The failure and solutions to the Food Allergen Labeling Consumer Protection Act and MA Allergen Awareness Law—Felix I. Zemel

Introduction
A recent report by the National Institute of Allergy and Infectious Diseases stated that as many as 5% of children under 5 years old and 4% of teenagers and adults currently suffer from food allergies in the United States [1]. These numbers are nearly double those that were estimated merely one decade ago [6]. Food allergies annually result in about 30,000 patient visits to hospital Emergency Departments, 2,000 hospitalizations, and 150 deaths [2,10]. 90% of these adverse health effects are caused by one of 8 “major food allergens”: peanuts, tree nuts, milk, soy, crustacean shellfish, fish, eggs, and wheat [8]. It was also determined that about half of the allergic reactions occurred as a result of prepared foods, and of those about 75% resulted from food prepared at a restaurant [28]. As a result of these startling numbers, the First Session of the 108th U.S. Congress enacted the Food Allergen Labeling Consumer Protection Act of 2004, which requires packaged food manufacturers to properly label products with the common name of any of the major food allergens that the food could potentially have had cross-contact with.
The Commonwealth of Massachusetts took allergen awareness regulation a step further when Governor Patrick signed the Act Relative to Food Allergy Awareness in Restaurants into law in January 2009. In this new amendment, the legislature required “all food establishments that cook, prepare, or serve food intended for immediate consumption either on or off the premises” to comply with multiple requirements related to posting a specific allergen notice on the establishments menu and menu board; post an allergy awareness poster in a conspicuous place for all food handlers to see; and for all certified food protection managers to view a 30-minute training video and for all other food handlers to view a 10-minute video about allergen awareness [3,11]. These regulations were to be implemented at various points in time (October 1, 2010 for the poster and signage; Feb 1, 2011 for the video).
Critique of the FALCPA and the MA Allergen Awareness Law
Both the FALCPA and the MA Allergen Awareness law have similar a similar goal: to decrease the morbidity and mortality of individuals resulting from accidental exposure (more specifically, ingestion) of food allergens to which they may be allergic. The method by which they each plan to achieve this goal is rooted deep within the Health Belief Model and the Theory of Reasoned Action.
The Health Belief Model, the basic premise of which is described by Rosenstock (1974) is that “…in order for an individual to avoid action to a disease he would need to believe (1) that he was personally susceptible to it, (2) that the occurrence of the disease would have at least a moderate severity on some component of his life, and (3) that taking a particular action would in fact be beneficial by reducing his susceptibility to the condition or, if the disease occurred, by reducing its severity, and that it would not entail overcoming important psychological barriers such as cost, convenience, pain, embarrassment” [17]. Salazar (1991) described the Theory of Reasoned Action by explaining that “behavioral change ultimately is the result of changes in beliefs, and that people will perform behavior if they think they should perform it…” [18]. Following the Health Belief Model, the logic behind the FALCPA and the MA Allergen Awareness Law was that if individual consumers was warned of the risks inherent in the consumption of particular packaged or prepared foods, that they would inherently choose not to consume those foods because their susceptibility to have an allergic reaction would be much greater and less beneficial than avoiding the food altogether. This would also follow the Theory of Reasoned Action, whereas once the belief is put in place that consumption of these particular foods is harmful, that the consumer would choose not to take the risk, and would thus forgo consuming the product.
The FALCPA has now been in effect for approximately 6 years. A variety of research studies have been performed in recent years to determine the effects (if any) that mandatory labeling of packaged foods has had on the behavior of individuals with food allergies [7,14,15,24,28]. The result of the research is startling. Researchers found that individuals with food allergies were significantly more likely to purchase a product with an allergen warning label in 2006 (after the enactment of the FALCPA) than in 2003 (prior to the enactment of the FALCPA) [7]. The research further showed that there were significant differences in the individuals’ likelihood of avoiding particular products based on the types of labeling that was placed on the packaging. Food manufacturers, especially large ones, have one big thing in common with large tobacco manufacturers: they “want to help the community”. The labeling on packaging for food originally started as a voluntary addition to food labels by manufacturers. Similar to the anti-smoking campaigns, where tobacco companies like Phillip Morris donated millions of dollars to fund inherently flawed campaigns to stop children from smoking, food manufacturers placed labels with allergen warnings ranging from “may contain…” to “may contain traces of…” to “manufactured in a facility that also uses…” to the greatest extreme of “packaged in a facility that also packages products containing…” [7]. As can be understood, the marketing specialists at large food manufacturing companies understand the basics of advertising theory and framing. Ogilvy (1964) said it well when he stated “a good advertisement is one which sells the product without drawing attention to itself. By utilizing different forms of framing, the food manufacturers were able to balance their perceived interest in preventing allergic reactions to their products while also not jeopardizing their bottom lines.
The US Food and Drug Administration (FDA), who is the enforcing authority for the FALCPA stated that “advisory labels must be truthful and not misleading” [15]. After the adoption of the FALCPA, the food manufacturers took advantage of this requirement even more. Pieretti et al (2009) found multiple violations of the FDA where manufacturers labeling packages with nonspecific verbiage, such as those described above, but then included derivatives of one of the top 8 allergens in the ingredients list. The manufacturers technically are not lying or misleading, because they are still warning the consumer of the risk of exposure to a potential allergen, but they are also downplaying the severity of the risk. When applying this to the Health Belief Model, the downplayed severity makes the individual consumer feel less susceptible to the adverse health effect and causes him/her to decide that maybe the risk is worth taking—resulting in him/her purchasing and subsequently consuming the food (following the Theory of Reasoned Action). Examples of this deceptive practice are when the ingredients list items like gelatin, but do not specify if it is pork, beef, or fish gelatin—as fish is one of the top 8 allergens. Another common practice was listing lecithin in the ingredient line, without listing its source (soy, sunflower seeds, eggs, or rice [15].
Similar to the fact that manufacturers are misleading individuals into believing that their risk of ingestion of a food that they may be allergic to is low, but they also list these items in understanding that individuals do not necessarily know all of the foods and other products that are derived from common allergens. If food manufacturers properly apply advertising and marketing theory through framing products’ perceived risk in particular settings, then they gain the trust of the individuals. A common item that the lack of labeling specific items as allergens has is that it also attempts to account for individuals not knowing if a particular ingredient is a derivative of one of the allergens that must be labeled. This is the major flaw of the MA Allergen Awareness Law. Although retail food establishments must post notice in all of their menus and on their menu boards telling the consumer “before placing your order, please inform your server if a person in your party has a food allergy” and have their staff be trained in allergen awareness, the law does not account for lack of basic knowledge on the part of both ends of the transaction. There is a common misconception that mayonnaise is a dairy product, leading many people to avoid due to milk allergy or lactose intolerance. In actuality, mayonnaise is based on eggs, which is a totally different food allergen (although 72% of individuals with an egg allergy also have a milk allergy [20]).
If neither party in the transaction knows that a particular food is a derivative of specific allergens, then the labeling requirement mandated by Massachusetts law is pointless. When applying the Health Belief Model and the Theory of Reasoned Action to a situation where neither party knows that an item like mayonnaise is derived from eggs, the following situation can be potentially fatal to the consumer: (1) the consumer notifies his/her server that (s)he is allergic to eggs, and asks the server if the tuna salad sandwich had eggs in it; (2) the server asks the cook if the tuna salad sandwich has eggs, the cook thinks that mayonnaise is dairy-based and tells the server that there were no egg ingredients in the tuna salad sandwich; (3) the server relays this message to the consumer, who subsequently purchases the tuna salad sandwich, has an anaphylactic reaction to the eggs in the mayonnaise resulting in respiratory arrest. In the preceding scenario, the consumer used the Health Belief Model to frame his risk in ingesting eggs. When he was told that there were no eggs in the tuna salad sandwich, the Theory of Reasoned Action made him decide that the potential risk of an allergic reaction was low resulting in him purchasing and consuming the tuna salad sandwich and having a severe allergic reaction to the egg that he did not know was even in the product.
These flaws are inherent in an intervention that relies so heavily on individual knowledge and understanding. It is also because of this lack of understanding of the differences and the lack of specificity in the labels that are places on packages of food that consumers are paying less and less attention to the labels. The Health Behavior Model and Theory of Reasoned Action were originally required in order to make it simpler for individuals who have particular food allergies to know which foods to avoid and which ones are safe. The fact that there is no consistency in the verbiage used on labels and that manufacturers are not listing (or framing in such a way that the individual consumer perceives a smaller risk than actually exists) decreases confidence of individuals who have food allergies, resulting in them not paying attention to the labels at much higher levels that existed prior to the enactment of the FALCPA. The lack of knowledge by food handlers makes is impossible for consumers to make a proper reasoned choice of purchasing/consuming the food item or not.
A new intervention must be developed that builds upon the existing interventions by eliminating their flaws of misleading labeling of which ingredients are actually allergens, lack of knowledge of the ingredients in particular items by consumers and/or food handlers, and the lack of consistency in the verbiage of labels on packaged foods—which allows manufacturers to frame the perception of risk to the consumer however the manufacturer wants. These practices show application of a large variety of social and behavioral theories that manufacturers utilize in order to manipulate decisions made by consumers [13]. If an intervention is successful at addressing these flaws, then its odds of effectiveness are greater.
A proposed intervention
As stated earlier, the three lethal flaws in the FACLPA and the MA Allergen Awareness Law were manufacturers’ use of misleading labeling information, a lack of knowledge by individuals and food handlers, and inconsistency in the labeling verbiage. A successful intervention can utilize the basic framework and social and behavioral theories that exist in the original flawed ones, but improve them by applying other theories and practices in order to eliminate the inherent flaws. In order for this to happen, a comprehensive view of the problem must be observed. The flaws described above were rooted in the ability of food manufacturers to utilize social and behavioral science theories in an effort to subvert the intentions of laws. These same social and behavioral science theories are used in the following intervention to subvert the subversions by food manufacturers in order to get closer, if not totally, to decrease or eliminate the number of deaths and injuries of individuals caused by accidental ingestion of food products to which they are allergic. This intervention addresses the flaws by implementing the following items: creation of a series of “symbols” indicating the allergen of concern; standardizing the verbiage permitted for use on FALCPA-mandated labels; and mandatory review of all menus (and changes thereof) by the local board of health (or other government subdivision charged with enforcement of food service codes) before the implementation of a new menu or any changes thereof. Through the addition of these interventions to the FALCPA and the MA Allergen Awareness Law, the flaws that are causing gaping holes in the effectiveness of those regulations can be resolved, resulting in a potential decrease of the incidence of morbidity and/or mortality of individuals as a result of accidental allergic reactions to food allergens.
