Thursday, December 18, 2014

Fighting Obesity, Not Obese People: A Critique Of Georgia’s Strong4Life Anti Obesity Ad Campaign – Morgan Minogue

            A life-threatening epidemic exists in the state of Georgia, placing nearly one million children across the state at increased risk for negative health effects at present, and in the future (1). This epidemic is not one that stems from infection or plagues a certain demographic, but rather one that centers on the behavior of children and their caretakers, and the constructs of the society in which they live. This epidemic is childhood obesity. Across the United States, national and state-level public health campaigns address the growing obesity epidemic among children as a means to prevent adult obesity and promote the future health of the country. In areas of the United States hit hardest by the epidemic, such as Georgia, anti obesity interventions are of great importance, while the steps taken to combat the public health problem have proven controversial.
             Georgia, second only to Mississippi in terms of the highest prevalence of obesity in the country, has one million children who fall into the category of overweight or obese (2). In 2011, Children’s Healthcare of Atlanta launched Strong4Life, a 5 year 25 million dollar public health intervention aimed at reducing the prevalence of childhood obesity in the state (1). Though the intervention has evolved greatly following it’s contentious beginning to include the training of pediatricians, programming in schools, and creation of a clinic to treat the medical and psychological issues related to obesity, the highly disputed advertisements created in the first year of Strong4Life will be the focal point of this critique.
            Strong4Life’s initial media campaign called “Stop Childhood Obesity,” took a tough-love approach to combat the alarming rate of childhood obesity in the state. The campaign, established in an effort to fight a genuine and increasingly problematic public health crisis, was nicknamed “Stop Sugarcoating It, Georgia,” as it was designed to shock families into acknowledging obesity as a problem (1). The media campaign includes a series of black and white advertisements produced in the form of both print and television Public Service Announcements, all which feature overweight children making blunt statements about the negative impacts they face in their current state of being obese. In print ads each child accompanies a warning sign with harsh statements such as “It's hard to be a little girl if you're not, "Big bones didn’t make me this way. Big Meals did,” “Fat prevention begins at home. And the buffet line,” and “Fat kids become fat adults” (3). The strong4Life television advertisements evoke a similar tone. In these advertisements, overweight children or their parents ask questions or make strong statements regarding how obesity negatively impacts their health and social status. Television ads end with a visual “75% of Georgia parents with overweight kids don’t recognize the problem” or “being fat takes the fun out of being a kid” followed by the Strong4Life tag line, “Stop sugarcoating it, Georgia.”(3).
            In analysis of the media campaign as a tool for behavior change, the following critique evaluates the assumptions Strong4Life made in the creation of the “Stop Childhood Obesity” media campaign. It delves into the theories and research surrounding the tactics Strong4Life used in combatting the issue of childhood obesity. It is important to note that while the media campaign certainly created awareness and was successful in getting people talking about the issue of obesity, it also created unnecessary and harmful stigmatization in the exact population it was trying to help. As indicated in the three criticisms below, the Strong4Life anti obesity advertisements lack the very characteristics needed to foster the change in behavior required to combat the public health issue of childhood obesity. At best, children walks away from the Strong4Life advertisements wanting to make a change, but unequipped to do so. At worst, they walk away shameful and helpless.
Critique Argument 1: Creates Stigma and Shame
            The first major critique of Stong4Life’s “Stop Childhood Obesity” campaign is that it produces stigma and shame in children who struggle with obesity, yielding undesirable heath consequences and lowering self-efficacy among those it seeks to help. Self-efficacy, defined as one's belief in their ability to succeed in a specific action, is highly important when creating interventions to target behavior change (4). The promotion of self-efficacy is entirely absent from the Strong4Life media campaign, leaving kids powerless and unconfident in their ability to take control of and manage their poor health behavior.
