Critique of the Delaware Based Public Health Campaign to Reduce Childhood Obesity: Potential Weaknesses in the Application of . . .

. . . Ecological Perspective Theory – Beth Morse

INTRODUCTION
The Delaware based Nemours Health and Prevention Services (NHPS) 5-2-1-Almost None intervention describes itself as a social marketing campaign that fights childhood obesity (1) yet it fails to adequately influence the public to develop healthy behaviors. The intervention appears to be based on an Ecological Perspective approach described by McLeroy et al. (1988) as an overarching public health approach that includes interpersonal, intrapersonal and community levels of intervention (2). The NHPS campaign fails at each level of intervention to make an impact on the lifestyle choices of families and children.

BACKGROUND: Nemours Health and Prevention Services 5-2-1-Almost None Campaign and Ecological Perspective Theory
The NHPS campaign to fight childhood obesity is a multiyear statewide campaign to improve the health of children in Delaware through policy change and social marketing for lifestyle improvement (1). The campaign promotes itself using the slogan “5-2-1-Almost None.” The numbers stand for 5 servings of fruit and vegetables a day, no more than 2 hours of screen time per day, 1 hour of physical activity, and almost no sugary beverages,” (1). The program reaches out to caregivers and policy makers with the message that children cannot develop healthy habits on their own and that they need adults to help. The campaign is split into two main parts; the first part focuses on policy and practice changes while the second part provides resources and tips to help caregivers teach their children to live a “5-2-1-Almost None” lifestyle. The teaching materials are not spread by NHPS itself but are made available online for groups or organizations who can use the resources to educate the public on a healthy lifestyle (1). The program advertises itself through billboards and radio adds that send the message ‘Children cannot do it alone, they need our help to live a healthy lifestyle,’ (1). The website does not appear very user friendly to the public but does offer a link for kids to play video games or watch episodes of The Mighty Timoneers, a group of cartoon pirates who battle a candy filled Sea and learn to eat healthier diets (1). Along with the cartoon program, the NHPHS website offers other useful materials for educating children and families on healthy lifestyle behaviors.
The major flaw in the NHPS campaign is that it fails to market itself in an effective manner. The campaign attempts to advertise itself through billboards and radio ads so that other groups will pick up the message and send out the educational materials thus creating a social network for the public health intervention. The problem here is that NHPS fails to adequately reach these social groups. Beyond the basic marketing failure of this campaign, the intervention is based on a combination of faulty social science theories. There are holes in the multiple social science theories upon which the Ecological Perspective theory bases its approach.
The NHPS intervention is based on an ecological perspective theory that encompasses multiple levels of intervention including intrapersonal, interpersonal and community (2,3). The goal is to change the physical and social environment that surrounds diet and physical activity in Delaware by influencing personal, social and community attitudes towards adopting healthy behaviors. An analysis of the NHPS campaign finds that intrapersonal attitudes are targeted with the health belief model, interpersonal attitudes are targeted with social learning theory, family relationships, and modeling, and finally community attitudes are targeted with organizational policy changes. There are failures within the basic social theory upon which each of these three levels are based. This paper will examine these failures.

INTRODUCTION TO THE CRITIQUE
The NHPS intervention is based upon an Ecological Perspective Theory (2). The basic assumption of the theory is that changes in the social environment will lead to changes in the individual and that individuals should be supported within the population in order to implement the environmental change (2). This applies to the NHPS intervention because the goal of the intervention is to change the social environment to bring about an individual’s focus on healthy lifestyle behaviors, and then to have those individuals support an increase in health behaviors and activities within the community.
There are three levels of analysis in the ecological theory that can be applied to the NHPS intervention: intrapersonal, interpersonal and community. The theory operates under the assumption that each level of analysis is based on existing effective psychological theory of health promotion. The basic failure of the NHPS intervention is that it fails to use adequate and effective social theory on each level of behavior change. The NHPS program fails to change the social environment because the basic theories upon which it is based are inappropriate for the intervention.

CRITIQUE #1: Failure to Reach Individuals at the Intrapersonal Level of the Ecological Perspective Theory though the Health Belief Model
As described by McLeroy et al., (1988) the Ecological Perspective Theory suggests that public health interventions should aim to change individuals at the intrapersonal level before there can be changes at the interpersonal and community levels. The NHPS intervention uses the Health Belief Model (4-8) to target caregivers and children at the intrapersonal level regarding their knowledge and beliefs toward a health behavior. This marks the first failure of the NHPS intervention. The Health Belief Model is ineffective in targeting caregivers and children because it cannot adequately address all of the contextual issues surrounding the audience and is unable to reach or influence the irrational element of human behavior (4-8).
The basic postulates of the health belief model as it is applied to the NHPS intervention are described below (2,4). It is important to note that the intervention takes the Model one step further by convincing caregivers that the health of their child is at risk, and using the caregivers to change the child’s behavior. The model applies to the NHPS campaign as follows:
o The individual must perceive that his/her child is susceptible to the poor health outcomes that may be caused by poor lifestyle behaviors and resulting obesity (2,4-8).
o The individual must perceive that poor diet and inadequate physical activity can lead to childhood obesity and that obesity can be a serious health threat (2,4-8).
o The individual must perceive that there is a low barrier cost in helping their children develop healthy lifestyle behaviors (2,4-8).

