Introduction: What is Traditional Health Education?
Health education is an integral component of an effective educational program. It has the ability to “reduce the prevalence of health risk behaviors among students and have a positive influence on students’ academic performance” (1). Moreover, many studies and articles support the idea that good health can help students perform better in school because they are more likely to attend school, to be able to concentrate, and to perform well - healthy children are more ready and able to learn (2-6). The Centers for Disease Control and Prevention (CDC) also suggest that academic success can be an “indicator for the overall well-being of youth and a primary predictor and determinant of adult health outcomes” (2). Health and academic outcomes are linked in a way that improving one is likely to positively influence the other. Health education has the potential to be an effective public health intervention which can improve the current health behaviors of students, future health outcomes as well as positively contribute to learning.
Despite the potential for health education, data from CDC from both the School Health Profiles and the Youth Risk Behavior Surveillance Survey (YRBSS), suggest that there are many students not receiving health education and that the current approach to health education may not be effective in decreasing risky behaviors. The 2012 School Health Profiles reveal that the percentage of states that require health education ranges from 51.3% offering a health education course in 6th grade, to 63.9% in 8th grade, to 57.2% in 9th grade and down to 47.1% in 10th grade (7). There are many states that still do not have health education requirements for grades at the secondary level which means that the reach of school based health education is limited. As a public health approach, it is clear that there is untapped potential for health education to impact students at a critical time when they are engaging in behaviors and forming behavior patterns that are likely to continue into adulthood.
While health education alone cannot directly impact the multiple influences on adolescent health behaviors (such as policies, environment, media, family and peers), it can be one aspect of an effective public health approach (8-10). Youth are engaging in a range of risky health behaviors many of which contribute to leading causes of death in the United States. Select data from the 2013 survey includes: 35% of high school students “currently drank alcohol”, 21% had 5 or more drinks in a row within the last 30 days, 23% currently use marijuana, 47% have ever had sexual intercourse, 34% are currently sexually active and only 59% used a condom during their last sexual intercourse (11). While this is a limited glance into the range of risky behaviors, this data supports the need for interventions which help students develop the knowledge and skills they need to choose health-enhancing behaviors and avoid risky behaviors. One way to do this is through effective health education in schools; however, a traditional approach to health education is not likely to help achieve these outcomes and yet this appears to be the current trend in schools in the US.
According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), traditional health education involves “learning about the human body, food nutrition, the importance of work and exercise and the problems of smoking, drugs and alcohol” (12). UNESCO further breaks down traditional health education into the following characteristics (12): Focus on disease; Moralistic tone; Focus on individual behavior; Didactic teaching methods; Emphasis on “doing the right thing”;
Health experts as guest lecturers; Focus on health education (as opposed to a healthy school approach); A biomedical view of health; Teacher to model “right” behavior (as opposed to enquiry methods); Students adopt prescribed attitudes and values.
Traditional health education has also been characterized by being “like any other lesson,” by teaching issues that are not always relevant for the students, and by focusing on future outcomes rather than present outcomes which is not as effective with adolescents (13).
While it can be challenging to collect data as to approaches actually implemented in classrooms (reported versus actual), data that is available supports that health education reflects a traditional approach. The median percentage of secondary schools that “have tried to increase student knowledge on health-related topics” are: 75.5% for suicide prevention, 81.8% pregnancy prevention, 88.7% STD prevention, 93.1% violence prevention, 93.5% tobacco-use prevention, 96.2% nutrition and dietary behavior and 98.5% for physical activity and fitness (7). In addition, the median for percentage of secondary schools with a health education curriculum that addresses all eight skills of the National Health Education standards (which is one way to determine the health education approach) is only 61.5%. It is important to note the language of the survey results/questions. In the “health topics” question it specifically asks if schools have tried to increase student knowledge whereas the skills question is much more general relating to having a health education curriculum which “addresses” skills. The phrasing “address skills” is more vague than “increasing student knowledge” and leaves room for interpretation about the extent to which the skills are “addressed” and how much emphasis is actually placed on the skills. For example, a more revealing question could be the extent to which the schools have “tried to develop the following skills in students” or the extent to which schools have “tried to increase students’ ability to demonstrate the following skills.” These questions would be more aligned with the “topic” question and get a better sense of what might actually be happening in classrooms. Nonetheless, the larger percentages of schools increasing student knowledge around health topics and the relatively low percentage of schools teaching skills suggests that there is still an emphasis on more traditional methods in health education.