            In an interview with NPR regarding Strong4Life’s media campaign, Linda Matzigkeit, Vice President of Children's Healthcare of Atlanta, said the campaign “has to be harsh. If it's not, nobody's going to listen.”(2). One Strong4Life television ad, features a young overweight girl who somberly states, “I don’t like going to school, because all the other kids pick on me.” Another pictures a young obese boy, who tells viewers “playing video games is what I like to do by myself, I don’t have to be around the other kids. All they want to do is pick on me.” Both ads end with the visual “Being fat takes the fun out of being a kid.” (3). After analyzing these advertisements, it is evident that Linda Matzigkeit is right about one thing, that these ads are harsh. And as research indicates, the nature of these messages actually harms the very audience they seek to help.  
            At the center of the “Stop Childhood Obesity” campaign is the idea that weight stigmatization is a useful tool of social control in discouraging unhealthy behaviors and is justifiable when used to improve the health of stigmatized individuals. Sociologist Erving Goffman defined stigma, in 1963, as “a process by which the reaction of others spoils normal identity”(5). Across American society, it is generally acknowledged that obesity leads to stigmatization, or identity threat. We see in schools, that stigmatization can become so extreme that overweight and obese children fall victim to harsh teasing and bullying from peers (6). This obesity related stigma is known to lead to negative health outcomes, as individuals who face this type of social discrimination tend to internalize it, making them more prone to engaging in unhealthy behaviors (7). In fact, studies illustrate that overweight children faced with weight-based teasing engage in binge-eating and unhealthy weight control behaviors at a higher rate than their normal weight counterparts, even after controlling for factors including BMI and socioeconomic status (8). Strong4Life ads place blame on the children without direction, leaving them completely unconfident in their ability to change behavior. The guilt inducing text to present in the advertisements, only further ostracizes and harm a population that already faces a great deal of discrimination though the use of victim blaming. Victim blaming, which leads to viewing behavior as being in control of the individual, promotes increased stigmatization in such obese children, yielding poor heath and psychological and health outcomes (9).
            Weight loss is championed, in Strong4Life’s commercials, on their billboards and across public transportation, as the means to social acceptance and a happier life.  However, the negative nature of these messages actually yields a decrease in motivation for their target audience, as stigma and shame promoted through television and print advertisements create a diminished sense of self-confidence (10). Studies indicate that the promotion of self-efficacy through positive messages can lead to healthy choices in those attempting to lose weight. According to Puhl et al., obesity related health messages perceived to be most positive and motivating focus on making healthy behavior changes without referencing an individual’s body weight (10). This is where Strong4Life is flawed, as the Strong4Life campaign centrals entirely on an individual’s state of being overweight or obese, using a negative tone to elicit fear, shame, and guilt in its viewers. The Strong4Life campaign assumes that the harsh tactics they use will inspire action, however as indicated above, they actually prove counterproductive as they diminish a children are left unconfident in their ability to change behavior.
Critique 2: Elicits Psychological Reactance in Target Audience
            The Strong4Life media campaign centers on the notion that making children shameful of their health status and fearful of social discrimination will lead to rational food choices. Research suggests the opposite, as advertisements that stigmatize and blame such a sensitive population, actually yielded an increase in negative food related health behavior (10). A study from Yale University’s Rudd Center for Food Policy and Obesity directly supports this theory, indicating that “when individuals feel shamed or stigmatized because of weight they're actually more likely to engage in behaviors that reinforce obesity: unhealthy eating, avoidance of physical activity, [and] increased caloric intake”(10). In another study, conducted by Puhl and Brownell, we see similar reactant behavior. In asking over 2400 overweight or obese women how they coped with stigma, 79% of the women said that they coped by eating, while 75% said that they coped by refusing to diet entirely (11). This research indicates that the nature of such message elicit an emotion which spurs action. This emotion is that of personal threat to freedom.
            The research above can be explained by the Theory of Psychological Reactance, which centers on the concept of individual freedom, a core value which people hold dear (12). The theory of psychological reactance, developed by Brehm and Brehm in 1966, concludes that if a “person’s behavioral freedom is reduced or threatened with reduction, the person will become motivationally aroused. This arousal would presumably be directed against any further loss of freedom, and it would also be directed toward the reestablishment of whatever freedom had already been lost or threatened” (12). According to this theory, the degree of reactance is affected by the strength of a threat, presence and importance of a freedom, and implication for future threat (12).