As seen in other interventions, the Health Belief Model contains certain limitations that contribute to failure of the model (8-10). A basic assumption, and weakness, of the Health Belief Model is that all people carry a central set of core values and will react rationally to information that targets these values (8-10). The NHPS campaign relies on the Health Belief Model in its assumption that the provision of information should be enough to convince caregivers that their child is at risk for poor health outcome (5). However, researchers have found that presentation of information does not always lead to intention. According to Thomas (1995) the Health Belief Model operates under the faulty assumption that all people will be similarly affected by the use of traditional scientific fact. It is not surprising that the NHPS campaign fails to create an ‘it could happen to my child’ attitude in the caregivers because the Model assumes that all people share the same value system for health and will respond uniformly to a traditional scientific approach (8). A better intervention would take the value systems of sub-units of the population into account before attempting to reach people at a statewide level.
Thomas (1995) cited that one of the assumptions underlying the Health Belief Model is that it only considers knowledge to have been gained if the behavior has been changed. This infers all adults will be changed once they learn that a behavior can affect their health. The faultiness of this approach is evident in the NHPS campaign where scare-statistics were cited to convince caregivers that their child needs a health intervention (1). The campaign provides this information to the caregivers with the intent that it will then relate the health issue, childhood obesity, to be something that is relevant to their own children’s health (3). The campaign fails to address the potential effect of environment context where individual subgroups may operate with unique core values (3).
Assuming that some people may respond straightforward effort of the NHPS campaign, the Health Belief Model remains ineffective because it does not provide sufficient motivation for caregivers to perceive their children as highly capable of improving their lifestyle choices. The Health Belief Model postulates that individuals will change their behavior when they hold the belief that following a certain health recommendation will reduce the risk of a perceived threat and that there is a low cost to implementing the new behavior (3). The NHPS intervention teaches caregivers that their children are at risk for poor health outcomes and that following the 5-2-1-Almost None model will reduce their risk of disease. The intervention operates on the basic assumption of the Health Belief Model that if the caregivers believe that there is a low barrier cost to changing behavior that they will work with their children to improve lifestyle choices. This aspect of the Health Belief Model is inappropriate for the NHPS intervention because it fails to address social or political barriers that may prevent some subsets of the population from seeking healthcare and other health behaviors (9,10). For example, some subsets of the population may be less likely to seek policy change within their schools or for available spaces for physical activity (3). The campaign must address these issues instead of assuming that all children have access to nutritious food and spaces for recreation.

CRITIQUE #2: Failure to Reach Individuals at the Interpersonal Level of the Ecological Perspective Theory
According to McLeroy et al. (1988), the Ecological Theory assumes that interventions at the interpersonal level will occur when social relationships have an influence on attitude and behavior change. The NHPS intervention focuses its interpersonal intervention on two elements. The first targets caregivers through relationships with caregivers who desire a healthy lifestyle for their child. The second is an interpersonal intervention using Modeling theory through the Mighty Timoneers interactive video games. The intervention fails to produce the appropriate interpersonal influence to create a sustained behavior change in children.
The interpersonal sector of the Ecological Perspective theory can only be effective if individuals are affected at the intrapersonal level before moving on to influence others at the interpersonal level (3, 5). The hypothesis that parental influence will lead the child to develop healthy behavior is based on the assumption that the caregivers were adequately influenced by the information provide by NHPS to make a change in their child’s lifestyle (5). As discussed in critique #1, this may not necessarily be the case. The failure to change behavior on one level may reduce the effectiveness of the intervention as a whole (3). For purpose of critiquing of the interpersonal approach, we will assume that the intrapersonal level of the intervention was effective.
The campaign attempts to target children at the intrapersonal level by using Social Learning Theory in networked video games where the child observes a social norm among cartoon children whose health behavior they can model (1,5). Social Learning Theory is used in the Mighty Timoneers video to accomplish behavior change through the child’s expectancies and incentives (5). The theory is intended to influence an individual’s expectancies about how a behavior may affect a certain health outcome and to convince the individual that they are capable of achieving that behavior change (5). The theory takes into account the factor of self-efficacy, reinforcement from past behaviors, and modeling those who have performed the behavior (5). The Mighty Timoneers video teaches children to model cartoon characters who are capable of fighting off the evils of unhealthy foods by being physically active and eating fruit and vegetables (1). Although the interactive video program may enforce some aspects of social learning theory, such as modeling the character’s behaviors and incentives for children to gain experience through food trials (5), it fails to address what may happen when the children are confronted with others who have not been exposed to the intervention. As described in Marks (1996) critique of the Social Learning Theory, the theory focuses too heavily on the individual and fails to take the effect of social and environmental context into account.
The NHPS video creates an influential social context within the parameters of population who plays the video game but fails to take outer social networks into account. McLeroy et al (1988) point out that a common flaw in public health interventions is that they often use interpersonal theory to change behavior through social influences while interventions may do better if they focus on changing the norms or social groups to which individuals belong. The NHPS campaign attempts to change the social norm by offering the Mighty Timoneers video to a wide social network that could potentially have an influence over the broad social environment of children in Delaware. However, because the intervention was not adequately marketed, it fails to compensate for what may happen when the child returns to siblings, classmates, or family who may continue to serve as an influence toward unhealthy behaviors.

