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.

REFERENCES:
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Live Healthy, Live Freely: A Critique and Reformation of Georgia’s Live Health Georgia Campaign – Sabrina Deveikis

I. Introduction
In the last decade a marked increase in obesity and other chronic diseases has become a cause of concern (1-4). Not surprisingly, the last decade has also shown a drastic decrease in some healthy behaviors, in particular physical activity (1,2). Studies have shown unhealthy lifestyles are an important contributor to chronic diseases such as cardiovascular disease (5,6).
In 2005 the Georgia Department of Community Health Division of Public Health sponsored a program called the Live Healthy Georgia campaign (7). The primary goal of the campaign is to encourage George residents to engage in healthier lifestyles to prevent chronic diseases (8). The program recognizes many challenges facing residents of Georgia in being able live a truly healthy lifestyle. Thirty percent of Georgia is classified as rural (9) and as a result, are more limited in their access to healthcare (10). Other factors include lower education levels, poverty, and race (8). Finally, already existing poor health behaviors are a challenge for any program. In particular, obesity, lack of physical exercise, and smoking present unique challenges (10).
The Live Healthy Georgia campaign adheres to the philosophy that prevention is the best method in preventing chronic disease and morbidity (8). The campaign is essentially an education program to teach the following messages:
· Get Checked (Receive appropriate health screenings)
· Be Smoke Free (Eliminate tobacco use)
· Be Active (Increase physical activity)
· Eat Healthy (Maintain a healthy diet)
· Be Positive (Maintain a healthy mental/spiritual outlook) (8).
The program hopes to promote Georgia’s Department of Human Resources as the best resource in Georgia for its messages and as the key resource in prevention of chronic diseases (8). With its website, outreach projects, and partnerships with other programs as part of the Take Charge of Your Health, Georgia! Georgia's 10-year Nutrition and Physical Activity Plan Georgians residents are to be provided with the educational resources to life healthier lives, less burdened with chronic disease (7,11).
This paper presents three critiques of Georgia’s Live Healthy Georgia campaign in Section II. In section III, an alternative campaign is proposed which takes into consideration of Maslow’s hierarchy of needs and marketing theory.
II. Critique of Georgia’s Live Healthy Georgia Campaign
The program launched by the Georgia Department of Community Health Division of Public Health to promote healthier lifestyles for Georgia residents is flawed for three reasons. First, the primary objective of the campaign is to educate or raise awareness of perceived susceptibility even though the campaigns own pilot studies have shown the majority of its target audience is already aware of the benefits of healthy living in terms of chronic disease prevention. Secondly, the primary tool the campaign hopes to instill into its target audience is self-efficacy but fails to address the larger environmental and social factors contributing to the unhealthy lifestyles. Finally, the program fails the basic concept of advertising and marketing theory of offering an attractive promise.
A. Raising Awareness When it Already Exists
The campaign appears to be very individual based attempts to spark behavioral changes through education by increasing awareness of risks and dangers of unhealthy life choices in relation to chronic diseases. The Health Belief Model defines four factors influencing individual behavior. Perceived susceptibility and perceived severity are weighed against the perceived benefits of the action and the perceived barriers of taking that action (12). The perceived susceptibility the campaign wants to education its target audience about is the increased risk of chronic disease and morbidity through unhealthy behaviors (7). The perceived severity would be a lifelong illness requiring daily medication and even mortality. The benefits of adhering to a healthier lifestyle would be fuller, healthier life, free from the burden of disease. The barriers in being healthy are both individual and environmental. The Live Healthy Georgia campaign was launched in March of 2005 and on April 1, 2005 the Georgia Department of Human Recourses released a report of findings of studies performed to serve as a baseline to evaluate the effectiveness of the new campaign (13). The study found that not only were Georgia residents aware of which health behaviors were the most beneficial to overall health but the majority of participants reported very frequent exposure to the very messages the campaign sought to convey (13).
In terms of the second message of the campaign, that of elimination tobacco use, the transtheoretical model is combined with the health benefit belief model in the campaigns approach in assisting people to quit smoking. The transtheoretical model defines the stages involved in a behavioral change and is usually applied to addiction interventions. The first stage is precontemplation when an individual is either not planning on taking an action or is unaware of the existence of a problem (14). In the second state, contemplation, the individual is weighing the perceived benefits and costs of taking a course of action (14). Preparation, or the third stage, marks the stage where a decision to act has been made and a plan for implementation is being formulated for the fourth state of action (14). The fifth stage is maintenance when the behavior has been changed but effort is required to ensure a permanent change. Finally, termination is when the change has been permanent and maintenance is no longer required.
On the campaigns’ website the only resource it provides for smoking cessation is a quit help line (7). The benefits of quitting are clearly outlined on the website and seem like the primary motivational tool to quit smoking offered by the campaign. The quit line offers information of the various cessation aides and even has a special intervention for teens seeking to quit (7). It merely attempts to walk smokers through the stages of change and does little beyond education of the benefits of not smoking and the aids available for quitting. It has been shown that the dangers of smoking are not only known by nonsmokers but smokers, themselves have had the dangers of their habit ingrained into their minds (15). Clearly, other methods must be utilized to cause more smokers to quit.
The campaigns goal of raising awareness of the benefit of healthy behaviors in the prevention of chronic diseases had been achieved before the program was even launched. In fact, the interventions target audience reported frequently receiving the program’s messages without any exposure to the program itself. The money and resources allocated to increasing the awareness of the benefits of a healthy lifestyle and trying to increase awareness in the susceptibility of its target audience can be better spent in ways that might illicit more of a wide spread behavioral change across the population of the target audience.