Health education has the potential to be an effective strategy for both improving students’ academic and health outcomes. However, in its current state, health education is not in a position to be a meaningful public health intervention. The three main critiques of the current approach are: 1) an emphasis on knowledge, 2) an emphasis on didactic methods and 3) the current framing of health education. However, there is a potential solution that is support by social science theory and research and which could be the approach that could help bring health education to the forefront as an effective intervention to address the health of today’s youth: a skills-based approach to health education.
Critique 1: Emphasis on Knowledge
There is limited evidence to support that knowledge of health topics will lead to behavior change (14-16). There needs to be more to health education than teaching “about” health topics (UNESCO). Health education should leverage the current research and theory about health behaviors which emphasizes an ecological approach to promoting health in which individual factors are only one piece of a larger puzzle rather than focusing on knowledge acquisition.
To rely on increasing knowledge as the main intervention in health education ignores many of the more potent influences on behaviors such as peer influence, media and norms (both real and perceived). Even health behavior theories that focus on the individual still include more than knowledge alone. For example, the Health Behavior Model includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. While knowledge might impact perceived susceptibility, benefits and barriers it will not address cues to action or self-efficacy, both critical components of the model. In another common theory, the Transtheoretical Model, knowledge might be used to help someone move through a stage or between stages it would be most likely to have an impact on the earlier stages of precontemplation and contemplation. Clearly, knowledge is not the most important factor even within individual health behavior theories.
Perhaps even more compelling is the fact that many have suggested that health behaviors are strongly influenced by social influences such as peers and the media. Thaler and Sunstein suggest that in order to “nudge” people into action three social influences should be addressed: information, peer pressure and priming (15). They argue that people are motivated to conform to social norms and to others behaviors whether real or perceived as well as the fact that people can be “primed” by providing them with cues and a channel to facilitate an action. The only knowledge involved here is in the form of “information” of social norms or of actions of others. Another example comes from Florida’s “truth” campaign in which they found that students did know the dangers of tobacco – “knowledge was not the problem” (17). As a result, the campaign focused in part on setting a tone that would connect with youth and making “truth” a brand in order to connect with the youth’s identify formation (17). Again, knowledge did not play a role in the campaign, in fact, it was clear that youth knew the dangers and that some still chose to smoke for reasons such as rebellion and as a way of asserting ownership over their decisions (17).
There is much evidence to support that knowledge is not a key determinant in behavior from health behavior theories to research from the field. Therefore, health education fails to be effective, in part, due to its reliance on knowledge as the main focus. Teaching students about health is not going to impact behavior. Health education needs to move away from a foundation of knowledge to a foundation that is aligned with current theory and research.
Critique 2: Emphasis on didactic methods
Similarly, a focus on didactic, teacher-directed methods is equally as ineffective. Talking “at” people, especially youth, is not going to engage them. Didactic teaching is also more aligned with the idea that people make rational decisions – if we tell people how bad a certain behavior is, logically they will not engage in the behavior or, more broadly, if we give people all the information about certain health topics, they will have what they need and logically, they will make the right decision. As with the focus on knowledge, this approach neglects to take into account the irrationality of people’s decision making.
Teaching health education can be compared to “selling” health much like many public health campaigns aim to sell a healthy behavior (not smoking, wearing condoms, etc.). Successful campaigns do not rely on “telling” people about the behavior, rather they engage an emotional appeal and use marketing techniques. For example, Randolph and Viswanath created a list of criteria necessary for successful public health campaigns including: ensuring exposure of messaging, creative marketing and messaging, a supportive environment, theory-based and targeted to the audience (18). If this is translated into the classroom one might expect to see a teacher who uses these methods in their instruction. For example, teachers have one advantage in that they can control the exposure to the message in their classroom and may also be able to impact messaging in the school. The teacher can create a supportive environment in which students feel safe and in which there is some ownership. The teacher can use participatory methods which engage students in order to create messages that will resonate with students and they could target their curriculum and their teaching to meet the needs of their students. This cannot occur in a didactic classroom where the teacher is mainly “giving” information to students through teacher-directed messages. In many ways, this is in contrast to what is known about how to compel an audience to change behavior or to “buy into” an idea or concept.