The use of universally-accepted symbols has been successfully implemented in a variety of public health campaigns through the years. Two symbols that come to mind the quickest are the universal symbols of two hands being washed with soap and water, and the international symbol for no smoking. When people see these two symbols, they can be expected to think about the meaning of the change and then weigh their options and use reasoned action to make a final decision leading to a final action. This application of the Theories of Reasoned Action and the Health Belief Model can be directly applied to the concerns about allergen awareness. Many restaurants list items on their menus with different asterisks, stars, check-marks, or other symbols to send the reader a particular message without wasting the space for words. A common symbol used for this is the () symbol used in menus to indicate an item is heart-healthy. An easy to implement intervention is to first develop what is to become a universally accepted indicator of a particular food allergen—say an picture of an egg, soybean, fish, peanut, tree nut, or crustacean shellfish (like a lobster), a gallon of milk, or a stalk of wheat—and then mandate that restaurants and producers of packaged foods label each of their menu [or packaged] items with one or more of the symbols in order to portray which allergen a consumer is at risk of coming into contact with.
The creation of these symbols will have benefits on multiple levels. The first benefit is that it will better illuminate the potential risks if the particular food item is consumed. This can then be translated through cognitive functioning into a belief about if the person should choose to make one action or another, letting the Theory of Reasoned Action take control. Although there are many factors, such as herd behavior, that can confound the reasoning process, the basic premise of the Health Behavior Model and Theory of Reasoned Action still stand. It can be assumed that if a person is a member of a particular group that is heading to a restaurant, (s)he is more likely to take heed of a warning that is blaring on the menu next to the name of the item than of wording that tells the consumer to notify his/her server if (s)he has a food allergy or a label on a bag of chips that states “this product was packaged on a line that also packages soy products” when lecithin is listed as one of the ingredients just a couple of lines above. Herd behavior often takes control over the individual when in a group setting, invalidating many of the theories that make up individual behavior change models, but the potential of their strength is potentially significantly lessened with proper signage and forced awareness [23,25].
Another intervention that will decrease the numbers of people ignoring the allergen warning labels on food packaging is forced consistency. At the onset of the MA Allergen Awareness Law, many foodservice companies did exactly what large food manufacturers still do about labeling the allergen warnings on the packaging: they applied advertising and marketing principles in order to frame the apparent risk in a much lower light. In anticipation of this behavior occurring the MA legislature added verbiage into the actual statute that all foodservice establishments in the Commonwealth of Massachusetts must have on all of their menus in order to maintain compliance with the law. The FALCPA must be amended where the law should mandate specific verbiage for labels on packaged foods.
Framing is used to bias individuals into thinking a particular way about a particular topic [4]. Its effects can be devastating to an improperly designed or implemented public health intervention, as is seen with the FALCPA. Research shows that people had much higher rates of paying attention to labels that stated “may contain…” or “may contain traces of…” labels versus ones that had convoluted statements like “packaged in a facility that also packages products containing…” (89% and 85% in 2006 versus 59% in 2006, respectively) [7]. Based upon the startling differences in responses between the three ways of saying the same thing (with different implications), the legislature should only allow one or two versions of the allergy warning label on packaged foods.
In addition to the consistency in the verbiage, the government must give further guidance in order to avoid what can easily be construed as misleading and untruthful labeling practices by food manufacturers. Regulations must be strengthened along with the verbiage too also require that derivatives of the 8 top food allergens be placed under the same category as the main food allergen. This would be alleviated somewhat if the wording so convoluted as “packaged in a facility that also packages products containing…” would be eliminated and the standardized labeling verbiage were put into place instead.
This leads into the final prong of the new intervention: local approval of menus and menu labeling for foodservice establishments. This is both its own intervention, but it brings the previous two together as well. Currently in Massachusetts, each of the 351 cities and towns has its own board of health that has the ability to create its own regulations, as long as they do not conflict with state or federal laws or regulations by weakening them. One of the primary responsibilities of local boards of health or health departments is the licensing and subsequent inspection of all foodservice establishments within its perimeter. Among the duties included in this is plan review and annual renewal of foodservice licenses.
Menus are a vital part of the foodservice establishment’s food service and safety plans. As was stated earlier, labeling of items containing major food allergens with symbols is imperative to bringing better awareness to the risks involved in consuming a particular food item. It was shown how this labeling plays into the decision making process by an individual consumer and applied to an action through use of the Health Behavior Model and the Theory of Reasoned Action. As was described earlier, food manufacturers use either deceptive practices or just lack the knowledge to know exactly what items contain major food allergens. Because of this, the verification must be made during the preliminary steps to the establishments’ opening: during plan review.
Local boards of health and health departments must implement a regulation that all menus must be properly labeled with appropriate symbols to indicate risks of consumption, and should require that all foodservice establishments provide the board of health or health department with a list of all of the ingredients in each particular item on the menu in order for the person reading the plans to verify that the warning symbols are correct. Foodservice establishments should not be permitted to change items on their menu without the prior approval from the local board of health of the particular food items. This would not preclude establishments from having rotating specials or other food items, if the list of ingredients for each of the rotating items was submitted and approved during the plan review.
The mandatory approval from the local board of health or health department will also eliminate any bias resulting from framing or other advertising methods utilized by businesses to subvert the attempts at improving the public’s health. Maintaining and improving the public’s health should be a priority of not just the policymakers or individual activists, but also of those who are interfacing with the public. Businesses have shown that they favor market forces much more than the potential for improving health. Marketing campaigns by businesses frame items in such a way that not only do they subvert the law, but they also place susceptible members of the public at risk of serious adverse health effects or death due to their negligence and greed. A public health intervention that counteracts the marketing and framing techniques utilized by businesses benefits the public’s health dramatically.
References
(1) Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010 December;126(6, Supplement 1):S1-S58.
(2) Buchanan R, Dennis S, Acheson D, Assimon SA, Beru N, Bolger P, et al. Approaches to establishment thresholds for major food allergens and for gluten in food: A report by the Threshold Working Group. The Center for Food Safety and Applied Nutrition, Food and Drug Administration 2006 March.
(3) Bureau of Environmental Health/Food Protection Program, Massachusetts Department of Public Health. Q&As for MDPH Allergen Awareness Regulation. 2010 19 August.
(4) De Martino B, Kumaran D, Seymour B, Dolan RJ. Frames, biases, and rational decision-making in the human brain. Science 2006 4 August; 313:684-687.
(5) Fleischer DM, Conover-Walker MK, Matsui EC, Wood RA. The natural history of tree nut allergy. J Allergy Clin Immunol 2005 November; 116(5):1087-1093.
(6) Green TD, LaBelle VS, Steele PH, Kim EH, Lee LA, Mankad VS, et al. Clinical characteristics of peanut-allergic children: Recent changes. Pediatrics 2007 December;120(6):1304-1310.
(7) Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007 July; 120(1):171-176.
(8) Hefle SL, Taylor SL. Food allergy and the food industry. Curr Allergy Asthm R 2004 January; 4(1):55-59.
(9) Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995; Extra Issue:80-94.
(10) Lowey N. Public Law 108-282: Food Allergen Labeling and Consumer Protection Act of 2004. 2004 2 August; H.R. 3684(108th Congress, First Session).
(11) MA Department of Public Health. 105 CMR 410.500: State Sanitary Code, Chapter X--Minimum sanitation standards for food establishments. 2010 9 June.
(12) McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993 10 November; 270(18):2207-2212.
(13) Ogilvy D. How to build great campaigns. In: Ogilvy D, editor. Confessions of an advertising man New York: Atheneum; 1964. p. 89-103.
(14) Ong PY. Are allergy advisory statements helpful to patients with food allergy? J Allergy Clin Immunol 2008 3 January; 121(2):536-537.
(15) Pieretti MM, Chung D, Pacenza R, Slotkin T, Sicherer SH. Audit of manufactured products: Use of allergen advisory labels and identification of labeling ambiguities. J Allergy Clin Immunol 2009 August;124(2):337-341.
(16) Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, et al. The prevalence of food allergy: A meta-analysis. J Allergy Clin Immunol 2007 July 12, 2007;126(3):638-646.
(17) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974;2(4):328-335.
(18) Salazar MK. Comparison of four behavioral theories: A literature review. AAOHN Journal 1991 March;39(3):128-135.
(19) Savage JH, Kaeding AJ, Matsui EC, Wood RA. The natural history of soy allergy. J Allergy Clin Immunol 2010 March;125(3):683-686.
(20) Savage JH, Matsui EC, Skripak JM, Wood RA. The natural history of egg allergy. J Allergy Clin Immunol 2007 December;120(6):1413-1417.
(21) Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: A 5-year follow-up study. J Allergy Clin Immunol 2003 December;112(6):12-3-12-7.
(22) Skolnick HS, Conover-Walker MK, Koerner CB, Sampson HA, Burks W, Wood RA. The natural history of peanut allergy. J Allergy Clin Immunol 2001 February;107(2):367-374.
(23) Sornette D. "Herd" behavior and "crowd" effect. In: Sornette D, editor. Why stock markets crash: critical events in complex financial systems Princeton: Princeton University Press; 2003. p. 91-114.
(24) Taylor SL. Reply: Are allergy advisory statements helpful to patients with food allergy? J Allergy Clin Immunol 2008 21 January; 121(2):537.
(25) Thaler RH, Sunstein CR. Chapter 3: following the herd. In: Thaler RH, Sunstein CR, editors. Nudge: improving decisions about health, wealth, and happiness New Haven: Yale University Press; 2008. p. 53-71.
(26) U.S. Food and Drug Administration. Food allergen labeling and Consumer Protection Acto of 2005 questions and answers. 2009; Available at: http://www.fda.gov/Food/LabelingNutrition/FoodAllergensLabeling/GuidanceComplianceRegulatoryInformation/ucm106890.htm. Accessed December 5, 2010.
(27) Vadas P, Wai Y, Burks W, Perelman B. Detection of peanut allergens in breast milk of lactating women. JAMA 2001 4 April; 285(13):1746-1748.
(28) Vierk KA, Koehler KM, Fein SB, Streeet DA. Prevalence of self-reported food allergy in American adults and use of food labels. J Allergy Clin Immunol 2007 25 April;119(6):1504-1510.