B. The Failure of Self-Efficacy
At least from the standpoint of the campaigns ads, the lesson instilled by the program to Georgians is, “You can do it,” (7). In other words, the intervention is attempting to give people the feeling of self-efficacy. Self-efficacy is a person’s belief that they can make the behavioral changes (16). The Live Healthy Georgia Campaign makes its target audience aware of all the benefits and makes it seem possible to achieve good health by following their simple guidelines to healthy living (2). Those guidelines are the five simple messages the program wants to convey. Unfortunately, it is one thing to say to get checked by your doctor regularly, it is another thing entirely if you’re in a rural community and the nearest doctor is twenty miles away and either cannot afford to take the time off of work or do not even have health insurance. These problems face many of Georgia’s residents and challenge the programs message.
Georgia faces several different challenges and factors, which can alter a person’s sense of self-efficacy. With thirty percent of the state residing in rural communities, the access to health care in those areas is less than in more urban areas (10). The level of education also plays a key role, and Georgia has the lowest rate of graduation in the country (17). Poverty is another important contributor. A quarter of the children in Georgia are living in poverty and 8% are living in extreme poverty (18,19). When faced with poverty, the cost and benefits of living a healthier lifestyle pale in comparison to the challenges of day to day life when perhaps even the means to get something to eat, not necessarily part of a well balanced diet, is a challenge, the messages of the program may fall on deaf ears.
C. The Promise?
The promise offered by the campaign may excite the insurance agencies more than Georgia’s general population because the promise is that prevention is more cost-effective and you can live healthier (7). Being healthier and saving the insurance company you have already given more of a portion of your paycheck than you were really willing to part with in the first place is not one of the core values in advertising and marketing theory (20). The one television ad available online is a cartoon character trying to walk up an incline with a second voice offering words of encouragement (7). The basic message is people can quit smoking, it will just take practice (7). There are no ads relating to the campaign’s four other messages, which undermines the efficacy of the campaign as a whole. The target audience of the ad is but a subset of the target audience of the Live Healthy Georgia intervention. Little branding has been done for the campaign itself and the ad has no indication it is part of a larger program, which promotes anything other than not smoking. Branding is an important part of marketing any campaign and the failure of this program to do so undermines the amount of success it can hope to achieve in changing the lifestyles of Georgia’s residents. (20).


III. A Reformulation of Georgia’s Live Healthy Georgia Campaign
Taking the aforementioned flaws into consideration, the following reformulation of the existing campaign is proposed. The proposed intervention takes more community based approach rather than the individual based approach currently being used.
A. Raising Access, Not Just Awareness
Where the current program sought to illicit behavioral changes through education, the new reformulation will promote greater access to the resources needed to live healthier lives. With the target audience being all adults living in Georgia, a more community-based approach will be more effective in generating a healthier population. The Socio-ecologic model will be useful in achieving the desired result. The individual and interpersonal results have already been seen thanks to the efforts of other state and national campaigns to raise awareness of the benefits of healthier living in relation to chronic diseases. Success in the upper levels of the model is the key to obtain a truly healthy Georgia.
Allocating the resources previously used at raising individual awareness will be diverted to create a means for the lifestyle changes necessary to becoming healthy to actually be possible. Incentives can be given to employers to have sports teams for their employees after work. High schools gymnasiums can be open after school hours for the public in a way that does not interfere with high school sports but provides a convenient and cost effective fitness option for working adults. Organizes sports or other physical activities can be offered by the local communities in parks. Finally, the state can provide funding and land for more parks and walking trails.
B. Increasing Self-Efficacy By Increasing State-Efficacy
In Maslow’s hierarchy of needs, if the lower, more basic human needs are not meet, an individual will not be able to allocate resources for the higher levels (22). Since Georgia struggles with poverty, low education, and restricted access to medical services, the more basic needs must be met before Georgians can start looking at their lifestyles and making changes.
The proposed intervention will promote, at the very least, affordable transportation in the rural communities. Other programs to try to draw more doctors away from the cities will need to be initiated, such as lower taxes on medical buildings in rural areas. Traveling doctors who make periodic visits to the larger employers will provide more options and convenience for both employer and employee.
To deal with the low level of high school graduation rates more money should be given to the schools. Programs to assist academically struggling students early on to help prevent the challenged students from slipping through the academic cracks and dropping out of high school out of frustration. More scholarships for both colleges and private high schools can help shift the level of education of Georgians in a more positive direction.
C. The Promise – Freedom
Clearly the promise of a healthier life does not promote many to action. For decades, the dangers of smoking have been widely known and still the tobacco industry is making billions off of a notoriously unhealthy habit. The promise has to appeal to one of our core-values, something we would be willing to pay or sacrifice for (27). The new promise of the proposed intervention will be freedom. Making healthier choices will not just make you healthier but will give you freedom. Freedom from the demanding toils of chronic diseases. Freedom to play with your kids without being sore. Freedom to run several blocks to catch the bus without a loss of breath. An hour doctor visit each year combined with a few simple choices can unlock the freedom to be all that you can be. The campaign to create a recognizable branding will also take place. Live Healthy Georgia will become synonymous with the promise of freedom offered in its advertising.
IV. Conclusion
In the campaign’s current incarnation, the Live Healthy Georgia program contains three flaws which interfere with it’s ability to effectively instigate changes in the behavior of its target audience. The first flaw is the primary goal of the intervention is to increase awareness of the benefits to healthier lifestyles but the resources of the program are being wasted on what has already been achieved prior to the launch of Live Healthy Georgia. The second flaw is the program promotes and encourages self-efficacy through its messages but the sense of self-efficacy falls flat when the extenuating circumstances surrounding the lives of many Georgia residences has them struggling to make ends meet. The final flaw is the program fails to take into account the tenants of advertising and marketing theory with making the promise of only a healthy life which is not a core-value most people will actively seek. A reformulation of the campaign seeks to amend the flaws of the current program by taking a more community-based approach and helping Georgia residents meet their basic needs giving them the opportunity to focus on being healthier. Finally, the message of a better promise, the promise of freedom will reach out to more people and have a far greater impact in changing the behavior of people in Georgia.
REFRENCES
1. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2008].
2. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [1998].
3. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 288:1723-7. 2002.
4. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.
5. Mokdad AH, Marks JS, Stroup DF, Gerderding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.
6. Stampfer MJ, Ju FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. New England Journal of Medicine. 2000;33;16-22.
