program undoubtedly have made a huge success in expanding its exposure. More than 900 local community sites in 50 states and 11 other countries have committed to using We Can! Over thirty national organizations and corporations are program partners, including Fortune 500 corporations and a number of government agencies. With this network, We Can! messages have reached nearly 700 million people (14).
However, knowing the messages is far from following the suggestions in the handbook or on the website. The messages marketed are not eye-catching or motivating at all. They contain merely information and depend solely on the flawed assumption that people’s behavior is rational and if they know too much calorie or little exercise is bad for their kids’ health they will take immediate action to prevent it from happening.
Additionally, the program does not incorporate basic principles of advertising and marketing theory. First, the core value this program tried to promote is health, which has been proved not one of the widely-held core values (15). Second, the whole program does not provide any convincing and desirable promises. In the center of their official poster, which shows four pictures of kids eating fruit and other healthy food or playing outdoor games with their parents, there is a slogan “ who can make it happen? We Can!” Although it sounds like a promise, it is actually an encouragement, because it doesn’t answer the question “what desirable thing will happen if we achieve the goal of eating healthy and exercising more?”
Possible Improvements for We Can! Program
Taking the three critiques into account, this section proposes some possible improvements for the current We Can! program. Part I of this section describes the new proposed interventions based on social norms theory, and Part II provides support on how the new interventions can solve the problems discussed above.
I. The Proposed Intervention
Social norms theory states that much of people’s behavior is influenced by their perception of how other members of their social group behave. Research has established that social norms not only spur but also guide action in direct and meaningful ways (16,17). Most previous interventions guided by social norms theory focus on conveying actual and misperceived norms to community. However, the real norm of healthy diet and physical activity is unclear and probably truly disappointing. Aimed to use social norms to affect children’s behavior, we intend to build a new norm in the refined program.
To apply social norms theory, first we want to retain the existing We Can! program. Their well-established network of partnership with community, corporation and NGOs may serve as a helpful infrastructure to build and defuse the new norm and the tools and tips on their website may provide parents valuable information to let them help children achieve the goal. In addition to the original We Can! program, a multi-faceted approach will be applied.
In the modified program, children’s role has to be emphasized since they are the ultimate target of behavioral change. To build the new norm, the program first tries to change the surroundings of children through collaboration of parents, school and community. The major purpose of it is to increase of exposure of healthy behavior (i.e. eating healthy diet, having more physical activity) while reducing the unhealthy one’s. For example, in terms of eating diet, schools and parents could replace sugary soda and high calorie snacks with low fat milk, juice and fruits in their meals and fridges. Schools may also add required after-school sports hours in their policy to send the normative message that sport is for every afternoon rather than TV and video games. Special attention should be put on the timing of those changes. All the changes, particularly school policy change, should take place gradually to avoid reactance of the students.
Furthermore, advertising and marketing theory might be an effective tool to disseminate normative messages. Children’s core value is quite simple compared with those of adults. They just want to be smart and cool in front of others. So in the program’s promotional campaign, advertisements and posters may send promises such as eating fruits and doing sports will make you popular and look better. Besides, one powerful way to build norms among 8-13 years children is to incorporate marketing and advertising theory into their favorite cartoons and comics, even through an unconscious way. For example, if the popular princesses or superheroes eat healthy in their every meal and only the evil or ugly guys drink soda and gorge burgers and fries, it’s easy to imagine which way the children will choose to follow.
Finally, the program also has several new interventions to help parents overcome external barriers and facilitate the formation of the social norms. The program may try to lobby policy makers to collect extra tax on sugary beverage and other high calorie food, especially those foods targeting kids. Participating corporations may distribute fresh fruits and vegetables to employees as a gift for every holiday. Communities and local government of poor or suburban area should appropriate more money on building more sport facilities.
II. Support For the Proposed Intervention
1. The Proposed Intervention Stresses the Role of Kids in Shaping Their Own Healthy Lifestyle
As mentioned above, the major change of We Can! program is to focus on interventions implemented directly on kids. One reason of doing so is social norms can be established more easily among kids since they have fewer deeply rooted pre-existing ones than adults, and presumably those social norms of healthy lifestyle will have influence in a longer term.
Another advantage of the improved program is it reduces children’s reactance. They perceived the normative information themselves from the surroundings, rather than from adult authorities. For those newly admitted kids, they can’t even notice the change in the school and will accept the new norms naturally. Additionally, the norm will defuse much faster among friends and peers and even beyond school and neighborhood.
In the new program, parents only play an auxiliary role in delivering the normative message and shaping kids’ healthy lifestyle. It releases parents since they don’t to take all the responsibility for their children’s behavior formation and don’t have to change their own bad habit in advance. That may somehow increase the impact of the program because it lowers barrier for parents to participate.