Analysis of Click It or Ticket and The Comprehensive Approach to A New, More Effective Campaign- Heather Valerio

Every hospital in every city in the United States has seen the effects of neglecting to use an automobile’s built in safety belts. Safety belt use is and has been an issue in the United States for quite some time. The use of safety belts significantly reduces the chance of serious injury or death when in an accident, yet some people continue to disregard them and not utilize them when driving or riding in a car. According to the National Institute for Highway Safety Research and Communications, roughly forty thousand people died from car accidents each year in 2009 (13). Their data states that this is the number one cause of death for individuals under the age of 35 and accounts for a disproportionately high number of deaths in the 16-19 year old age group. The NIHSRC goes on to report that the use of safety belts in this age group is only around 41% in drivers of all reported accidents and only 29% of passengers. Passengers are more likely than drivers to refrain from using safety belts, and the highest percentage of those who choose to refrain are 14-20 years old in both passengers and drivers. This data is striking, and indicates a need for intervention.
In the 1980s American health officials noticed the need for intervention and developed the “Click It or Ticket” campaign (13). Although public officials see the success in this program, when it is closely looked at and critiqued, the flaws become quite evident. Because of its flaws, Click It or Ticket does not reach an optimal number of people and therefore does not achieve its full potential as a public health campaign. The Click It or Ticket campaign has seen success in only those who respond to threats from law enforcement and those who care about their current health outcomes. This indicates a strong need for a campaign that focuses on teenagers, as motor vehicle accidents are the number one cause of death for this age group, and are more prone to psychological reactance (4). The Click It or Ticket campaign is focused on the legality of wearing a safety belt, when in reality it should be framed as a public health issue (13). This campaign also focuses only on safety belts, when there are a lot of other contributing factors to motor vehicle injuries and deaths. The need for a comprehensive, group prevention program that takes psychological and social theories into account is evident and should be made a state and nationwide priority.
Most Click It or Ticket commercials are mainly focused on the law enforcement consequences of refraining to wear a seatbelt (13). These television announcements show images of police pulling over and ticketing those who are not wearing a seatbelt. The announcements state that there is no way to avoid a ticket, and that if a person is not wearing a seatbelt, they will most definitely be caught (13). The remaining small minority of commercials focus on the health benefits of wearing a seatbelt stating that if you are not wearing a safety belt and get into an accident, you will most definitely die, and on the other hand if you are wearing a safety belt and get into an accident you will most certainly live (13). Everyone knows that this is not the case. These television commercials rely on scare tactics, whether it be from law enforcement or death (13). This flawed campaign strategy does reach a small amount of people, but fails to reach the population that needs an intervention most: teenagers (13).
Failure to adapt to age group that is most prone to neglect safety belts
Teenagers, more than any other age group, are more likely to disregard the Click It or Ticket campaign. This is due to the fact that this campaign relies heavily on the effects of law enforcement and makes it seem like the police are taking away freedom when making it necessary to wear a safety belt when riding in cars. Reactance theory states that when one perceives their freedom to be in danger, he or she will act out in the opposite way, in order to preserve their liberty (2). Teenagers are prone to reactance theory, other wise known as psychological reactance (4). This is important to consider because it has been found that an increase in psychological reactance increases one’s risky decision making, especially in adolescence (7). This means that teenagers or adolescents will do whatever they can in order to maintain their freedom and that this threat to freedom will cause these adolescents to act out in a risky behavior. If someone of authority tells adolescents to do something, they are most likely going to do the exact opposite in order to take a stand for their freedom (7). It is of vital importance to take into account when building a public health campaign. One should not build a campaign meant to target an entire population that uses a do this or else strategy (6).
Neglect to take other aspects of dangerous driving into account, in order to prevent automobile crashes.
Drivers in the sixteen to nineteen year old age group are more likely to be “distracted drivers,” (10). Distracted drivers are those who engage in other activities along with driving such as talking on a cell phone, texting, or letting car conversation effect your focus on the road (10). This data indicates that this group, more than ever, needs an intervention that successfully tackles safe driving and usage of seatbelts. The Click It or Ticket campaign focuses only on seatbelt use and not on preventing those things that cause accidents in the first place (13). This campaign should be broadened in order to incorporate a prevention plan for distracted driving. Data has shown that, distracted driving is the number one cause of fatal or injury causing motor vehicle accidents (10). More and more state officials are hoping to cut down on the amount of distracted drivers by passing laws that ban talking on a cell phones and texting while driving . According to the Governor’s Highway Safety Association (GHSA), talking on a hand held cell phone use is banned in eight states (California, Connecticut, Delaware, New Jersey, New York, Oregon, and Washington), (11). This means that citizens in these states cannot hold a phone up to their face and drive, but use of a bluetooth device is acceptable, though these too are arguably distracting. In addition to talking, The GHSA reports that thirty states ban text messaging and driving (11). Some states enforce this law to all ages and others just target teenagers (11). While these laws have the good intention of reducing distracted driving, they still create a psychological reactance type of response. Those laws that target teenagers only seem unfair to them, and they will be more prone to act out, and therefore to text, talk, and not wear a safety belt.
Failure of the Health Belief Model
The Click It or Ticket safety belt campaign is built and based on the health belief model. The health belief model is a balancing act between the perceived benefits and the perceived severity of a certain behavior (9). According to this model, whatever side has more weight reigns supreme and the actions that follow that side will be taken (9). This is an individually based model that assumes that people act rationally and always take both views into account when making a health decision (9). This model has some positive attributes, as it calls to attention the need for education and prevention before a positive health behavior can be initiated. The health belief model is also good for predicting one time decisions such as whether or not to get immunized. The health belief model, however, is not a good predictor of habitual behaviors such as putting on a safety harness upon entering an automobile. Because safety belt use is a habitual behavior, an intervention or public health campaign that targets this topic should not be based around the health belief model.
Because the health belief model is individually based it should not be used with the intention of changing behaviors of a population. This is a major mistake in the Click It or Ticket campaign. The makers of this campaign believe that people will change their behavior based on solely facts (13). They believe that after seeing their ads, viewers will weigh the costs (death or monetary loss) and benefits (life), and that all viewers will see the overwhelming benefit in life and choose to wear their seatbelt (13). In this model, the person must take into account his or her perceived susceptibility, perceived severity, perceived barriers, and perceived benefits in order to make a health changing decision. Teenagers are not likely to sit down and weigh out options of susceptibility, severity, barriers, and benefits (9). Teenagers are also not likely to be motivated by health outcomes, as they are prone to a false perception of invincibility (3). Adolescent males are notoriously egocentric and have a false perception of invincibility (5). This fact contributes to both lack of following guidelines for safe driving and failure to wear a safety belt. These particular teens believe that they will not fall victim to a crash—so why bother looking uncool in a seatbelt, or following traffic laws (5). The makers of this campaign believe that the legality of “buckling up,” through phrases such as “the cops are cracking down,” is enough to persuade anyone to wear use a safety harness (13). Along with health outcomes, legal issues are non-motivators to many adolescents (3). Adolescent’s false perception of invincibility translates to legality; they believe that if they break the law, they have a lesser chance of being caught than someone else (3).
The Click It or Ticket campaign utilizes both mass media and highway signs to get their message to the masses (13). The flaw in this, however, is that the programming they choose to show their commercials in programs that are not watched by any target population. Unless shown during a major sporting event, their advertisements are sporadically placed in adult programming, making them nearly unseen by adolescents. The Click It or Ticket highway signs are small and go relatively unnoticed by passers by (13). When looked at the signs only read “Click It or Ticket,” and are accompanied with a picture of a stick figure or the representing state with their respective dollar fines (13). Few people can identify with a stick figure, and most wish not to be reminded of potential fines they can incur on the road. These bland signs and random commercials do not create a sense of familiarity and instead they get overlooked or disregarded. This campaign fails to recognize the need for different media outputs for different age groups and target audiences.