7. http://www.livehealthygeorgia.org/
8. http://health.state.ga.us/pdfs/healthtopics/lhg.overview.2005.pdf
9. U.S. Bureau of the Census. U.S. Census 2001 Total Population Estimate. Washington: The Bureau; 2002.
10. Silliman SL, Quinn B, Huggett V, Merino JG. Use of field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke. 2003;34:729-733.
11. http://health.state.ga.us/pdfs/familyhealth/nutrition/NutritionandPhysical ActivityPlanFINAL.pdf
12. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire issue.
13. Georgia Department of Human Resources Assessment and Evaluation Study (April 2005) http://health.state.ga.us/healthtopics/lhg.asp
14. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis Fm, eds. Health Behavior and Health Education, 3rd Ed. San Fransico, CA: John Wiley & Sons; 2002.
15. Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281:1019-1021.
16. Individual health behavior theories (chapter 4), In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury. MA: Jones and Bartlett Publishers, 2007, pp 35-49.
17. Manhattan Institute for Policy Research. High School Graduation Rates in the Country. Available at: http://www.manhattan-institute.org/cr_baeo.pdf.
18. Kaiser Family Foundation. State Health Facts Online, Individual State Profiles. Georgia: Poverty Rate by Age, state data 2000-2001, U.S. 2001. Available at: http://www.statehealthfacts.kff.org/cgi- bin/healthfacts.cgi?action=profile&area=Georgia&category=Demographics+and+the+Economy&subcategory=People+in+Po verty&topic=Poverty+Rate+by+Age.
19. Kaiser Family Foundation. State Health Facts Online, Individual State Profiles. Georgia: Poverty Rate by Race/Ethnicity, state data 2000-2001, U.S. 2001. Available at: http://www.statehealthfacts.kff.org/cgi-
20. 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.
21. McLeroy, et, al, an ecological perspective on health promotion program a Health Education Quarterly 1988, 15:351-77
22. Maslow AH. A theory of human motivation. Psychological Review 1943; 50;376-396.

The President’s Challenge-A Good Fit for Childhood Overweight and Obesity?-Marlaina Lee

Childhood overweight and obesity is undoubtedly one of the most important health issues facing the United States. Overweight and obesity is quantified by the use of the Body Mass Index. According to the Centers for Disease Control and Prevention, CDC, an overweight child has a Body Mass Index of greater or equal to the 85th percentile. An obese child is classified as having a Body Mass Index of greater or equal to the 95th percentile (1). Youth overweight and obesity has been on the rise in the United States for the past four decades (2). Data from the most recent National Health and Nutrition Examination Survey, NHANES (2003-2006), finds that 33.3 percent of children ages 6 –11 and 34.1 percent of children ages 12–19 qualify as overweight (2). Three classes of contributing factors for childhood overweight and obesity have been identified by the CDC: genetic, behavioral and environmental (3). In response to the proclaimed “Obesity Epidemic” in the United States, research efforts have focused on the causal factors linked to obesity and effective interventions for behavioral and environmental influences (4). Additionally, the United States’ federal government recognizes the problem of increased overweight and obesity at all ages and committed to a goal of reducing the rates of childhood overweight and obesity to 5 percent in Healthy People 2010 (5). This goal will be retained for Healthy People 2020 (5).
The President’s Challenge
One of the most recognized government programs intended to promote physical fitness and activity is the President’s Challenge sponsored by the President’s Council on Physical Fitness and Sports, PCPFS, an office within the Department of Health and Human Services (6). The President’s Challenge began in 1966 with the development of the Presidential Physical Fitness Award; the program continues today as an age-specific recognition and awards program comprised of a physical fitness test, health fitness test, active lifestyle program and Presidential Champions program (7). The most prominent aspect of the President’s Challenge is the physical fitness test that includes curl-ups, push-ups, pull-ups, a shuttle run and a v-sit flexibility test. Awards are distributed in three categories: Participant (those not meeting the 50th percentile), National (above the 50th Percentile), and Presidential (above the 85th percentile) (7). Besides having nation-wide participation, the Challenge has demonstrated proven benefits for its participants. An independent study conducted at Louisiana State University found that students who receive recognition (Presidential Fitness Awards) for their physical fitness efforts “reported higher levels of task orientation, perceived competence, enjoyment, effort, and stronger intentions to participate in fitness testing in the future than those who did not receive awards” (8). While the program has many positive aspects and outcomes, this intervention could achieve greater potential if three critical areas, program design, acknowledgement of limited physical education, and marketing/advertisement were addressed and improved.
Flawed Design
The President’s Challenge is designed based on standards developed from the 1985 School Population Fitness Survey (9). This data is used to set the award levels for physical fitness achieved amongst participants (9). This is a critical flaw in the design of this public health intervention. Current participants are being compared to the performance of a previous generation. The comparison of the 1976-1980 and 2003-2006 NHANES surveys shows that overweight rates have more than tripled for children ages 12-19, increasing from 5 percent to 17.6 percent (10). The landscape of the US population, rates of overweight and obesity, and physical activity guidelines have changed drastically over this same time period. The use of 25 year-old data as a standard significantly hinders the potential effectiveness of the President’s Challenge. One could argue that this previous generation was healthier and holding today’s students to those physical standards is beneficial, however, this demonstrates a lack of understanding of the population the initiative attempts to serve. A student taking the physical fitness test today may not meet the 50th percentile of the 1985 standards and be discouraged by his results. His results might be very different if compared to updated youth standards. This child could possibly qualify for the next level of recognition if compared to accurate peer data, but the use of the 1985 numbers prevents this. Furthermore, the discouragement generated by the 1985 comparison could prevent the student from having self-efficacy in regards to physical activity and fitness. The theory of self-efficacy argues that the “expectation of personal mastery and success determines whether or not an individual will engage in a particular behavior” (11). If a student does not meet the 50th percentile, and earns only a “Participant” achievement level, he will not cultivate the sense of mastery described in the theory of self-efficacy. This could have lifelong behavioral repercussions if the student elects not to partake in future physical activity for fear of below average performance. Self-efficacy is a component of many health behavior change models and is a primary element in sport psychology (12). Holding today’s children to the standards of a prior generation is counter-productive to the President’s Challenge because it ignores the potential source of negative reinforcement and neglects to foster self-efficacy. The use of the 1985 School Population Fitness Survey does not account for the societal or lifestyle changes that have occurred in this time-period and does not necessarily provide participants with a realistic view of their individual physical fitness levels.