Didactic teaching also goes against the principles in the ecological approach to health education. In particular, didactic teaching is less likely to meaningfully address perceptions, skills, motivations and the social environment (19). While there are multiple ways to address these factors, participatory teaching methods are more effective than didactic. Participatory teaching techniques include the use of techniques for skill development, interactive teaching, and a social context for learning (6). This results in instruction that allows students to see change in the present, as opposed to teaching them knowledge that might help them in the future. Students are directly involved in their learning experiences and much of the instruction is focused on giving students the knowledge and skills they need now and in the future. These ideas are much different than those presented above regarding traditional health education which focuses on didactic learning and fact acquisition. When one engages students through a participatory approach, students can explore and discuss their perceptions. The teacher can also use principles of social influence to “nudge” students toward health-enhancing behaviors and attitudes. The teacher can create a social environment that is supportive (successful public health campaigns), that focuses on health enhancing norms and behaviors and which provides opportunities for students to positive influence one another. Finally, participatory methods provide opportunities for students to develop skills, another key determinant in an ecological approach to health behavior.
Didactic methods are not aligned with practices in public health campaigns or an ecological approach to health behavior. While health education is not a traditional public health campaign, lessons learned from the public health field can be directly applied to health education in the classroom. Upon evaluation, a didactic approach is not aligned with current practice in the public health field. Lessons learned from the public health field should be applied, where appropriate, in the health education classroom which would include moving away from a didactic approach which is a second reason why health education is not currently an effective public health intervention.
Critique 3: Current Framing of Health Education
A third critique of health education is the weak framing of health education in schools. There are four main frames for school-based health education described here:
Frame: 1) Health Education Matters – Really! 2) Health and Academics 3) Health Education on the Periphery 4) Not the school’s job
Core Position: Health education, despite current opinion, does make a difference and belongs in schools. Health contributes to academic success (and alternately negative health behaviors negatively impacts academic success). Health education is not a core part of a quality education.
Parents/families, not teachers and schools, should be educating students about health.
The main issues with these frames are that three are defensive frames and one is a frame against health education in schools. It not surprising then that health education is not a requirement in more schools and why greater attention hasn’t been paid to health education as a viable public health approach.
Health education is fighting an uphill battle to begin with and when the main messaging relies on a defensive stance it serves as a cycle where people’s ideas that health education doesn’t matter are essentially reinforced since the frames seem to acknowledge the same facts – that health education is on the periphery in schools, that health but not necessarily health education can support academics and that despite what people think, it does matter – really. With weak frames like these, it would follow that there isn’t strong support for health education and then that there would be a lack of attention paid to health education. Instead of these frames, health education should use a value frame and an offensive stance that health education belongs in schools and is an effective intervention. There is data that supports health education in schools that should be leveraged to create a frame which has a core position that health education is a core subject which can provide students with the knowledge and skills necessary to be healthy now and in the future. Finally, there is also data to support that parents do want health education in schools (20) and the frame could use a “right to education” core value to argue that students have the right to health education delivered by a qualified teacher who has been trained in health education. Relying on outside sources can lead to misconceptions, misinformation and a lack of development of skills and attitudes needed to be healthy. The current framing is a third problem with health education in its current form.
Proposed Intervention: A skills-based approach to health education
The first major aspect of skills-based health education is the content – the actual subject matter that is taught to students – which includes both health-related concepts and skills. The National Health Education Standards (NHES) were created by the Joint Committee on National Health Education Standards to provide a framework for “aligning curriculum, instruction, and assessment practices” in health education (21). The standards were recently revised from the original published in 1995 to reflect the need for “health-related knowledge, skills and healthy beliefs, and values and norms” in school curricula (22). The standards themselves also reflect this need as only one of the standards relates to health-related concepts, the other seven relate to the following skills: analyzing skills, accessing information, interpersonal communication, decision-making, goal-setting, practicing health-enhancing behaviors and advocacy (21).
Health educators using a skills-based approach should use these national standards as a foundation on which to build their curriculum. The health-related concepts to be included in the curriculum should be integrated into these skill areas, should be appropriate for local needs, should be relevant for the students and the times, and should meet the needs of the students (21). Knowledge in skills-based health education should not be limited to health-related concepts for the purposes of learning facts because that makes the curriculum “incomplete and inadequate” (23).
Instructional methods in skills-based health education should be “student-centered, interactive and experiential” (23). This includes, but is not limited to, the following instructional strategies: role play, large and small group discussions, debates, cooperative learning, problem solving, brainstorming, and games/simulations (6, 23). Lecture or direct instruction, usually associated with disseminating factual knowledge or concepts, is not included in this list. The implication is that the focus in skills-based health education is not on the acquisition of facts/concepts alone, but on the larger aim of teaching skills, changing attitudes and influencing behaviors through the use of more interactive teaching methods.