The Click It or Ticket campaign does not take adolescent’s psychological factors or reactions, such as perceived threat to freedom or flawed sense of invincibility, into account (13). This neglects to reach the demographic that needs an intervention most (13). The campaign’s sole use of the health belief model makes it look like an outdated program with an intense need for rethinking their approach. While the Click It or Ticket campaign has good intentions, it is not utilizing the right behavior change theories or techniques to promote the safest driving possible. As shown, the campaign only focuses on one aspect of safe driving instead of encompassing everything that goes into the responsibility of operating a motor vehicle (13). The campaign also has a series of flaws that surface when considering it was designed in order to change the behavior and effect the overall morbidity and mortality rates of the general population. As indicated, the campaign also fails to account for the many age groups of driving. Many changes must be implemented to this campaign in order for it to be most effective.
Proposal of New Campaign Plan
As seen, there is a great need for a new way to address both safe driving and safety belt use. The following proposed program is fictional, but provides a more concise and new approach to this issue. This program will include all aspects of safe driving: safety belt use, cell phone use, and everything that goes along with distracted driving. The new campaign will use group based intervention models, as it is trying to change the behavior of a population (1, 8). Because there really is no clear cut campaign for teens to utilize safety belts, this proposed campaign will focus mainly on the adolescent age group. This safe driving and safety belt promotional campaign will be called “Let’s Get It On”. This campaign will utilize a few psychological strategies of health behavior change, instead of focusing on just one like Click It or Ticket.
Utilization of Alternative, Group-Based Behavior Change Models: Advertising Theory and Marketing Theory
Campaigns such as Click It or Ticket should be broadened from the individually based health belief model to a group-based model. The Let’s Get It On safety belt campaign aimed at teens will use advertising theory to adequately deliver its message of safety belt use. Campaigns that utilize advertising theory should adopt the techniques of advertisement executives when creating their commercial (15). Television advertisements for the Let’s Get It On campaign will deliver a promise and back it up with images (15). Let’s Get It On will deliver the promise that being safe can be part of the fun. The campaign will back up this message with laughing teens getting into an automobile and buckling their seatbelts in a rhythmic fashion. The commercial will go on for thirty seconds showing different teens getting into cars and bucking their seatbelts in this same rhythm, signifying that they are part of this “rhythm of life.” The commercial will then end with the key phrase of the campaign, “Let’s Get It On.” Some of these commercials will include images of teens turning off, closing their cell phones, or handing them to passengers, thereby adding to this rhythm. This advertisement is predicted to be better received than the traditional Click It or Ticket campaign because it does not establish a sense of psychological reactance in the viewer. The phrase “Let’s Get It On” will be well received in the adolescent community because it is nonthreatening and fun.
Throwing health statistics or legal fines at viewers is unnecessary, as this campaign takes psychological reactance into account. These advertisements will also be loosely based around marketing theory (14). Campaign directors will first identify what our target audience, adolescents, identifies as core values (14). Upon research, campaigners should utilize the values of friends, fun, feeling as part of the group, freedom, and humor. Friends are an important element in the adolescent world, therefore the advertisements will show teenagers getting into the car with other teenagers, not authorities figures. This will work to reduce the amount of psychological reactance felt by the target audience, as no one in these advertisements is blatantly telling them what to do. Most adolescents would much rather be having fun or going out than going to school, therefore these commercials will show teenagers getting together to head somewhere social—the mall, a football game, or someone else’s house. The advertisements will utilize the core value of acceptance and feeling as part of the group through the creation of a rhythmic flow throughout the commercial. This shows that the teens are a part of something bigger than just buckling up every time they get into a car; as indicated, it shows them that they are part of this rhythm of life. As explained through the theory of psychological reactance, adolescents feel the need to express their freedom in any way possible. This core value of freedom will be respected in this campaign. As stated, advertisements will only show teenagers getting into the car with people they wish to be with, and going somewhere they wish to go. The last core value this campaign will use, humor, will be in the campaign name itself: “Let’s Get It On.”
Utilization of Modeling
This campaign will work with the idea of modeling, and getting people to emulate what they see. When adolescents see people they look up to doing something, they are more likely to do it (8). In order to effectively use modeling, the campaign will first contact the major television networks and ask them to feature more safe driving snippets in shows. Ideal shows would be ones that teenagers watch such as Glee or How I Met Your Mother. Writers of these shows can subtly include scenes where a character gets in a car, puts on a safety belt, and refrains from cell phone use. Teen Mom, a show on MTV, should also receive this message as they are constantly showing these teenage mothers driving their children around and talking on cell phones, and sometimes neglecting to use safety belts on themselves. Implementing this strategy will instill a modeling effect in watchers and they will therefore be more likely to use more precautionary measures when behind the wheel. This tactic can even start in shows that preteens and children watch. This will create a habitual effect so that when these children are old enough to drive, they know they have to do so safely.
Liking, Familiarity, Social Learning Theory and Celebrity endorsements
Modeling can also come in another form: celebrity endorsements. While taking the easy road out and using a celebrity endorsement is seen as cheesy or like a reach, they will be effective in this instance (8). It has been shown that celebrity endorsements have the ability to sway young people’s behavior in whatever way people want them to act (1). In the Let’s Get It On campaign, some advertisements will use celebrities to get their message across. Ideally, this will cover the majority of the print messages. Attractive celebrities will be pictured with just the line “Let’s Get It On” under them, and with a message in smaller print that reads “[name of the celebrity] gets it on every time he/she is in a car.” These celebrity endorsements can be broadened to fit the visual campaigns. Famous musicians that are popular in the adolescent community will be asked for permission of their songs and possibly their time to use in the television advertisements. Ideally, these popular songs will be used in the commercial and the buckling of the safety belts will follow the beats of these famous songs and the artist will make a cameo appearance. If a commercial were to go on the air today, makers of the Let’s Get It On campaign would find it in their best interest to sign today’s popular artists such as Cee Lo Green and use his song “Forget You.” This will instill a liking and familiarity effect in the target audience and they will be more likely to respond positively to the messages that are being presented.
Conclusion
The Click It or Ticket campaign needs a major facelift if they want to effectively reach all age groups of drivers and change their behavior. The campaign also neglects to take into account the need to stop behavior that gets drivers into accidents in the first place. There is an obvious need for a more comprehensive plan that takes all areas of safe driving into account, that targets the population that needs it most, and that does not use scare tactics to get them across. The Let’s Get It On campaign does all that. This campaign makes it look like when you are wearing a safety belt, you are part of the crowd. This campaign also takes into account the core values of its target population and effectively delivers its message. Let’s Get It On subtly hints at putting away your cell phones or giving them to your passengers to man for the ride. This campaign is well thought out and if instated, will be received positively. So next time you get in a car, disregard threats from the National Highway Traffic Safety Administration and think like Marvin Gaye… get it on.

 
References
Journal Articles:
1. Austin, E. W., Pinkleton, B. E., Van de Vord, R., & Epstein, E. (2008). Celebrity endorsements and their potential to motivate young viewers Mass Communication and Society
2. Brehm, S. S., & Weinraub, M. (1977). Physical barriers and psychological reactance: 2-yr-olds' responses to threats to freedom. Journal of Personality and Social Psychology, 35(11), 830-836. doi:10.1037/0022-3514.35.11.830
3. Crook, M. W. (2005). Tool development to measure the adolescent perception of invincibilityProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 65(9-) Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=psyh&AN=2005-99006-187&site=ehost-live&scope=site. (2005-99006-187)
4. Drivers aged 16 or 17 years involved in fatal crashes -- united states, 2004-2008. (2010). MMWR: Morbidity & Mortality Weekly Report, 59(41), 1329-1334. Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=cin20&AN=2010836898&site=ehost-live&scope=site
5. Drucker, A. D. (2000). Egocentrism and invincibility in adolescent male automobile drivers: An applied perspectiveProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 61(1-) Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=psyh&AN=2000-95014-017&site=ehost-live&scope=site. (2000-95014-017)
6. Frank, S. J., Jackson-Walker, S., Marks, M., Van Egeren, L. A., Loop, K., & Olson, K. (1998). From the laboratory to the hospital, adults to adolescents, and disorders to personality: The case of psychological reactance. Journal of Clinical Psychology, 54(3), 361-381. doi:10.1002/(SICI)1097-4679(199804)54:3<361::AID-JCLP6>3.0.CO;2-S
7. Miller, C. H., & Quick, B. L. (2010). Sensation seeking and psychological reactance as health risk predictors for an emerging adult population. Health Communication, 25(3), 266-275. doi:10.1080/10410231003698945
8. Nangle, D. W., Erdley, C. A., Adrian, M., & Fales, J. (2010). A conceptual basis in social learning theory. In P. J. Norton (Ed.), Practitioner's guide to empirically based measures of social skills. (pp. 37-48). New York, NY US: Springer Publishing Co. doi:10.1007/978-1-4419-0609-0_3
9. Rosenstock, Irwin M, Hochbaum, Godfrey M. (1961). Some principles of research design in public health American Journal of Public Health Nation's Health, 51(2), 266-277.
10. Wilson, F. A., & Stimpson, J. P. (2010). Trends in fatalities from distracted driving in the united states, 1999 to 2008. American Journal of Public Health, 100(11), 2213-2219. Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=cin20&AN=2010833940&site=ehost-live&scope=site