Environmental Constraints
Educators are the individuals who implement the President’s Challenge in schools. Materials are available to assist educators in operating the program; there is an online tracking system to enter students’ progress, online order forms for the rewards, etc (13). However, these enhancements to the well-established program do not address the critical issue of the national trend towards the reduction or elimination of allocated physical education in schools (14). Physical Education is omitted from the core subjects included in the No Child Left Behind Act, which has greatly influenced the shape of US K-12 curriculum since its passage it 2002 (15). No Child Left Behind focuses on reading and mathematics and has pushed curriculum developers to reduce health and physical education in an effort to allocate more time for core subjects (14). The Shape of the Nation 2006, a report published jointly by the American Heart Association and the National Association for Sport and Physical Education, NASPE, states the number of students participating in daily physical education has declined from 42 percent in 1991 to 28 percent in 2003 (16). Another survey conducted by the CDC, the 2006 School Health Policies and Programs Survey, found that 21.7% of schools participating in the survey did not have any physical education requirement (17). With instructional physical education time being extremely limited or non-existent, participation in the President’s Challenge can be difficult for teachers to implement. Classes that are actually held present educators with large student enrollment and time constraints. This restrictive environment to not conducive to participation in the Challenge or for conducting bi-annual fitness testing as recommended by the PCPFS (18).
For a public health initiative to be successful, it is necessary for the individuals designing the initiative to have an understanding of the environment in which the intervention will be executed. The President’s Challenge is designed with the assumption that teachers will have sufficient time to enact the program and be able to track performance. When the PCPFS first introduced the concept of fitness awards, the program was being released to a public whose school children had regular, if not daily, physical education (14). There is a reduced opportunity for reinforcement of positive physical activity behaviors if time spent in the intervention environment is limited. Social Learning Theory, developed in mid-1980’s, maintains that:
People are influenced by observing others, and their health behavior is affected by knowledge of steps necessary to avoid risk, motivation to avoid risk, the perceived benefits of the protective action and the belief that one can effectively carry out the protective action…four major conditions are needed for behavior change: (a) information (b) the development of self-protective skills and controlling self-efficacy; (c) skill enhancement and building resilient self-efficacy; (d) and social supports for desired personal changes. (19)
The Challenge is presented as a school-wide group activity, with the physical education classroom as its setting. Without instructional classroom time, the program has no means to provide the Social Learning Theory’s conditions for behavior change. Limited instructional time prevents students from observing each other’s participation in the program, developing their own physical activity skills and self-efficacy and receiving social support for their Challenge participation. According to the Social Learning Theory, these are all vital components and reinforcements of health behavior change; the physical education classroom is the only structured outlet provided for these activities contributing to the success of the Challenge. Though the Department of Health and Human Services has listed as a new initiative in Healthy People 2020 to “increase the proportion of States and school districts that require regularly scheduled elementary school recess” (20), recess is not instructional physical education, and this increase will not influence curriculum changes or assist teachers in implementing the Challenge. Overall, the Challenge’s failure to address time constraints and limited exposure to physical education demonstrates a lack of environmental consideration in the program’s design and leaves it susceptible to failure.
Promotion Pitfalls
The President’s Challenge has existed for many decades and over 70 million individuals are estimated to have received Presidential Fitness recognitions since the program’s commencement. Despite its history, the free program is not consistently utilized throughout the country. State participation rates vary greatly from state to state and some states do not even meet the minimum three submissions for certain state-wide awards programs (21). Though the Challenge makes print media materials and a user-friendly website available for schools and individual participants, there are no Public Service Announcements or widely circulated mainstream advertisements promoting the program. The program recently branched out through a more popular social network by launching a Facebook group, but it has a mere 1,650 members, most of who appear to be adults (22). It order to expand participation on both the school and individual levels, the President’s Challenge needs to effectively utilize mainstream media outlets and networking resources. Facebook is a start, but low membership reflects a limited interest in the program. Furthermore, the page does not even offer a full description of the many aspects of the President’s Challenge. Effective utilization of popular communication methods could generate greater awareness, interest and participation in the program.
Multiple studies have been conducted evaluating the influence of social networks on health behaviors and outcomes. A social network consists of the people one regularly communicates and comes into contact with. A student’s teachers and classmates are part of their social network, as are their Facebook friends. Researchers at Harvard University have established that “network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions” (23). Since networks contribute to and can influence rates of obesity, they should be employed as agents of health behavior change. The Challenge has put a limited effort into taking advantage of both media and social networks to promote itself. The most fantastic website will not achieve wide circulation if the only advertisement for it is a printed poster hanging in the corner of a school gymnasium. The program does itself a disservice by putting forth a mediocre media and social networking campaign. Without exciting promotion, student interest in the program can falter and participation rates will remain stagnant.
The President’s Challenge has many positive features and should not be hastily cast aside. The faulty aspects of the President’s Challenge could be altered to better serve the youth population. Its foundation as a national program to promote fitness, its accessibility and relatively simple methods of fitness testing are redeeming qualities that if combined with recent data, thorough environmental assessment and strategic marketing/networking could produce a strong childhood overweight and obesity initiative.