            An important application for the promotion of psychological reactance in a health intervention is that when faced with the pressure to change, an individual will often react to a threat by acting in direct opposition to the proposed message (12). A 2008 study by Considine and Quick, supports this theory. In their study, which examined the use of forceful language in designing exercise persuasive messages for adults, they found that forceful language yielded a feeling of threat among participants, translating into reactant behavior in the form of anger and negative emotions (13). At the center of the “Stop Childhood Obesity” campaign, we see such threatening, powerful messages present. Across the campaign, advertisements seek to shock families with blunt warnings stating that “chubby kids may not outlive their parents” and “Fat kids become fat adults”(3). The messages present in the Strong4Life campaign, which threaten individual freedom by mitigating free choice, encourage this psychological reactance in children who are obese as they act in a way directly opposing the advertisements original intent. Though advertisements may have been successful in promoting awareness, the provocative wording used in the campaign likely reinforces the unhealthy behavior that originally led to obesity. Thus after seeing and hearing such threats, children become more apt to practice poor health behavior as a way to re-establish the their personal freedom and control.
Critique Argument 3: Leaves Parents and Kids ill Equipped to Prevent and Manage Childhood Obesity
            The final major critique regarding the Strong4Life media campaign is that it focuses primarily on the individual and his or her state of being obese, failing to employ a preventative approach and lacking the actionable steps children and their parents can take to manage the health issue. According to Children’s Health Care of Atlanta, the “Stop Childhood Obesity” ad campaign was created to promote awareness among the high prevalence of parents who fail to recognize obesity as a medical issue (1). It sought to shock kids into behavior change through acknowledging the debilitating nature of the disease.  In two of Strong4Life’s billboards, young girls struggling with obesity are pictured along with the phrases “Warning: fat kids become fat adults” and “Warning: chubby kids may not outlive their parents”(3).  The only Strong4Life advertisement, which even mentions the prevention, is a print advertisement of an overweight child alongside the phrase “Fat prevention begins at home. At the buffet line”(3).
            These advertisements were intended to function as a cue to action. The campaign, as illustrated above, singularly targets the individual child and his or her state of being obese, entirely disregarding the notion that normal or underweight children may also be at risk. These billboards and PSAs were likely designed with the Health Belief Model in mind, under the assumption that individuals act rationally, and that by knowing the facts and recognizing ones health status, children and parents will change behavior.  The Health Belief Model is an individual level health belief theory that has been the foundation of public health interventions for decades. The theory, developed by a group of social psychologists in the 1950’s, details the process an individual goes through in making decisions regarding their health behavior (4). It encompasses the idea that individuals act will act rationally when weighing the costs and benefits of a given behavior. Health seeking behavior of an individual is said to be influenced by four distinct factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (4).  Interventions utilizing this model target these components as they hope to motivate individuals to seek health and change their behavior.
            Strong4Life’s reliance on promoting perceived susceptibility and severity as triggers for obesity related behavior change proves to be a major limitation across the campaign. In a study evaluating the accuracy of parental perceptions in children’s weight status, parents of obese and overweight children generally underestimate their child's weight status (14). Stong4Life’s advertisements target such parents, with the stark visual that “75% of Georgia parents with overweight kids don’t recognize the problem.”(3). Here, strong4Life makes the inaccurate assumption that such a statistic will yield an increase in perceived susceptibility, as parents viewing these advertisements will see the obese children in the ads as a reflection of their own, causing them to address unhealthy behavior in the family. However, advertisements simply highlight the health problem of childhood obesity, without addressing solutions to prevent or steps to manage it. As the research indicates, many parents deny or fail to categorize their child as overweight or obese (14). Thus as viewers, such parents would not recognize themself or their child as the target audience of such a message. It is unlikely that these advertisements would promote the desired call to action among targeted parents, as they fail to recognize their perceived risk to obesity. This would leave them ignoring the present and future severity of the health problem, and enable a continued disregard of the problem. 