Websites:
11. Governors highway safety association: State laws and funding. (2010). Retrieved 12/5, 2010, from http://www.ghsa.org/html/stateinfo/laws/index.html
12. National highway traffic safety administration: Click it or ticket. (2010). Retrieved 12/5, 2010, from http://www.nhtsa.gov/CIOT
13. National institute for highway safety research and communications. (2009). Retrieved 12/5, 2010, from http://www.iihs.org/research/fatality_facts_2009/default.html
Books:
14. Lovelock, Christopher & Wirtz, Jochen. (2004). Services Marketing: People, Technology, Strategy. Upper Saddle River, NJ. (8)
15. Percy, L. (1980). In Percy L., Rossiter J. R. (Eds.), Advertising strategy: A communication theory approach (1st ed.). New York: Praeger Publishers.

Graphic Warning Labels For Cigarette Packs Using The Health Belief Model- Chris Sardon

Introduction
Smoking has become one of the biggest health issues affecting the United States of America. Its devastation not only affects those who smoke, but also the people around smokers. According to the Centers for Disease Control and Prevention (CDC), tobacco use is responsible for 1 in 5 deaths with about 443,000 deaths due directly to tobacco use and 49,000 deaths due to second hand smoke (5). Smoking causes cancer, lung diseases, heart disease, and stroke and for every person who dies from a smoking related disease, twenty people suffer from a serious illness due to smoking (5). Clearly, cigarettes have catastrophic consequences thus making smoking a prime target for public health interventions.
Recently, a law was passed that gave the Food and Drug Administration (FDA) the power to regulate tobacco products through warning labels. Nine graphic warning labels will be chosen and they will take up half of the surface area of a carton or pack of cigarettes and a fifth of any advertisements. The graphic labels aim to get smokers to quit by vividly demonstrating the dangers of tobacco use. Amongst the potential labels are: a man blowing smoke through a hole in his neck, women blowing smoke into their baby’s faces, and people in coffins.

This public health intervention to combat smoking is based on the health belief model. The intervention assumes that people are weighing the perceived benefits with the perceived barriers to quitting smoking and making rational decisions based on that balance. It assumes that people plan their behavior and it aims at helping the individual, not a group of people. This model for a public health intervention is significantly flawed and will most likely fail to reach its intended purpose.
Critique Argument 1: Assumes Behavior is Rational
The main flaw of this intervention is that it assumes behavior is rational. The interventionists expect smokers to see these labels and weigh the perceived benefits and barriers of behavior change. After this balancing act, it assumes that the balance will shift to smokers intending to quit and eventually changing their behavior towards quitting smoking. But the intervention does not factor in that intention to do a behavior doesn’t always lead to the behavior. The health belief model relies on the individual taking in information and making an educated decision. This is not effective because it does not take into account the social factors that people encounter. This intervention, and the health belief model in general, does not answer the question: why do people smoke? Any intervention that does not factor in this essential question will not be successful.
Individual behavior is not rational because often times people follow a crowd. This is called the herd mentality. One person might be smart, but a group of people can be stupid. When individuals frame their behavior based on what a group of people are doing, it can often lead to irrational behavior. In this case, people see a group of others smoking and follow suit. The social network theory (6,7) demonstrates that the people they are connected to affect peoples’ behavior. In this theory, people won’t just quit smoking by seeing these labels; rather they will quit smoking if others are also doing it. They will quit in clusters instead of as individuals. Because the warning label intervention is based on the health belief model, it is aimed at affecting the individual and not a group, thus rendering the intervention likely to fail.
The health belief model is incapable of affecting the barriers to behavior change. Thus, this intervention does not make it easier for smokers to overcome the obstacles stopping them from quitting smoking. The model and intervention can only affect the perceived severity and susceptibility of the diseases caused by smoking. The label intervention aims to make smokers perceive that they are more susceptible to the diseases associated with smoking but this is a flawed assumption because the human perception of perceived risk is irrational. The optimistic bias theory states that people may have an accurate impression of getting an adverse health problem, but they believe that their personal risk is less (1,12). Therefore, smokers will underestimate their risk of developing lung cancers, heart disease, and strokes (1,10,11). The illusion of control theory also adds to this idea. It states that people tend to overestimate the degree to which they have control over events, which leads to an inaccurate perception of risk (9). Both of these theories lead to a lessened perceived susceptibility and severity of disease associated with smoking, consequently not shifting the balance between perceived benefits and barriers enough to theoretically alter behavior.
Critique Argument 2: Doesn’t Relate to Youths
Another major flaw of the label intervention is that it does not relate to youths. The intervention assumes that youths will be more affected by pictures than written warning labels and, as a result, be more likely to weigh the benefits and barriers to quitting smoking. This is an ignorant assumption. Any parent can tell you that their children’s’ behavior is often driven by rebellion. Rebellion is based on the theory of psychological reactants. The theory of psychological reactants makes the claim that people will rebel when they lose control or freedom (3). These labels are telling youths not to smoke. Youths will perceive being told not to smoke as a threat to their freedom to choose to smoke. These labels will not stop youths from smoking; they will rather increase the amount of smoking in youths because the youths will be trying to restore their control.
Once again, this intervention concentrates on the individual making an educated decision about behavior change. It does not take into account any social factors. Social factors are a big determinant driving the behavior of youths. The theory of social proof backs this assertion. It states that people will do an action if they see other people doing it. People will model their behavior after the norms of those around them. A terrific example of this is the “Bystander Effect.” The “Bystander Effect” is the phenomenon that people will not help a person in need because they see that other people aren’t doing it (2). They know that a person needs help but do not give it to them because it is against the norm of the people around them. This comes into play for teenagers. If they see their peers smoking, they are going to model their behavior after their peers in order to stay with the social norms around them.
The label intervention also does not approach the reason why youths smoke. Often, a person’s behavior will be attributed to their attributes and character. The fundamental attribution error theory shows that this is a poor way to approach this issue. The fundamental attribution error states that behavior is significantly affected by the context of the situation (8). Youths do not smoke because they have character flaws. They smoke because the environment they are in makes it “cool” to smoke. As demonstrated earlier, the context that contributes to a youth’s behavior is based on the social structure surrounding them.
Youths will also do dangerous behaviors even when they know the risks. They do this because they feel that they are invincible. This thought process is based on the theory of optimistic bias and the theory of illusion of control. As stated previously, the optimistic bias leads to people believing that they are at less risk than others. This is evident in the behavior of youths, as they believe their dangerous actions will not affect them. Youths also believe that they have complete control over their lives. This is consistent with the theory of illusion of control. Youths believe that they have more control over their events and accordingly perceive that they are at a smaller risk. Both of these theories demonstrate why youths believe that they are at a lower risk than others when it comes to the effects of smoking. Thus, this intervention is not going to work on youths because their perceived risk due to smoking is quite low. They know the consequences that come with smoking, but they believe that is for everyone else in the world but them. This is why this intervention is going to be useless on the youth of America.
Critique Argument 3: Does Not Deal With Addiction
A major limitation of the health belief model is that it does not deal with addiction. People who are addicted to smoking are affected by the stereotype or label they are given which leads to irrational behavior. This is based on labeling theory. People take on the characteristics of the label they are given (4). Smokers know what the risks of smoking are but choose to do actions based on the expectations of their label. People addicted to smoking are expected to smoke. Because they are expected to smoke they choose to behave in a way that meets these expectations. By knowing the consequences of smoking but choosing to meet the expectations placed on them, smokers are making the irrational decision to continue their unhealthy habit.
People also have the fundamental inability to control their actions. This lack of self-control leads to irrational behavior. Many smoking addicts have tried multiple times to quit but do not have the self-control to succeed. By seeing labels like these, it makes them feel defeated. This feeling decreases their self-efficacy to quit. It lessens their belief that they can quit their addiction. This is a fundamental problem to this intervention. People NEED to believe they can quit. Without that confidence, changing ones behavior is nearly an impossible task to accomplish. The other problem with this intervention pertaining to addicts is that it gets to them too late. These labels are hardly seen until someone is actually in the process of buying the cigarettes. People have already made the decision to smoke and at the point when they buy the cigarettes, it will be too late to change their behavior.
The theory of optimistic bias again factors in with addicts. These people have been smoking for a long time and have not seen the effects that the statistics claims are happening. If it has not happened to them over the years, they feel as if they are at a decreased risk. They do have an accurate perception of what could happen, but they believe that it won’t happen to them. They now perceive a much lower risk of illness due to smoking based on their own personal experience. The theory of illusion of control also factors in here. Many addicts believe that they have the control to stop whenever they want. Sadly this is not true. They have the belief that they can in fact control their actions, therefore leading to an inaccurate perception of risk. These two theories again demonstrate that smokers will believe that the risk to them is significantly less than the statistics show.
Conclusion
This smoking label intervention is simply not going to work. People who smoke already know what the risks associated with their actions are. This approach is too simplistic. It assumes that people are rational beings and are not affected by the people around them. This is a naïve belief. Initially, there is going to be a big shock to the public once the intervention is implemented. This will last a limited time, as people will become used to the new packaging. The same thing happened when the written labels were first placed on cigarette packs. People noticed them at first, but now people don’t even recognize they are there. I also believe that people will develop ways to block out these images. People use koozees on beer cans. Who is to say that the tobacco companies aren’t going to make a similar product for cigarette packs? As people naturally adapt to their environments, people will adapt to these new packages rendering the intervention useless. This intervention fails to acknowledge why people smoke. Without taking on that question, any intervention to get people to quit smoking will likely not succeed.