A New Challenge
An improved and remarketed program could be designed based on the President’s Challenge. A “National School Fitness Challenge” would incorporate the positive aspects of the President’s Challenge, but utilize more current standards, accommodate limited physical education and advertise itself as a nationwide, school-spirit, physical activity competition. The program would run annually for the duration of the school year and include fitness testing and physical activity participation both inside and outside of the school facility. This proposed program would develop partnerships with athletes, sports teams and celebrities to provide incentives, such as school appearances and apparel to motivate students and prompt participation. Currently, the highest performing “Champion Schools” in the President’s Challenge receive a school award certificate and emblems to place on student award certificates (21). The new program would strive to secure more desirable incentives to spark student excitement for the program.
Current Data
The School Population Fitness Survey has not been conducted since 1985, but other more current physical fitness data has been collected and is readily available to the public. In 2004, NASPE published physical education standards for every grade level (24). These would be appropriate standards to develop a program curriculum around, since NASPE represents physical educators through the country and is a part of the American Alliance for Health, Physical Education, Recreation and Dance. These standards were developed with an understanding of the current physical education environment and because of that are more conducive to promoting self-efficacy in students. The standards include concepts such as achieving and maintaining a health-enhancing level of physical fitness, and valuing physical activity for health, enjoyment, challenge, self-expression, and/or social interaction (24). The standards include both performance and participation-based assessment which creates a positive fitness attitude. Using these standards would allow students to develop a sense of self-efficacy, a critical component of behavior change.
Environmental Embraces
Understanding the constraints on instructional physical education time, the National School Fitness Challenge would include supplementary activities that could be completed outside of the gymnasium and at home. Students would be encouraged to participate in physical activity at both recess and home and complete their own fitness logs on the program’s website. If students do not have access to the internet at home, there would be a paper-based method to submit physical activity logs. The use of at-home activities would supplement and enhance physical education. The at-home activities would also serve as reinforcement for physical activity and aid in the information and skill development elements outlined in the Social Learning Theory (11). Classroom time would be optimized by participation in the nationwide program because it would be a year-long reinforcement of fitness concepts with a rewarding conclusion at the end of the school-year.
Popular Communication
In order for the National School Fitness Challenge to have any impact, it must be creatively marketed as an exciting competition that ignites school spirit. General Mills sponsors “Box Tops for Education” which encourages students to collect General Mills product box tops and bring them to school. Based on the number of collected box tops, General Mills makes a donation to the school. In 2008, because of such high participation rates, General Mills donated $50.6 million dollars to participating schools (25). Though the National School Fitness Challenge would not offer monetary incentives for school participation, it would utilize the benefits of marketing and advertising theories utilized by General Mills for the promotion of the program. Since box tops are located on General Mills’ products, the company promotes its school program through the advertisement of its products. David Ogilvy, founder of the global Ogilvy advertising agency writes that in advertising “your most important job is to decide what you are going to say about your product, what benefit you are going to promise” (26). Most Americans could quote General Mills’ Cheerios as being “heart healthy” (27) and Cheerios have delivered on this promise for decades. To successfully advertise the National School Fitness Challenge, the promise of a fun, beneficial, school physical activity program would have to be amplified through television, print and internet advertisements where it would reach the targeted population of children and educators.
This promise would be further spread through appropriate social networks, both physical and virtual, by using online communities such as Facebook to promote the program to the targeted audience. Obesity researchers suggest:
The spread of obesity in social networks appears to be a factor in the obesity epidemic. Yet the relevance of social influence also suggests that it may be possible to harness this same force to slow the spread of obesity. 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. (19)
If network phenomena are truly influential in health behavior, their utilization is key to promoting this childhood intervention. If individuals see their peers and counterparts involved in the National School Fitness Challenge, they might be more inclined to participate. If a student sees his classmate completing fitness logs, this may result in a form of positive peer pressure motivating the student to do the same. Cross-country friends could notice a Facebook friend’s school participating in the Challenge and urge their teachers to enter their school into the competition. The combination of advertising and social networking would launch the program into the schools and homes of every potential participant. Awareness of the program will prompt higher participation, making the program more exciting for participating students and translate into a greater impact.
The identification of school physical education programs as a vehicle to combat childhood obesity is not new. Conversely, many of the obstacles and tools presented to public health program designers are new and are still in the process of being demystified. Pre-existing programs like the President’s Challenge have value in the health-conscious principles they aim to promote. However, updated and modified programs like the proposed National School Fitness Challenge are better equipped to advance the nation’s aspirations of reducing childhood overweight and obesity.
References
1. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/childhood/defining.html
2. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood: Trends: NHANES. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/childhood/prevalence.html
3. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood: Contributing Factors. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/childhood/causes.html
4. The Campaign to End Obesity. The Campaign to End Obesity: About the Campaign. Washington, DC: The Campaign to End Obesity. http://www.obesitycampaign.org/
5. Healthy People 2010. 19-3-Reduce the proportion of children and adolescents who are overweight or obese. Washington, DC: US Department of Health and Human Services. http://www.healthypeople.gov/document/html/objectives/19-03.htm
6. President’s Council on Physical Fitness and Sports. The President’s Council on Physical Fitness and Sports: About the Council. Washington, DC: President’s Council on Physical Fitness and Sports. http://www.fitness.gov/about_history.htm
7. The President’s Challenge. Educators. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services. http://www.presidentschallenge.org/educators/program_details.aspx
8. Domangue, E., Solmon, A. Relationships Between Motivation and Award Status on Norm-Referenced Fitness Tests. 2009 AAPHERD Exposition. Tampa, Fl: http://aahperd.confex.com/aahperd/2009/finalprogram/paper_12890.htm
9. The President’s Challenge. Educators-Physical Fitness Test. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services. http://www.presidentschallenge.org/educators/program_details/physical_fitness_test.aspx
10. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood: Trends in Childhood Obesity. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/childhood/trends.html
11. Salazar, M. Comparison of Four Behavioral Theories. American Association of Occupational Health Nurses Journal March 1991; 39:3:128-135.