CRITIQUE #3: Failure of Ecological Perspective Intervention to Address Social Influences at the Community Level
The NHPS campaign attempts to influence policy in Delaware for improving nutrition in school lunches and expanding locations for physical activity. The campaign uses little advertising and appears to rely on theories such as the Diffusion of Innovation Theory to spread its message across the state. The intervention fails because it does not support the maintenance of existing networks of communication and fails to create awareness within social networks and norms (3).
The environmental phase of the ecological perspective includes an intervention that aims to change organizations in order to support individual behavior changes (3). As previously discussed, the ecological perspective model is built so that the efficiency of one level of the model is dependent on those that come beforehand. McLeroy et al. (1988) suggest that the effects of interpersonal relationships are the first step to changing behavior through environment because interpersonal relationships exist outside the individual and can lead to implementation of changes in the community.
The basic failure of NHPS at the community level intervention is that its message was not properly diffused. For example, members of the community may not be aware of supplemental opportunities for physical activity even if they do exist. A study by Cevita & Dasgupta (2007) examined the use of the Diffusion of Innovation Model for development of a diabetes management program. The authors found that this model can only be effective if there is a maintenance of the network from which the information was first diffused (12). In other words, if the early adopters of health behaviors fail to communicate their achievements, the intervention will go nowhere. In the NHPS example, a neighborhood association who creates a recreational space but does not communicate their achievement to other communities is not helping propel the behavior change across the state. If there is no tipping point (12), then those who have not yet adopted the change may fail to do so.


ALTERNATE APPROACH: Improving the NHPS Intervention
The NHPS intervention can be considered a strong campaign because it is based on Ecological Perspective Theory, which combines multidisciplinary efforts at the individual, social and community level (5, 11). There are weaknesses, however, in using this Ecological Perspective. The overarching issue is that the approach is dependant upon the campaign having had an effect on the individual level before it can affect the interpersonal and then community level. The campaign will not work if it targets only the community but fails to have a strong foundation in its effect on the individual or interpersonal level. There are areas within each of these three phases that need improvement before the campaign can be effective. The following proposal will describe alternate approaches to reach children and caregivers at the intrapersonal, interpersonal and community levels. These approaches include: introducing Optimistic Bias, creating new social relationships, and introducing the ‘social’ in a Socioecological Theory.

DEFENSE OF NEW INTERVENTION #1: Use Elements of Optimistic Bias as well as the Health Belief Model to Support Behavior Change
The intrapersonal element of the NHPS ecological approach should be expanded to include Optimistic bias (13) to the Health Belief intervention in order to effectively influence caregivers to initiate behavior change. The health belief model assumes that if caregivers believe their child is at risk for poor health, they may make a change. If Optimistic Bias is introduced to the intervention, then the caregivers will become overly optimistic that they are capable of using the available resources to help improve their child’s chance for a healthy life. This optimism can serve as the spark to ignite a behavior change among families and children.
Weinstein (1980) cites that individuals tend to be unrealistically optimistic about future life events if they perceive the event as highly desirable, probable, and controllable. The author also cites that an individual may have optimism about an event based on prior experiences (13). This theory can be used to influence caregivers and children to become optimistic about their ability to improve their health through lifestyle behavior change. For example, the intervention can remind a caregiver who has had successful weight loss in the past that their child may be able to easily follow in their footsteps. The intervention should send the message that caregivers can easily control their child’s health behaviors and that this will increase the probability for a healthy and happy life. If caregivers and children believe that they can easily achieve a healthy lifestyle then they may be motivated to begin to make the necessary behavior changes. Some health behavior studies have shown that people are often intimidated by the amount of effort that they perceive is required to improve health (14,15). If the intervention can implement optimistic theory to supplement the health belief model, then this will lower the perceived barriers to entry (8) and may motivate caregivers and children to initiate a change in behavior that could ultimately lead to a healthier life.

