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.
REFERENCES
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