12. Cox, R. Sport Psychology: Concepts and Applications. New York, NY: McGraw-Hill, 2002.
13. The President’s Challenge. Educators. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services. https://www.presidentschallenge.org/order_center/index.aspx
14. Azzarito, L. “Shape Up America!”: Understanding Fatness as a Curriculum Project. Journal of the American Association for the Advancement of Curriculum Studies. February 2007. http://www.uwstout.edu/soe/jaaacs/vol3/azzarito.pdf
15. US Department of Education. Elementary and Secondary Education Act. Washington, DC: US Department of Education. http://answers.ed.gov/cgi-bin/education.cfg/php/enduser/std_adp.php?p_faqid=4
16. National Association for Sport and Physical Education. The Shape of The Nation. Reston, VA: National Association for Sport and Physical Education. http://www.aahperd.org/naspe/publications/upload/ShapeOfTheNation.pdf
17. Lee, S., Burgeson, C., Fulton, J., Spain, C. Physical Education and Physical Activity: Results From the School Health Policies and Programs Study 2006. Journal of School Health, October 2007. 77:8:435-463. http://www.ashaweb.org/files/public/JOSH_1007/josh_77_8_lee_p_435.pdf
18. The President’s Challenge. Educators-Testing Guidelines and Events. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services. https://www.presidentschallenge.org/educators/program_details/physical_fitness/events.aspx
19. Choi, K., Yep, G., Kumekawa, E. HIV Prevention Among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention, 10, 1998:19-30.
20. Healthy People 2020. Physical Activity and Fitness-PAFHP2020-12. Washington, DC: US Department of Health and Human Services. http://www.healthypeople.gov/hp2020/Objectives/ViewObjective.aspx?Id=110&TopicArea=Physical+Activity+and+Fitness&Objective=PAF+HP2020%E2%80%9312&TopicAreaId=39
21. The President’s Challenge. Educators-Recognition. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services. http://www.presidentschallenge.org/educators/school_recognition/state_champs.aspx
22. The President’s Challenge Facebook Group. http://www.facebook.com/search/?q=president%27s+challenge&init=quick#/group.php?gid=60919158657&ref=search&sid=1612845.3699929596..1
23. Christakis, N., Fowler, J. The Spread of Obesity in a Large Social Network over 32 Years. New England Journal of Medicine 2007;357:370-379.
24. National Association for Sport and Physical Education. National Standards. Reston, Va: National Association for Sport and Physical Education. http://www.aahperd.org/naspe/standards/nationalStandards/PEstandards.cfm
25. General Mills. Box Tops for Education-Success Stories. Young America, MN: General Mills. http://www.boxtops4education.com/share/Stories.aspx
26. Oglivy, D. Confessions of an Advertising Man. New York, NY: Atheneum, 1964. 93.
27. General Mills. Cheerios. Young America, MN: General Mills. http://www.cheerios.com/forAdults/YourStories/AdultStories_home.aspx?story=4

Failure To Account For The Effect Of Environment: A Critique of the “Take The Stairs – Every Step Counts!” Campaign – Mollie Wright

I. Introduction
Over the past two decades, obesity has risen significantly in the United States, developing into a major public health problem (1). A drop in physical activity and increased access to calorie dense, high fat foods has created an environment in which Americans are taking in more energy than they are burning (2). In 2006, The US Department of Health and Human Services introduced the “Small Steps” Campaign, promoting 100 small lifestyle changes to combat the obesity epidemic (3). Small Step #67, “Take the stairs instead of the escalator”, prompted the development of the “Take the Stairs – Every Step Counts!” Campaign by the Boston Public Health Commission. The intervention is designed to promote exercise in the work place because physical activity has been shown to enhance employee morale, reduce absenteeism, better retain healthy employees, and lower overall health care costs (4). Placing signs near escalators and elevators, at the point-of-decision, has been shown to be effective in increasing stair use (5). However, a review of eight studies evaluating sign interventions suggests that the effect may not be significant enough to reduce obesity prevalence on a population level (6). Public health campaigns require an understanding of human decision making. Specifically, taking into account irrational decision making, in the form of context, expectations, and framing, and the external environment may be beneficial (7). Modifying the way the signs are presented by understanding how people make decisions may enhance the overall effect of the intervention and prove to be a valuable recommendation in the national “Small Steps” campaign.
II. Critique of the “Take the Stairs – Every Step Counts!” Campaign
A. The Effect of Context Stair on Stair Usage
It is important to understand the effect of context when analyzing human behavior. A common mistake is to overestimate an individual’s character, and underestimate the effect of the environment on decision making. (7) Specific to the “Take the Stairs” Campaign, the intervention succeeds with the placement of the signs at the point-of-decision (5). The signs are placed next to elevators and escalators, encouraging individuals to use the stairs instead (4). While many interventions have shown increased stair use after the signs are placed, the overall effect is not currently strong enough to affect the prevalence of obesity (6).
The original intervention is based on an individual level theory of behavior, as opposed to an environmental level model. Individual behavior theories, such as the Health Belief Model, weigh perceived benefits and barriers of the decision before choosing the behavior. The problem with these theories is that they assume that human behavior is rational, planned, and static. There is no room for spontaneity and the effect of the environment is not taken into account. (8) In contrast, environmental level theories describe behavior as unplanned and dynamic, while considering the effect of the environment and structural factors (9).
Therefore, a possible failure of this intervention is the assumption that reading the sign will be enough to encourage an individual to take the stairs. By not taking into account the environment, the intervention isn’t considering that many buildings are not designed with central staircases and they can often be difficult to locate. If the signs fail to provide information about where to actually find the stairs, then individuals may perceive the staircases as being difficult to find and will most likely choose the escalator or elevator. (10) The context in which an individual is presented the decision will directly affect their behavior (7). In this case, the environment, specific to the building design, may inhibit the effectiveness of the intervention.