DEFENSE OF NEW INTERVENTION #2: Create a New Social Role for Children
According to McLeroy et al. (1988), Ecological Theory should aim to change the nature of existing interpersonal relationships so that the relationship can become one that nurtures healthy behavior. The current NHPS intervention aims to create a nurturing relationship between caregivers and children, but has failed to make a difference. This lack of change can be traced back to the fact that caregivers are not properly influenced at the intrapersonal level to actively try to help their children improve healthy behaviors. A solution for this could be to target both the children and caregivers to change their interpersonal relationship, and not just the caregivers. It might be mutually beneficial if both the caregivers and children are pushing each other toward a healthy lifestyle.
McLeroy et al. (1988) suggest that social relationships can provide access to new social roles and that social interactions can have an influence on attitude and behavior change. This can be observed in the NHPS intervention where caregivers are urged to develop a social role where they help their child develop healthy lifestyle behaviors. Children are given the opportunity to create a role for themselves where they can choose to perform health behaviors by modeling the cartoon characters from The Mighty Timoneers (1). Yet the intervention fails to produce adequate social influence to maintain behavior change. A new intervention should capitalize on the effect of social relationships and role-playing by allowing the children to create a new social role for themselves where they influence their caregiver and/or peers. This new social role will create a reciprocal relationship where the child is influencing others while at the same time creating a space for social support within the group.
The interactive Mighty Timoneers video can be a useful aide for implementing social behavioral theories to improve health behaviors of children if it reaches children in the correct manner. According to Leiberman (1992), properly implemented video games have been found to improve mediating factors for health behavior change among children. One of the factors that Leiberman (1992) mentions is that the game should improve the communication that a child has with their peers and caregivers who can provide social support for making the behavior change. A good way ensure that a peer or caregiver can provide the necessary social support is to create a mutually supportive relationship where the child can motivate the caregiver or peer with the new information while gaining personal health motivation from that relationship. Research has found that direct experience, such as role-playing, can strengthen the relationship between a newly developed attitude towards health and the health behavior (17). Perhaps children can improve upon their lifestyle choices by role-playing as the teacher to influence others around them as well as reinforcing their personal attitude toward health behaviors.

DEFENSE OF NEW INTERVENTION #3: Introduce Social Elements to Ecological Perspective Theory via Socioecological Theory
The ecological perspective is useful in that it encompasses a wide range of behavior change theories at various personal and community levels of the population (18). The NHPS program should continue to use the Ecological Perspective Model, but supplement it by combining a sociological model. Stokols (1996) describes a Socioecological Theory as it applies to community health promotion. The Socioecological Perspective Theory operates under the assumption that health is a product of the relationship between individuals and the environment (17). As previously discussed, an individual benefits when there is a mutual relationship where he or she is able to influence others toward taking up a health behavior while reinforcing the behavior on a personal level. This can be expanded to the community level where the individual can develop a neighborhood exercise program as a way to participate in making a difference. This is mutually beneficial for the individuals and the community and, if communicated properly, can expand on itself through the Diffusions of Innovation Model described in the above critique. The goal is to give the individual a personal attachment to the changes in their community so that they will want to spread those achievements on a public level (17).
According to McLeroy et al., (1988), interventions can effectively promote health by creating opportunities for large groups of people to gain access to the health behavior in the space where they spend most of their time. It might be useful if the campaign to introduces voluntary organizations within neighborhoods and communities to create opportunities for physical activity such as kickball teams and more.

CONCLUSION
A new intervention should maintain the strengths of the Ecological Perspective Model by continuing to target the campaign at the intrapersonal, interpersonal, and community levels (3). Critiques of the Ecological Perspective Model cite that it assumes interventions are effective at each level of the ecological framework. (3,17). As described in the defense of the new intervention, social influence can broadly affect the community at both large and small interpersonal and group levels. It may be useful to introduce more of a social focus to the ecological perspective theory.
A Socioecological Perspective Theory may be more effective than a basic Ecological Perspective Theory. In the future, public health professionals who use this approach should keep in mind that if done correctly, the Socioecological Perspective can be very influential but that it is important to ensure that each level of the intervention is effective.

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