Proposed Intervention
As we observe society, we can conclude that people are not rational. A person can be given all of the statistics and data in world about smoking, but will still probably behave in an irrational manner. Previous interventions have relied on people’s reasoning skills and have proven to be unsuccessful. The optimal way to change a person’s behavior when it comes to smoking is to make it personal. If you can hit a person in the heart, they will be more likely to make behavior changes towards a healthier life.
I believe an effective intervention to get smokers to quit and to stop people from starting to smoke would be through a personalized commercial. In each region of the country, I would air a commercial starring a well-respected celebrity from that area with a personal story about how smoking has affected his or her own life. This approach is based on the law of small numbers. This law says that the perception of risk for people is related to the people they see around them or the stories that they hear, not through statistics. In this commercial, I would try to use a celebrity that can relate to young and old people. They will discuss how smoking personally affected their life and say that the tobacco companies have control over you when you smoke. This will hit people in the hearts as they can relate to this person as well as trigger the viewers desire to regain their freedom and control. At the end of the commercial, the celebrity would encourage people to talk about why they smoke and how they can quit with their family and friends while also providing the phone number and website for a smoking hotline. The closing of the commercial will be the celebrity making a promise to the viewer that cutting smoking out of your life will make you a happier person.
This approach is based on advertising theory, the health belief model, and the social network model. These different models and psychological theories allow the commercial intervention to influence a broad range of people. It will affect the common irrational person, youths, and smoking addicts. By taking into account multiple social psychology approaches, this intervention will be more successful than the current package labeling intervention. This approach factors in social aspects, personal stories, and the desire for control in order to appeal to a large audience.
Defense of Intervention: Plays to Predictably Irrational Behavior
This intervention does factor in that people do not make rational decisions. The health belief model portion of this intervention aims at the balance between perceived benefits and barriers. Normally smokers don’t believe that they are at much of a risk because they have a skewed perception about the risk they are at. They see the statistics of illnesses associated with smoking, but do not have personal affiliations with these diseases. This commercial will get the smokers and potential smokers to see a personal story, thus making the risks of smoking more close to “home.” This will make the perceived benefits of quitting seem larger, therefore shifting the balance towards healthier behavior. These personal stories will reduce the optimistic bias that a person feels. People will now have a more accurate perception of what their own personal risk is. This will also decrease the illusion of control. Viewers might see a former professional athlete who is suffering from smoking related illnesses. If a phenomenal athlete like that can’t have control of their own body, than how can a normal person have control. This will get the viewer to realize that they have less control over events than they previously thought. This commercial is taking advantage of this by selling control, not health.
This intervention also factors in that people are affected by society around them. People tend to follow groups and want to fit in with the crowd as stated by the social network theory. By getting smokers to talk to friends and family about why they smoke, they could potentially find support in others who don’t smoke and want to follow their lead. Also getting a smoker to come to the realization as to why they smoke is key to behavior change. If a person doesn’t understand their own reasoning for a behavior, it will be harder for them to change that behavior. The first step to changing the behavior of smoking is to identify the reason for smoking. Once the reasoning has been pinpointed, the smoker can concentrate on that point and try and correct it with the support of their family and friends.
Defense of Intervention Section 2: Relates to Youths
A strong point of this intervention is that it plays to youths. First off, by using a prominent celebrity from the local region, the youths will have a better time relating to that person. This is based on the principle of liking. If a youth likes or relates to a person giving a message, he or she is more likely to follow that message. Basically, the more similar a person is, the more likely they are to respond to the message.
As stated earlier, teenagers thrive on rebellion. This intervention, with its advertising theory basis, plays to this phenomenon. The key here is to convince kids not to trust the tobacco industry. When the celebrity that they are familiar with talks about how the tobacco industry controls you when you smoke, the youths will want to rebel to restore their control and freedom. Advertising theory has a foundation in promises and support. By promising the viewer that he or she will live a happier life without smoking, they are appealing to the core value of happiness. This will motivate people to think about changing their behavior regardless of if the promise is true. The way this works is by supporting it with a story, which the commercial does. The promise of the core value of happiness and control is the key to stopping and preventing children and teenagers from smoking.
As previously stated, this intervention factors in the societal environment that the people are in and the newly acquired perception of personal risk due to minimization of optimistic bias and the illusion of control.
Defense of Intervention Section 3: Approaches Addiction
Addiction to smoking is a tough dilemma to approach. Many people are set in their ways and are in denial of their addiction. The commercial intervention relies somewhat on the social network theory. It assumes that the people they are connected to influence people’s behavior. If the commercial does its job, it will convince smokers to talk to the people around them. This can help them realize that they have an addiction and come to a conclusion as to why they smoke. This is a big step for addicts because it gets them to admit that they have a problem. By hearing a celebrity’s story and talking amongst friends, an addict will see the support that he or she has. This realization of support, along with the minimization of optimistic bias and the illusion of control, will increase the addicts’ self-efficacy to quit smoking. This is a huge step for any addict. They need to believe that they have the power to quit. This newly found self- belief combined with a support system would help the addict change their behavior. Addicts are the toughest group to appeal to and I believe this intervention could help their progression to a healthier life.
Conclusion
There is not a single social psychological theory that can solve the smoking epidemic on its own. Every theory has its benefits and flaws. The commercial intervention attempts to take multiple theories and combine them in order to affect the most people possible. It acknowledges peoples’ predictably irrational behavior, youths desire to rebel, and addicts’ inability to recognize their problem. If implemented correctly, this intervention could have a dramatic effect on smoking simply because it confronts the reasons as to why people smoke. Finding the reason is the key to an interventions’ success and I firmly believe that this intervention is a step in a positive direction.





















REFERENCES

1. Ayanian J. and Cleary P. Perceived Risks of Heart Disease and Cancer
Among Cigarette Smokers. JAMA 1999; 281 (11): 1019-1021.
2. Bickman L. The Effect of Another Bystanders’ Ability to Help on
Bystander Intervention in an Emergency. Journal of Experimental Social Psychology 1971; 7 (3): 367-379.
3. Brehm S. and Weinraub M. Physical Barriers and Psychological
Reactance: 2-yr-olds’ Responses to Threats to Freedom. Journal of Personality and Social Psychology 1977; 35 (11): 830-836.
4. Bustamante J. The “Wetback” as Deviant: An Application of Labeling
Theory. The American Journal of Sociology 1972; 77 (4): 706-718.
5. Centers for Disease Control and Prevention. Smoking and Tobacco
Use: Fast Facts. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.
6. Christakis N. Social Networks and Collateral Health Effects. British
Medical Journal 2004; 329: 184-185.
7. Christakis N and Fowler J. The Collective Dynamics of Smoking in a Large
Social Network. New England Journal of Medicine 2008; 358 (21): 2249-2258.
8. Harvey J. et al. How Fundamental is “the Fundamental Attribution Error”?
Journal of Personality and Social Psychology 1981; 40 (2): 346-349.
9. Langer E. The Illusion of Control. Journal of Personality and Social
Psychology 1975; 2: 311-328.
10. Stretcher V. et al. Do Cigarette Smokers Have Unrealistic Perceptions of
Their Heart Attack, Cancer, and Stroke Risk?. Journal of Behavioral Medicine 1995; 18: 45-54.
11. Weinstein N. Accuracy of Smokers’ Risk Perceptions. Annals of Behavioral
Medicine 1998; 20: 135-140.
12. Weinstein N. Unrealistic Optimism About Future Life Events. Journal of
Personality and Social Psychology 1980; 39 (5): 806-820.

Why Transtheoretical Model is Making Small Step Campaign Have a Small Impact: A Critique Based on . . .