B. The Effect of Expectations on Stair Usage
Expectations are another aspect of irrational behavior that can be modified to affect individual decision making. Overall, people behave the way they are expected to behave. Stereotypes and priming have been shown to directly affect behavior, even when there is no rational reason. (11) In the United States, health disparities between ethnic groups have become an increasing problem. Blacks and Hispanics have a 51% and 21% higher prevalence of obesity, respectively, than Whites. Obesity and overweight are associated with comorbidities such as hypertension, cancer, and heart disease. (1) Studies evaluating the effectiveness of the “Take the Stairs” campaign found higher rates of increased stair use in White men and women than in Black and Hispanic men and women (6). In particular, one study found no significant change in stair use for Black men and women with the placement of the signs (12).
As explained before, the original intervention is based on an individual level behavior model. If the decision to take the stairs was based entirely on weighing the expected outcomes with the social acceptability of the behavior, as modeled in the Theory of Reasoned Action, then designing signs to promote this behavior would be simple and effective, because the behavior would be predictable (8). However, the failure of these signs in reaching Black and Hispanic populations reveals the complexity of human behavior. Expectations and social norms are different for different ethnic groups and need to be taken into account (13).
If overweight has become the social norm for Blacks and Hispanics, it may also not be the norm for these populations to choose the stairs over escalators and elevators. People are behaving the way they are expected to behave (7). Therefore, a possible failure of the “Take the Stairs” campaign is that the signs do not identify with specific ethnic groups. In order to enhance the effect of the intervention and lessen the health disparities between groups, it may be important to take into account expectations and social norms by personalizing the signs, rather than assuming that all populations will identify with standard messages.
C. The Effect of Framing on Stair Usage
Framing is another characteristic of irrational behavior that directly affects human behavior and decision making. How a decision is framed or presented can persuade an individual to make a certain decision, despite being irrational. (14) Framing is commonly used in public health as a way to encourage healthy behavior changes. It has been found that most people do not prioritize health when asked to list their core values. Freedom, control, love, and acceptance are typically thought of as important, but health is rarely considered (15). Based on this idea, public health campaigns that frame a behavior recommendation as a change for improving health are not as effective as those that promote core values (12).
Once again, the original intervention is based on an individual level model of behavior. As described with the Health Belief Model and the Theory of Reasoned Action, individual level models assume rational decision making, based on weighing the pros and cons of a behavior (8). However, if an individual does not prioritize their health, it is unlikely they will view taking the stairs as a beneficial decision. The perceived barrier of locating the stairs and the effort required to climb them may be too high if the message delivered is framed as a health based one, rather than one targeting core values.
The “Take the Stairs” campaign offers a mixture of template signs, most of which emphasize taking the stairs for health reasons. Two of the signs offered made reference to the stairs as a replacement gym, such as “Do some reps, take the steps!” and “The cheapest gym anywhere…” However, the rest of the signs simply asked “Have you thought about the stairs?” (4) Therefore, a possible failure of the “Take the Stairs” campaign is the emphasis on health and lack of emphasis on the values that people tend to prioritize.
III. Proposed Changes to Enhance the effect of the “Take the Stairs – Every Step Counts!” Campaign
A. The Effect of Modifying Context and Building Design
The concept of herding behavior is a group level theory describing the mob effect, or the alignment of thoughts and behavior of individuals in a group without centralized coordination (16). The idea that groups tend to move as a unit, choosing the same behavior, can be applied in the promotion of stair use. The building design and environment may be inhibiting people from choosing to take the stairs over the elevator or escalator. A study looking at the effects of neighborhood and street design on physical activity in children found that the presence of sidewalks and the attractiveness of a neighborhood have a positive effect on walking behavior (17). This same idea can be applied to building design and stairwells, such that if a pathway is provided in a visually pleasing setting, it is more likely to encourage pedestrian use.
Buildings are usually designed for function and many institutions closely constrain where people are allowed to walk within a building. Therefore, site design should involve pedestrian elements to encourage walking around within and between buildings. Features, such as a central staircase, can promote physical activity in the work place. (10) Taking the stairs would become the primary choice because pedestrian traffic is directed in that direction, taking advantage of herding theory and modifying the context of stair use.
For older buildings, the effect of space, light, and bright paint colors make stairwells more inviting and encourage more use (10). Also, the addition to the sign of an arrow or map, directing individuals to the stairwells, can encourage stair use. The visual of showing where to locate the stairs will lower the perceived barriers of using the stairs and may change the context in which the sign is presented to increase use. Therefore, the presence of other users and the visual setting plays a key role in pedestrian choices and behavior (10).
B. The Effect of Modifying Expectations and Designing Signs Specific to Ethnic Groups
Social Expectations Theory is a group level model used in public health to determine what human behaviors are social norms. As the social norms change, measured behavior changes along a diffusion curve. (18) This theory can be applied when considering the norms of physical activity in certain populations. A study looking at activity levels found that individuals in neighborhoods with low sidewalk connectivity were associated with a higher body fat percentage (19). If the neighborhood environment prevents regular physical activity, the inhabitants of that area are less likely to make exercise a part of their lifestyle. This habit may extend beyond the home and affect the activity level of the individual in other neighborhoods and in the workplace.
If the social norm is for certain ethnic groups to choose the escalator or elevator over choosing the stairs, then the goal of the “Take the Stairs” Campaign should be to create signage specific to individuals from these groups. When implemented, studies evaluating the effect of the signs found that stair use was higher in White men and women than in Black and Hispanic men and women (6). Therefore, it is important to target signs to Black and Hispanic populations.
A community intervention in Baltimore created culturally sensitive signs to promote stair use by Black men and women in the subway. They found that Black men and women increased their stair use from 10.3% to 16.4%, with the greatest increase in Black women. Additionally, White commuters increased their stair use from 23.1% to 28.3%. Therefore, the study confirmed that signs encouraging stair use can be effective in targeting specific ethnic groups without alienating others. (20) Modifying and targeting signs to Black and Hispanic individuals has the potential to change the social norms and expectations for these groups. If choosing the stairs over the escalator and elevator becomes the social norm, this increase in physical activity could extend beyond the workplace and potentially lessen the health disparities for these groups.