            In addressing children, the Strong4Life advertisements create the image that thinner kids are happier kids. One advertisement states “It’s hard to be a little girl, if you’re not.”(3). Warning Ads, as referenced above, show heavy children discouraged and sad regarding their current state of being overweight or obese. What these ads fail to do, is detail the factors that contributed to the child’s weight status or what he or she can do to relieve herself of the problem.
            In cohesion with the Health Belief Model, Strong4Life’s campaign centralizes on the notion that individual lifestyle choices are the primary factor contributing to childhood obesity, failing to recognize that social or environmental factors that likely have an affect on the public health problem. Though truthful and effective in promoting awareness, these advertisements fail to properly educate families about the susceptibility to and severity of obesity, as they lack important information regarding the risk factors for and health effects of Childhood obesity. Simply warning kids with phrases such as “fat kids become fat adults,” without acknowledging the unhealthy behaviors that lead to the public health issue or the seriousness behind it, only leave them feeling helpless. In fact, there is no mention about what a parent can actually do to prevent or manage childhood obesity other than to 'stop sugarcoating” it.
Articulation of the Strong4Life Alternative:
            As part of the 5 year 25 million dollar public health intervention, Strong4Life’s original “Stop Childhood Obesity” ad campaign was simply used to create awareness, the first step the program used to reduce the prevalence of childhood obesity in the state. In sparking a major controversy throughout the state, the media campaign accomplished its goal of creating awareness. However, it failed in many respects, promoting stigma and shame and proving counterproductive in the very population it sought to help. The campaigns main messages, which sought to inspire motivation through fear and shock, left target audiences unconfident and helplessness. While in lacking the prevention and management tools necessary to promote obesity related behavior change, it left families unaware and unable to change behavior.
            An alternative to the Strong4Life campaign is a media campaign targeted towards all children, rather than one that seeks to single out and stigmatize only children who are obese. It would be one that motivates and inspires a healthy lifestyle, rather than one that threatens children’s personal autonomy. And finally, it is an ad campaign that not only promotes awareness, but also addresses prevention and manageable solutions for obesity, through the use of relatable, personal stories. This campaign is the “Love Your Peach Community” campaign.
            The goal of the Love Your Peach Community media campaign is similar to that of Strong4Life, to promote awareness regarding an important public health issue. However, this campaign will place its primary emphasis on concepts such as choosing to participate in a healthy lifestyle, and promoting “health” rather than “weight loss” as the key to living a long, healthy life.  One of the primary foundations of this ad campaign will be to mold advertisements to specific communities, which is how the campaign got it’s name. Television advertisements will run state-wide, focusing on the use of personal stories to illustrate the seriousness of childhood obesity and the tools needed to prevent and manage it, while print advertisements and billboards will be designed on the community level, by local health departments and health care advocacy groups. Print advertisements designed at the community level will not only be designed by public health professionals, but also by youth, promoting a feeling of solidarity and community wide responsibility and support regarding health promotion.
            Through promoting an underlying tone of youth empowerment, the Love Your Peach Community media campaign will promote the idea of becoming a “Peach Community Kid,” using branding as a method of reducing stigma related to obesity, and helping children take control of health related behavior. Another aspect of the Love Your Peach Community campaign, designed to both inspire and inform, are the campaign wide “I have a right” statements. These come in the form of state and community print advertisements, which centralize on the concept that kids have the right to choose to be free from obesity. In these ads, children of all sizes are featured with one of the “I have a right” statements. These statements include anything from “I have a right to eat healthy food at school lunch” to “I have a right to walkable sidewalks.” The goal of such advertisements is to reframe the issue of childhood obesity in a way that reduces stigma and promotes the need for social, environmental, and individual action.