2. The Proposed Program Avoids Many Decision Making Processes thus Decrease the Influence of Irrational Behavior
Irrational behavior is coded in human’s instinct thus is very difficult to change. One effective way to reduce its influence is to avoid individual decision making processes and only let them respond spontaneously to external change. That is why tobacco taxes for reducing adolescent smoking and seatbelt law are two of the most successful public health interventions on health behavior so far. In the proposed program, parents don’t have to weigh the benefit of tasty high calorie food against risk of obesity of their family in the future anymore. They just purchase less of those products due to higher tax. The function of tax could also be explained in another way as it counteracts the misjudgment of the future susceptibility of obesity, therefore help parents make the right decision.
The proposed program also acknowledges the external social and environmental factors that may affect behavior. For example, distributing fruits and vegetables as holiday gift by employer and building sports facilities by local government all increase accessibility to healthy lifestyle around those underserved area.
3. The Proposed Program Applies Advertising and Marketing Theory to Help Build Social Norms Among Kids
The proposed program realizes that health is not a wide-held core value, especially for the kids. It identifies the core value that children cherish the most is looking smart, cool or beautiful in front of their friends. Based on this core value, it makes a promise in their promotional campaign that if you eat healthy and exercise more, you would looks better and become popular among your peers. Consequently, school children are more likely to be affected by such a promise.
The idea of incorporate marketing and advertising theory in the most popular cartoons and comics may have great influence on building social norms. This strategy, called embedded marketing, has been adopted long time ago by commercial marketing, and is very popular in recent decade. Actually, this measure of marketing “diet” has been proved effective back in early 20th century. Popeye the sailor is a famous fictional hero in cosmic strips and animated films. His most memorable feature is he will gain superhuman strength right after swallow a can of spinach. In 1930s, when Popeye first became very popular in the US, the spinach consumption raised 33% from 1931 to 1936. Ironically, the appearance of spinach was not for public health purpose at that time, but attributed to a misprint of decimal point of a research result, which gave spinach ten times its actual iron content (18).
NHLBI’s We Can! program may have limited effect in promoting healthy eating, frequent exercise and less screen time among 8-13 years old children. This is because it overestimates the role of parents in transforming their kids’ behavior. Parents may fail to serve this purpose because their children may psychological reactance to their order, they are unable to change their own behavior thus fail to become a role model, and their behavior might be affected by irrational and uncontrollable factors. Additionally, the program fails to convince more family to actually take action because it doesn’t incorporate advertising and marketing theory.
After several improvements, the program shifts the focus from parents to children and the main goal is to build new social norms among them. It also applies advertising and marketing theory in an innovative way to help achieve this goal. Therefore, the new program is more likely to win bigger and more lasting victory in the battle against childhood obesity.
1. Centers for Disease Control and Prevention. Prevalence of Overweight among Children and Adolescents: United States, 2003-2004. Hyattsville, MD: National Center for Health Statistics, 2006.
2. National Heart Lung and Blood Institute. We Can! Background. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/about-wecan/background.htm
3. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. The Lancet 2002; 360: 473-482.
4. Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M. Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health and Nutrition Examination Survey. JAMA 1998; 279: 938–42.
5. Brehm SS, Brehm, JW. Psychological Reactance: A Theory of Freedom and Control. New York: Academic Press, 1981.
6. Swadi H. Individual risk factors for adolescent substance use. Drug and Alcohol Dependence 1999; 55:209-24.
7. Kandel D, Kessler R, Margulies R. Antecedents of adolescent initiation into stages of drug use: a developmental analysis (pp. 73-99). In: Kandel D, ed. Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Washington, DC: Hemisphere, 1978.
8. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
9. King DE, Mainous AG, Carnemolla M, Everett CJ. Adherence to healthy lifestyle habits in US adults, 1988-2006. American Journal of Medicine 2009; 122:528-534.
10. Edberg M. Individual health behavior theories (pp. 129-143). In: Edberg M, ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones & Bartlett, 2007.
11. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39(3): 128-135.
12. Weinstein, ND. Unrealistic optimism about future life events. J Pers Soc Psychol 1980; 39:806-820.
13. Centers for Disease Control and Prevention. Health, United States, 2008. Hyattsville, MD: CDC National Center for Health Statistics, 2009.
14. National Heart Lung and Blood Institute. We Can! Factsheet. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/factsheet.pdf
15. Siegel M, Lotenberg LD. Marketing public health—An opportunity for the health practitioner. In: Siegel M, Lotenberg LD, eds. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones & Bartlett, 2007.
16. Aarts H, Dijksterhuis A. The silence of the library: Environment, situational norm, and social behavior. Journal of Personality and Social Psychology 2003; 84:18–28.
17. Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Griskevicius V. The constructive, destructive, and reconstructive power of social norms. Psychological Science 2007; 18(5):429-434.
18. Hamblin TJ. Fake! British Medical Journal 1981; 283:1671-1674.