C. The Effect of Modifying Framing and Promoting Core Values
Advertising Theory is another group level model that can be applied to public health interventions. According to the theory, effective advertising contains a primary promise and supporting facts that focus on core values. (21) A study looking at the use of signs to promote stair use for heart health found that signs promoting health were less effective than those promoting weight control (12). As described before, very few people will list health when asked to list their values and priorities (15). Therefore, it is important to design interventions that promote values other than health with a specific behavior change.
In the case of stair use, this form of physical activity has a number of health benefits. Specifically, the added exercise to an individual’s schedule can help with weight maintenance. Therefore, personalizing and catering signs that promote weight loss could identify with individuals who prioritize looking attractive. For example, one study looking at physical activity and obesity in adolescents found that most of the participants interviewed were more interested in being thin than being healthy in order to be accepted by their peers. In this case, weight loss was prioritized for social acceptance, rather than health. (22) Also, signs that indicate the lack of time wasted waiting for an elevator could target people who prioritize freedom and control. Personalizing and framing the recommendation of taking the stairs as something that will benefit each person in a way that they find important could make the “Take the Stairs” campaign more effective.
IV. Conclusion
The “Take the Stairs” campaign has the potential to be an effective way of modifying behavior and promoting a healthy lifestyle change. Studies have shown that signs posted at the point-of-decision can be effective in promoting stair use (5). However, the campaign is currently not effective enough to affect obesity on a population level (6). Also, studies have shown that the behavior change is not sustained after the signs are removed, with the number of people using the stairs reverting to baseline levels by three months (12). Therefore, the building environment and the type of signs used may need to be modified to increase use. The intervention design needs to move away from individual level behavior models and take into account the environment, spontaneity, and irrational decision making behavior. Specifically, the characteristics of context, expectations, and framing that describe irrational human behavior could be used to direct decision making and promote stair use. Taking the stairs is just one of many USDA recommendations toward a healthier lifestyle. It is important to promote this change and show the general population that this is an easy modification that could benefit their lives. With obesity and comorbid conditions on the rise in the United States, the “Take the Stairs” campaign has the potential to be very effective in changing behaviors.
REFERENCES

1. Center for Disease Control and Prevention. Overweight and Obesity. CDC Website. 2009. Available at: http://www.cdc.gov/obesity/data/trends.html#State. Accessed December 1, 2009.
2. Shephard RJ. Asolphe Abrahams memorial lecture, 1988. Exercise and lifestyle change. British Journal of Sports Medicine. 1989; 23:11-22.
3. Small Steps: Take Small Steps Today! U.S. Department of Health and Human Services. 2009. Available at: http://www.smallstep.gov/lm/take_small_steps_today.html. Accessed December 1, 2009.
4. Take the Stairs – Every Step Counts! Boston Public Health Commission. 2009. Available at: http://www.bphc.org/programs/cib/chronicdisease/heal/takethestairs/Pages/Home.aspx. Accessed December 1, 2009.
5. Russell WD, Dzewaltowski DA, Ryan GJ. The effect of a point-of-decision prompt in deterring sedentary behavior. American Journal of Health Promotion. 1999; 13:257-9.
6. Dolan MS, Weiss LA, Lewis RA, Pietrobelli A, Heo M, Faith MS. ‘Take the stairs instead of the escalator’: effect of environmental prompts on community stair use and implications for a national ‘Small Steps” campaign. Obesity Reviews. 2006; 7:25-32.
7. Siegel, M. Models of Individual Behavior Change, Part 1. Lecture Notes. September 24, 2009.
8. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 13-19.
9. Siegel, M. Alternative Models of Behavior Change – Introduction. Lecture Notes. October 8, 2009.
10. Zimring C, Joseph A, Nicoll GL, Tsepas S. Influences of Building Design and Site Design on Physical Activity. American Journal of Preventative Medicine. 2005; 25:2S2.
11. Salganik MJ, Dodds PS, Watts DJ. Experimental Study of Inequality and Unpredictability in an Artificial Cultural Market. Science. 2006; 311:854-856.
12. Anderson RE, Franckowiak SC, Snyder J, Bartlett SJ, Fontaine KR. Can Inexpensive Signs Encourage the Use of Stairs? Results from a Community Intervention. American College of Physicians-American Society of Internal Medicine. 1998; 129:363-369
13. Pasick RJ, Nurke NJ, Barker JC, Joseph G, Bird JA, Otero-Sabogal R, Tuason N, Stewart SL, Rakowski W, Clark MA, Washington PK, Guerra C. Behavioral theory in a diverse society: like a compass on Mars. Heath Education Behavior. 2009; 36:11S-35S.
14. De Martino B, Kumaran D, Seymour B, Dolan RJ. Frames, Biases, and Rational Decision-Making in the Human Brain. Science. 2006; 313:684-687
15. Siegel, M. Advertising and Marketing Theory, Part 2. Lecture Notes. October 22, 2009.
16. Raffat RM, Charter N, Frith C. Herding in Humans. Trends in Cognitive Sciences. 2009; 13:420-8.
17. Committee on Environmental Health, Tester JM. The built environment: designing communities to promote physical activity in children. Pediatrics. 2009; 123:1591-8.
18. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th Edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 218. White Plains, NY: Longman Inc., 1989.
19. McAlexander KM, Banda JA, McAlexander JW, Lee RE. Physical activity resource attributes and obesity in low-income African Americans. Journal of Urban Health. 2009; 86:696-707.
20. Anderson SE, Franckowiak SC, Zuzak KB, Cummings ES, Bartlett SJ, Crespo CJ. Effects of a culturally sensitive sign on the use of stairs in African American commuters. Soz Praventivmed. 2006; 51:373-80.
21. How to build great campaigns (Chapter 5). In: Ogilvy D. Confessions of an Advertising Man. New York; Atheneum, 1964, pp89-103.
22. Booth ML, Wilkenfeld RL, Pagnini DL, Booth SL, King LA. Perceptions of adolescents on overweight and obesity: the weight of opinion study. Journal of Pediatrics and Child Health. 2008; 44:248-52.

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

Introduction
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.

Conclusion

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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