. . . Social Marketing and Integrated Theory of Health Behavior Change – Annie Peer

For a limited time only the price to get you 640 calories and 39 grams of fat will get you double - nearly 1300 calories and 80 grams of fat! Soon you too will be on your way to craving this many calories at every meal until you are in the “select” group of 72 million Americans in the obesity club. (1). If Burger King advertised their new buy one Original Chicken Sandwich and get one free offer in this way, obesity would not be such an issue as it is in America today. Instead Burger King focuses on people getting people what they want, how they want it, and with bigger portions than they imagined. The sandwich is described as being “unchanged since 1979, which no other burger can say” and “not a handful but a handsful”. Even the website allows the consumer to decide how much food, fun, and king images they want on the main menu as seen below:
Figure 1 www.bk.com
This is what public health intervention against obesity is up against. “Obesity is the second leading cause of preventable premature death in this country, with some researchers predicting it may soon outpace smoking as the leading cause of preventable death. A solution will likely be multi-faceted, with emphases on prevention, improvements in treatments, policy change, and environmental changes, among others” (1). One attempt to make exercise and healthy living more “do-able” is the Small Step campaign that was started by the government. This makes exercise look easy by just getting into the habit of small changes everyday that will make you healthier such as taking the stairs instead of the elevator.
Using the six-stage behavior change theory (transtheoretical model) to plan their approach, researchers determined that the public is aware of the dangers of obesity but remains complacent about it (has yet to take action, see rewards from doing so, and commit to ongoing change). Why? Because people want a quick-fix in modern life and none of the promised "quick-fix" diet plans actually work, so consumers have concluded that it's impossible to get healthy.
The transtheoretical model shows the six stages that a person must pass through to achieve behavioral change:
Consciousness/Awareness
Emotional Arousal/Interest
Self-evaluation/Preparation
Commitment/Action
Reward/Positive Reinforcement
Self Liberation/On-going Commitment to Change
(2)
Critique 1 – Transtheoretical Model Does Not Account for Everyone
The primary use of the transtheoretical model is the first mistake this campaign makes. This model “integrates two interrelated dimensions of change, stages of change and processes of change, along with the constructs of self-efficacy and decisional balance. Stages of change represent when an individual is ready to change. Self-efficacy refers to the conviction that one can successfully execute the behavior required to produce the desired outcomes, and decisional balance encompasses the pros and cons or perceived benefits and barriers of making the change” (3). The stages of change reflect a person’s intention to change or the degree to which a person gives serious consideration to change. Individuals may progress through stages at varying rates, may regress, and may reenter the continuum of change at carrying points.
Cons to the physical exercise model showed that “precontemplators” see physical activity as having nearly as much cost as it has benefits and score highest on the cons of engaging in physical activity. (3). A study by Marcus, et al. (4) found that, similar to self-efficacy, pros and cons of physical activity were related to physical activity behavior only indirectly. The pros and cons constructs were related to stage of physical activity readiness (intention), and stage of physical activity readiness served as the mediator influencing actual physical activity patterns. Compared to individuals who were not regularly physically active, individuals who engaged in regular physical activity used physical activity to cope with unpleasant emotions such as stress and fatigue, rewarded themselves for engaging in physical activity, made a commitment to be physically active, and employed reminders to be physically active. Furthermore, these regularly active individuals had more confidence in their ability to be physically active and placed greater emphasis on the benefits of being physically active. It appears that those who were not physically active had less confidence in their ability to be physically active and perceived the barriers to engaging in physical activity as outweighing the benefits. (3).
Transtheoretical Model posits that decisional balance, self-efficacy and processes of change are the most important stage transition determinants. (5). The evidence for the importance of these constructs is mostly based on cross-sectional data and more convincing evidence based on longitudinal data or experimental research is mostly lacking.
Critique 2- Food Ads Dominate in Exposure Time over Small Campaign
The fact that unhealthy food advertisements are dominant and result in fatter people is the second critique. Small Steps’ handful of ads and website isn’t nearly enough to counteract the pervasiveness of advertisements for unhealthy food -- particularly for teens. A study (6) found that fast-food restaurant advertisements were found to make up 23.1% of all food ads seen by adolescents (21.5% and 23.6% for African-American and white teens respectively), and McDonald’s and Burger King advertisements made up approximately 44% of fast-food ads seen by teens. Sweets and beverages ads counted for 22% and 17% of all food ads, respectively, while cereal ads made up 11%.

Figure 2 shows the distribution of the advertisements seen by a group of adolescents in a study done by Powell et al. (6).
Food advertising that promoted snacking, fun, happiness and excitement (i.e., the majority of children’s food advertisements) directly contributed to increased food intake. In addition, these effects occurred regardless of participants’ initial hunger. (7). Furthermore, the amount of calories consumed by the participants after viewing snack advertisements was completely dissociated with the adults’ reported hunger. This was particularly true for men and those attempting to diet. (7). In addition, the effects persisted after the viewing session.
It is not even as simple as restricting television advertising of calorie-dense, nutrient-poor foods… one study (8) proposed a food marketing defense model that posits four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability and motivation to resist. While it is extremely complicated and involved to control the effect of advertising, is it suggested here under the understanding category, to propose a way to effectively market foods and healthy behaviors is a way to defend against food marketing. The way to successfully achieve this will be discussed later in the improved intervention. Psychological theories predict that food marketing, in all its forms, has a profound negative impact on public health among young people and adults. Similarly they predict that proposals by the food industry, such as increased marketing of “better for you” foods or the inclusion of physical activity in food advertising, would not even begin to counteract these effects, and could make them worse. (8).
Critique 3- Health Belief Model Does Not Account For Social And Environmental Factors
The last critique is that the website is based on the health belief model and that people just need education to adopt a healthier lifestyle. This idea of the public simply needing information about nutrition is very wrong. A study (9) showed that providing calorie information at the point-of-purchase on a fast food restaurant menu had little effect on food selection and consumption among a sample of adolescents and adults who eat regularly at fast food restaurants.
Even when people are familiar with a specific risk, social norms and support play a huge role in a campaign’s success. When looking at diabetes prevention in Latino and other racial/ethnic populations (10) they found that integrating cultural factors into prevention interventions involves a proactive analysis of the needs of a specific cultural sub-group, and of how specific cultural factors (perceptions, attitudes, skills in self-regulation, family obligations, low social supports for a healthy lifestyle, etc.) may operate as personal or cultural barriers (or a facilitators) of sustained behavior change.
Broad contextual factors found that cultural influence included aspects of the built environment, as well as local norms and national policies that influence lifestyle choices. Consideration of these factors may augment cultural sensitivity, ideally facilitating program participation and thus enhancing the efficacy of interventions designed to change dietary and exercise behaviors. The Small Step program’s website focuses on educating the public about nutrition, while social norms and individual environments are not addressed.
The consumeR Campaign
The “consumeR” campaign will show how consumerism in America has made Americans fat. The blame for being fat will be placed on the companies’ campaigns to manipulate people into eating more thereby making them more money. This campaign will have people rebelling against fast-food by creating their own independent thoughts. The person that is a member of this “I am not a consumeR” web group will live up to this rebellious title according to the labeling theory. The R in consumeR will always be capitalized to emphasize that resisting consumption at these types of establishments relates to the second part of the campaign called “Reality check”. The “Reality” will take people behind big business to have people question the messages behind the ads and why they are getting bigger sizes or second hamburgers for free.
Since public health campaigns do not typically have large budgets, the considerable amount of the influential food advertisements would be combated by this rebellion against big food companies. Additionally, a website will be made where people can sign up for text messages to motivate them to exercise and stay away from fast-food. A section of the website will be a forum where members can post a ridiculous ad put out by companies designed to get them to eat more. When told that these companies are trying to get the consumers to not think and just be followers, they will rebel.
Solution 1- Segmentation to Appeal to Each Segment of the Population
Since the Small Step campaign does not appeal to “precontemplators”, the new campaign will take into account that all people need to be healthy and will use a variety of mediums to appeal to a diverse population. Developing interventions that are indeed stage-matched requires knowledge about important and modifiable stage transition determinants…making specific action plans may help people to turn their intentions into health promoting action. (5). The Transtheoretical model used in Small Step does not account for all people. It assumes that everyone watching is at point of being willing to make the changes necessary to live a healthier lifestyle.
There are nearly 66% of Americans who are overweight and they do not form a homogeneous group - attitudes, demographic characteristics and lifestyle choices vary greatly within this subset of the US population. (11). Segmentation theory tells us that a “one size fits all” approach to marketing social change may not meet the needs of all people. Further, marketing research has revealed the importance and effectiveness of tailoring messages and incentives to meet the needs of different population segments. Social marketing is defined as “a social change campaign organized by a group which intends to persuade others to accept, modify or abandon certain ideas, attitudes, practices or behavior” (11). Just as the “truth” campaign was able to appeal to the teens’ need for a feeling of independence and rebellion using the social marketing theory against smoking (11), this new campaign for obesity prevention will target different segments too. While overweight adults will primarily be the television ad viewers, teens and kids will be more into the website design. Looking at the following screen shots of the facts pages on the “truth” and “Small Step” campaign, it is easy to see which one is more appealing to teens.