The instructional methods used in skills-based health education are based around the premise that learning occurs in a social context and that the learning environment is student-centered and allows for social interactions (24). Students learn from the people around them including their teachers, peers, parents and other role models in their lives. This is especially important to consider due to the fact that during adolescence peer pressure and the perception of peer behaviors have been found to influence behavior (25). It would follow that it is important to address norms of health-related behaviors to help influence students’ attitudes towards certain behaviors, to acknowledge and listen to what students’ believe are the behaviors their peers are engaging in, to allow time for practice and feedback so that students can see each other applying skills successfully, and to address the influences in their lives that will guide their decisions. Direct instruction may not have the same impact on the students because it eliminates much of the social context of learning. Student centered learning environments and social interaction can be facilitated best through participatory learning through the use of discussion, brainstorming, role plays, and other techniques discussed above (6, 24).
Defense of Intervention 1: Effective Health Education IS Skills-Based
Research examining effective prevention programs (not just school-based) also supports the fact that skills are a core component of effective programming. Nation et al. discussed five principles of effective programs: varied teaching methods, comprehensive, theory driven, opportunities for positive relationships and sufficient dosage (26). Most relevant to health education are varied teaching methods, comprehensive programs and opportunities for positive relationships. Teaching methods found to be most successful are active, skill-based approaches that include interactive, hands-on experiences that increase participants’ skills (26). Greenberg et al. support this finding as they found that modeling behaviors with opportunity for rehearsal and feedback, having students set behavioral goals, and including cues to prompt behavior in a variety of settings are effective techniques in prevention programs (27). These are all methods of the participatory learning style that is associated with skills-based health education.
Nation et al. identified comprehensive programs as ones that have multiple interventions and multiple settings (26). “Multiple interventions” refers to addressing issues from multiple perspectives such as increasing awareness and skill teaching (26). Skills-based health education uses a variety of learning experiences and interventions from skill teaching and practice, to providing relevant information about the health-related concepts, to addressing norms about behaviors, to using group processes for learning. Research about prevention programs has revealed that teaching across multiple settings (school, community, peers) improves outcomes. In skills-based health education, health-related concepts and skills should be taught and applied in a variety of settings. One of the most important is the peer setting because of the significant influence peers have on health behaviors especially during adolescence. Finally, the interactive nature of participatory teaching methods used in skills-based health education provide an opportunity to work with other students in a safe environment through role play, small and large group discussions and other group processes that allow students to foster positive relationships.
Defense of Intervention 2: Theory Supports It
This skills-based approach is also supported by Bandura’s Social Cognitive Theory (SCT) (14). The multifaceted components of SCT are an effective framework for supporting the three main aspects of a skills-based health education approach which are: knowledge, skills and attitudes/beliefs. SCT suggests that health behavior is determined by the following influences: knowledge, self-efficacy, outcome expectations, goals and perceived facilitators and impediments (14).
The knowledge component of SCT addresses the fact that skills-based health education includes both content and skill knowledge because students need to know and understand certain concepts before they can apply them in their own lives and/or demonstrate their learning in the classroom. Skills-based health education also helps students develop self-efficacy through the opportunity for skill practice and evaluation of their skill performance. These opportunities also allow for teaching and learning regarding the attitudes and beliefs of certain health behaviors (both health-enhancing and risky behaviors) and the potential effects (or outcomes) of performing a certain skill or health behavior. Skills-based health education offers the opportunity for that type of learning to occur.
Lastly, certain skills included in the standards, specifically: goal-setting, analyzing influences, accessing information, and advocating for self and others, can help students learn to set goals and recognize facilitators and impediments in their lives. Goals along with facilitators and impediments are the remaining two determinants of health behavior according to SCT (14, 21). In addition to the research that supports the use of skills-based health education, SCT supplies a theoretical framework which furthers the case for skills-based health education.
In addition, unlike a traditional approach to health education, a skills-based approach also addresses multiple components of an ecological approach to health promotion as well as provides opportunities to use principles of effective public health campaigning such as social influences, targeted messages, branding, etc. This approach to health education is directly supported by SCT but also includes many opportunities to bring in core components of other health behavior theories and public health approaches.
Defense of Intervention 3: Provides a New Frame
Shifting from a traditional approach to health education to a skills-based health approach provides an opportunity to reframe the discussion from trying to justify why an approach which is not support by research or public health best practice (traditional) really does belong in schools – really! Instead, health education can be framed as an engaging, relevant, current and research-based approach which combines research and best practice from education and public health to meet the needs of students.