Defense of Intervention #1: Motivates Behavior Without Blaming the Victim  
            Strong4Lifes “Stop Childhood Obesity” campaign used as weight stigmatization as a justifiable means of promoting behavior change, yet backfired as negative messages left children unconfident in their ability to address their health problem, even if they wanted to. Negative messages such as those portrayed in the Strong4Life campaign are proven to exacerbate the stigma experienced by obese children, lowering their self-esteem (9,10). Low self-esteem experienced from such obesity related stigma, likely inhibits children from combatting the complex decisions often associated with losing weight and eating healthy. Thus addressing this lack of self-esteem should be of primary concern in the Strong4Life’s alternative. The Love Your Peach Community campaign, was creatively crafted with this notion in mind, as it seeks to promote self-efficacy for a healthy lifestyle, through the use of positive messages that promote empowerment and motivation across the target audience
            Puhl and Brownell cite Attribution Theory as a useful framework with which to understand this obesity related labeling, and the stereotypes surrounding obese and overweight individuals (9).  According to this model, people associate certain negative connotations with overweight or obese individuals as a way of explaining the underlying causes of their condition (9). The obese are thus often labeled as being lazy, lacking self-control and willpower and even considered “morally irresponsible” (9). In seeking to avoid such harmful obesity related stigma and shame, Love Your Peach Community will focuses on these social factors, attempting to mold social norms around health behavior and promoting a feeling of tolerance regarding all sizes, rather than simply singling out those who are overweight or obese. Though still considered an anti-obesity campaign, Strong4Life’s alternative takes Attribution Theory into consideration, rarely mentioning the word obesity or focusing on an individual child’s state of being overweight or obese. In doing so, the Love Your Peach Community campaign minimizes stigma and bullying originally promoted through Strong4Lifes campaign.
            The focal point of “Love Your Peach Community” advertisements will be to promote an accepting and non-judgmental environment that promotes individual self-esteem and solidarity for health, while changing previous social norms. Advertisements motivate individuals to seek health behavior, rather than blame them for the failure to do so. Through the utilization of branding, advertisements will champion the notion of becoming a “Peach Community Kid.” Love Your Peach Community television advertisements will depict groups of children, all shapes and sizes, getting outside and enjoying all their Peach community has to offer.  Once a local board of health decides to become a Georgia’s “Love Your Peach Community,” they will promote the idea of becoming a “Peach Community Kid” on the local level. Schools will promote “Peach Community Days” where children will have the opportunity to take a hands-on approach to promoting health, as they gain exposure to healthy cooking techniques and will have the opportunity to design and manually build a community garden for their school. Unlike the Strong4Life campaign, the Love Your Peach Community campaign will provide a sense of community and belonging for obese children and their families, ultimately diminishing stigma and addressing issues of low self-esteem.
Defense of Intervention #2: Sells Freedom of Choice to limit Psychological Reactance
            Strong4Life advertisements left obese children defensive as messages promoted disapproval of their weight status, eliciting physiological reactance in the very children it targeted. The Love Your Peach Community campaign seeks to directly limit the degree to which children feel their freedom is being threatened, by promising freedom and control through the pursuit of health behavior as its main objective. One way the Love Your Peach Community campaign will minimize reactance is through the application of Marketing Theory, placing a focus on packaging health promotion in a manner that appeals to the target audience. According to literature, one way to properly do this is through utilization of the perfect messenger, or the individual that delivers the message the campaign seeks to promote. Messengers, which may be used to deliver information, demonstrate behavior, or provide testimonials, are proven to enhance audience engagement, as well as promote message credibility and relevance when chosen in the right way (15). Part of this principle relies heavily on the likability of the messenger, as audiences are likely to feel less threat associated with messages that come from someone they like or can identify with (15). In choosing their messengers, the Strong4Life alternative will use kids of all sizes and backgrounds to deliver inspiring messages about the actions they take to promote health. Some advertisements show adults who were overweight as a child and discuss the very manageable solutions they took in achieving health.