Figure 3 www.thetruth.com

Versus:


Figure 4 www.smallstep.gov
Another way to appeal to more people is through the use of more technology. A study (12) found that text messages were shown to be highly effective and used in several ways: to promote interaction with the intervention, send motivational messages (e.g., reminders of the benefits of exercise), challenge dysfunctional beliefs, or provide a cue to action. Use of communicative functions, especially access to an advisor to request advice, also tended to be effective. It may be that, although the Internet provides a suitable medium for delivering interventions, personal contact via email, online, or text message helps to support behavior change.
Solution 2- Marketing Healthy Behaviors
Social marketing of health behavior change posit that educational interventions may help to improve motivation to change, but that better opportunities for healthy behavior are needed to move people to action. (13). Findings suggest that in contexts like physical activity, condom use and recycling, negative messages about non-enactment will be inherently less efficient than positive messages about enactments. In contrast, in substance abuse-related contexts, the use of positive messages will be inherently less efficient than negative messages due to the negated linguistic form of the target, anchoring concepts denoting non-enactment. (13). While the consumeR campaign with not directly focus on physical activity and labeling people with being active, it will focus on encouraging people to not fall prey to big food chain advertisements by thinking for themselves.
One possible solution to the inefficiency problem is to utilize affirmative brand names to anchor associations with non-enactment concepts. A predominate example of this strategy is “truth” campaign, which was intended to establish “truth” as an aspirational nonsmoking brand. (14). Teens’ social images of smoking (e.g., promoting the appeal of nonsmoking as a way of achieving a desired personal image of independence or rebelliousness) appears to be a useful framework within which to understand intended campaign effects. Evaluation of the campaign’s effectiveness suggests that “truth” has affected social imagery about nonsmoking, achieved high brand equity among its target audience, and contributed to reduced rates of smoking initiation. (15). In other words, blame company instead of yourself.
The campaign should have people revolting against the ridiculousness of unhealthy food commercials since they have been shown to increase food consumption. Therefore, the campaign that sells exercise, as way for people to maintain their freedom and youth will be successful because it focused not on the product but on the desires of the audience. Key core ideals that people do not want taken away include youthfulness and freedom.
Solution 3 – Social Support and Environment Addressed
To assist people working to live healthier lifestyles, the Integrated Theory of Health Behavior change has been found (16) to be helpful. The ITBC is an integration of past successes and makes substantive contributions to understanding health behavior by combining knowledge and beliefs, self-regulation processes, and social facilitation. According to this theory, persons will be more likely to engage in the recommended health behaviors if they have information about and embrace health beliefs consistent with behavior, if they develop self-regulation ability to change their behavior, and if they experience social facilitation that positively influences and supports their engagement in preventative health behaviors.
Knowledge and belief systems impact behavior-specific self-efficacy, outcome expectancy, and goal congruence. Self-regulation is the process used to change health behavior and includes activities such as goal setting, self-monitoring and reflective thinking, decision making, planning for and engaging in specific behaviors, and self-evaluation and self-managing physical, emotional, and cognitive responses associated with health behavior change. Social facilitation includes the concepts of social influence, social support, and negotiated collaboration between individuals and families and healthcare professionals.
Figure 5: Integrated Theory of Health Behavior Change (16).
Another study found that one of the strongest correlations with a child’s BMI was a parent’s BMI. (17). Since the environment in America is so commercialized with a heavy emphasis on food, the social norms and environment must be accounted for in obesity intervention. Although altering American social regarding fast-food will not be an easy task, a website that challenges these norms will be a good start. Members will be a part of a rebellious group going up against food companies that prey on their vulnerabilities.
Competing against huge corporations that have succeeded in controlling the emotions of a majority of Americans is a difficult task. However, the “consumeR” campaign will draw attention to unnoticed unhealthy behaviors by highlighting the absurdity of food advertisements. Social support is given through a fun and resourceful website with forums and text/email motivation. The “consumeR” campaign will draw attention to the lack of thought that Americans put into food and exercise choices. The campaign’s revelation that people are merely blind consumers getting tricked into making harmful personal choices by the advertisements of multibillion-dollar food companies will motivate rebellion. Furthermore, allowing people who never considered themselves as unhealthy - merely because they are not obese- to think differently, will be a huge benefit in setting them on healthier paths and preventing a worsening obesity epidemic in America.
REFERENCES

1. Bean, M. K., Stewart, K., & Olbrisch, M. E. Obesity in america: Implications for clinical and health psychologists. Journal of Clinical Psychology in Medical Settings 2008; 15(3): 214-224.
2. Woods, C., Mutrie, N., & Scott, M. Physical activity intervention: A transtheoretical model-based intervention designed to help sedentary young adults become active. Health Education Research 2002; 17(4): 451-460.
3. Barrett, B. S. An application of the transtheoretical model to physical activity. Ph.D. dissertation, University of Minnesota, United States -- Minnesota. 2007. Retrieved December 3, 2010, from Dissertations & Theses: Full Text.(Publication No. AAT 9815016).
4. Marcus, B. H., Eaton, C. A., Rossi, J.S., & Harlow, L. L. Self-efficacy, decision-making, and stages of change: An intergrative model of physical exercise. Journal of Applied Social Psychology 1994; 24:489-508.
5. Gollwitzer, P.M. Implementation intentions: strong effects of simple plans. American Psychologist 1999; 54: 493-503.
6. Powell, L. M., Szczypka, G., & Chaloupka, F. J. Adolescent exposure to food advertising on television. American Journal of Preventive Medicine 2007; 33(4, Supplement 1): S251-S256.
7. Harris, J. L., Bargh, J. A., & Brownell, K. D. Priming effects of television food advertising on eating behavior. Health Psychology 2009; 28(4): 404-413.
8. Harris, J. L., Brownell, K. D., & Bargh, J. A. The food marketing defense model: Integrating psychological research to protect youth and inform public policy. Social Issues Policy Review 2009; 3(1): 211-271.
9. Harnack, L. J., French, S. A., Oakes, M., Story, M. T., Jeffery, R. W., & Rydell, S. A. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trail. International Journal of Behavioral Nutrition and Physical Activity 2008; 5(63).
10. Castro, F. G., Shaibi, G. Q., & Boehm-Smith, E. Ecodevelopmental contexts for prevention type 2 diabetes in Latino and other racial/ethnic minority populations. Journal of Behavioral Medicine 2009; 32(1): 89-105.
11. Kolodinsky, J. & Reynolds, T. Segmentation of overweight Americans and opportunities for social marketing. International Journal of Behavioral Nutrition and Physical Activity 2009; 6(13).
12. Webb, T. L., Joseph, J., Yardley, L., & Michie, S. Using the Internet to promotes health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change technique, and mode of delivery on efficacy. Journal of Medical Internet Research 2010; 12(1): e4.
13. Brug, J., Conner, M., Harré, N., Kremers, S., McKellar, S., & Whitelaw, S. The transtheoretical model and stages of change: A critique. observations by five commentators on the paper by adams, J. and white, M. (2004) why don't stage-based activity promotion interventions work? Health Education Research 2005; 20(2): 244-258.
14. Freeman, D., Shapiro, S., Brucks, M. Memory issues pertaining to social marketing messages about behavior enactment versus non-enactment. Journal of Consumer Psychology 2009; 19(4): 629-642.
15. Evans, W. D., Wasserman, J., Bertolotti, E., Martino, S. Branding behavior: The strategy behind the Truth campaign. Social Marketing Quarterly 2002; 8: 17-29.
16. Ryan, Polly. Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist 2009; 23(3): 161-172.
17. Elder, J. P. et al. Individual, family, and community environmental correlates of obesity on Latino elementary school children. Journal of School Health 2010; 18(1): 20-31.

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:
1. Nemours Health and Prevention Services. 5-2-1-Almost None. Newark, Delaware. Nemours Children’s Health System.
2. McLeroy KR, Bibeau D, Steckler A, & Glanz, K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly, 1988; 15, 351-377
3. Stokols, D. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 1996; 10, 282-298.
4. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs. 1974; 2,(4).
5. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education Quarterly. 1988; 15(2), 175-183
6. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21
7. Edberg M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. 51-54
8. Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.
9. Cotton D. A comparison of protection motivation theory and the health belief model for explaining smoking cessation [e-book]. US: ProQuest Information & Learning; 1994. Available from: PsycINFO, Ipswich, MA. Accessed November 28, 2010.
10. Knight R, Hay D. The relevance of the Health Belief Model to Australian smokers. Social Science & Medicine [serial online]. 1989;28(12):1311-1314. Available from: PsycINFO, Ipswich, MA. Accessed November 28, 2010.
11. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21
12. Cevita MD, Dasgupta K. Using diffusion of innovations theory to guide diabetes management program development: an illustrative example. Journal of Public Health. 2007; 29(3): 263-268.
13. Weinstein ND. Unrealistic optimisim about future life events. Journal of Personality and Social Psychology 1980; 39:806-820
14. Kreitler, S. Cognitive orientation and health-protective behaviors. International Journal of Rehabilitation and Health; 1997 3(1).
15. Baranowski, T. Beliefs as Motivational Influences at Stages in Behavior Change. International Quarterly of Community Health Education. 1992; 13(1).
16. Lieberman, D.A. Interactive video games for health promotion: Effects on knowledge, self- efficacy, social support, and health. Mahwah, NJ: Lawrence Erlbaum Associates
17. Jackson, C. Behavioral Science Theory and Principles for Practice in Health Education. Health Education Research. 1997; 12(1).
18. Edelman & Mandle. Health Promotion Throughout the Lifespan. St. Louis, Missouri: Elsevier, 2006