            The Love Your Peach Community campaign will also place a heavy focus on the substance of the message in which the messenger promotes, ensuring it is one that motivates and inspires a healthy lifestyle, rather than one that threatens personal autonomy. Strong4Life generally follows the traditional approach to prevention, as it presents a fear appeal in an effort to focus attention on the negative consequences of a poor health behavior. This Love Your Peach Community takes a different approach, by placing its focus on promoting the desirability in a positive alternative, by creating commercials that champion a child’s right to be free from obesity and the manipulation of the food industry. The campaigns “I have a right” advertisements do just this.  By using messengers who practice behaviors that put them at risk for obesity, the Love Your Peach Community campaigns shift the focus to prevention and management while empowering kids to address environmental and social barriers to health. In using the “I have a right” statements, kids begin to obtain a feeling of control regarding their health behavior. These advertisements generally tend to motivate their target audience, as the rewarding gains of healthy lifestyle behavior are promoted as something obtained through choice.
Defense of Intervention #3: Provides Actionable Steps to Manage the Public Health Issue
            The “Love Your Peach Community” campaign takes a different approach to promoting perceived susceptibility and severity to childhood obesity. Rather than simply focusing on the individual child and his or her state of being obese, this campaign takes advantage of peoples distorted perception of risk through the application of the Theory of Unrealistic Optimism. Through the use of will state-wide public service announcements, a focus will be placed on the use of personal stories to illustrate the seriousness of childhood obesity as well as the tools needed to prevent and manage it.
            The Theory of Unrealistic Optimism, which explains that individuals perception of risk is not always rational, describes that individuals generally overestimate their risk of having good things happen to them, while underestimate risk of bad things happening (16). In addition, “among negative events, the more undesirable the event, the stronger the tendency to believe that one’s own chances are less than average.” Strong4Life seeks to take advantage of peoples distorted perception of risk, in promoting perceived susceptibility in the “75% of Georgia parents with overweight or obese children who fail to recognize the health problem.” However, in failing to illustrate the behaviors that led to their child’s weight problem, such parents cannot relate to the message and thus are left to simply disregard the facts. 
            Love Your Peach Community tackles this issue in a different manner, highlighting the health problem, while also addressing solutions to prevent and steps to manage it. Across the campaign parents, detail the moment they realized what they were feeding their kids could be causing harm. One mom indicates, “Tamara’s doctors told me her diet was placing her at high risk for future chronic health problems. That was the moment I knew I needed to change the food I was feeding my family.” An ad such as the one described here, is one parents with children at risk can relate to, emphasizing that they too may be at risk of exposure to the debilitating nature obesity. Other advertisements indicate perceived seriousness of childhood obesity showing Brian discussing his classmate and friend Martin. He explains “I never knew my best friend Martin was at risk for harmful disease because of his weight. I never knew the food my school was providing was adding to this risk.” This advertisement ends with one of the Love Our Peach Community slogans “We have a right to be free from harm at school.” This ad specifically, provokes emotion as well as the need for policy change and regulations across Georgia. It acknowledges that there are outside factors contributing to the problem of obesity, outside of individual food choices.
            The use of personal stories from both parents and children serve as a mode of creating the perceived susceptibility and severity needed to diminish unhealthy behavior. Research indicates that among young audiences, emotional messages tend to be better remembered than non-emotional ones and enhance the ads’ effectiveness (17). Love Your Peach Community is modeled after Pam Laffin’s Outrage campaign, one of the most successful anti smoking campaigns, which used a testimonial format to elicit such emotional response while providing credible information about the severity tobacco use (18). In her campaign, a young mother is depicted dying of smoking related emphysema, while her children are shown faced with the harsh reality of losing their mother (18). Love Your Peach Community follows this model in promoting the desired call to action among targeted parents and children as they use information to inform families about the harsh realities associated with childhood obesity, with an added benefit of not telling them what to do. Through use of personal testimonials, families become more likely to listen to the messages presented in the ads. By promoting specific healthy choices, such advertisements yield a sense of personal empowerment in those who view them, while also providing parents and children with the tools necessary to make change happen.  

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