The frame could be “Students Need Skills” with a core position that a skills-based approach is a core subject that teaches students essential skills which they need in order to be healthy for life. This frame would be a position of strength and could build on some of the key points of the current frames but use them in a more proactive and positive way. It would also weaken the “it doesn’t belong in schools” frame as the core skills included (i.e., goal-setting, decision-making) are all skills included in the 21st century skills framework and are all included in other core subjects. This would change the language used in discussions since the argument would no longer be about who should be providing students with information or whether it belongs in schools, rather it will be that schools are a place where students develop skills that they need to be successful which also supports the relevance and place for a skills-based approach to health education in schools.
Conclusion
Health education has the potential to be an effective public health intervention which can make an impact on the health of youth. However, the current emphasis on a traditional approach which focuses on disseminating information through a didactic approach is not working. The proposed intervention is a skills-based approach to health education which would address the main critiques of the traditional approach and provide an opportunity for a new frame which will further strengthen the proposed approach.
References
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Thursday, December 18, 2014
Calorie Labeling at Point of Purchase in Chain Restaurants and Food Establishments: How Educating Fails to Combat Consumer Behavior -Emily Lawrence
Introduction
Approximately one in three of American adults and one in six American children are obese (1). The rise of obesity in America is a result of a verity of complex factors, one of which is the way that Americans eat has changed (1). Americans now consume approximately one third of their calories outside of the home and spend almost half of their annual food budget outside of the home (2,3). These restaurant and fast foods are typically higher in calories, sugar and fat and their calorie content is usually underestimated by the consumers (2,3). On November 25, 2014 the Food and Drug Administration (FDA) finalized two rules under the 2010 Patient Protection and Affordable Care Act to address this issue of lack of awareness and overconsumption of calorie dense food (4). The rules require that chain restaurants, similar food establishments and vending machines with 20 or more locations must clearly list calorie information on menus and menu boards next to the name or price of the item. The objective of the rules is to help consumers make informed and healthy diet choices for themselves and for their families (2, 4). Although some states and restaurants have already implemented calorie labeling on menus, this new legislation sets a uniform standard for all states (2). In order to help patrons recognize the significance of the calorie information menu boards will display this statement “2,000 calories a day is used for general nutrition advice, but calorie needs vary” (2).
The theory behind menu labeling is that if consumers are confronted with the calorie content of their food at the point of purchase, they may adjust their purchasing pattern and by doing so, may influence food localities to offer healthier options (5). The design of the Calorie Labeling Policy follows a Health Belief Model (HBM), which does not align appropriately with the target population, consumers. The objective of the Calorie Labeling Policy is to present consumers with facts, in this case, calories about their food options when eating out, thus “cueing” them to choose healthier food options. In addition to this cost-benefit analysis, “cues to action” are used to “push” individuals to act; in this case, the calorie labels are a “cue to action” (7).
There are multiple flaws within the design of the Calorie Labeling Policy. To begin with, the policy assumes that consumers undergo a rational weighting of health costs and benefits when making food choices at the point of purchase. In fact consumers often prioritize taste, convenience, price and hunger over health when making food based decisions. Additionally, the policy uses calorie labeling on menus to inform and influence consumer behavior, however this may confuse consumers more than it helps them. Finally, the policy assumes that by informing consumers on the nutritional content of their food, they motivate them to make healthier food choices. The problem is that intention doesn’t always lead to action. These fundamental flaws in the policy prevent it from accomplishing its objectives.
Flaw 1: Assuming that consumers make rational choices.
The Calorie Labeling Policy assumes that by increasing consumers awareness on calorie content will allow consumers to make a rational cost-benefit-analysis about what food item to choose in relation to how it will impact their health and or weight (6-9). This model, like other individual level models, is flawed because assumes that individuals always undergo a rational weighing of cost and benefits when making a health related decision. In the context of the Calorie Labeling Policy, it also assumes that consumers value their health and nutrition and will use the calorie labels to weigh the costs and benefits of choosing an item in relation to how it will affect their health. The use of this model underestimates the strength of other factors consumers are confronted with when deciding what food to order. Taste, price, convenience, along with the bombardment of media and advertising influences are likely play heavily in consumer behavior (6).
In a qualitative study by Schindler et al of 105 low-income New York City residence it was found that the majority of participants had noticed or heard of menu labels, but had not used them (14). The study found that habitual ordering, confusion over labels, price and hunger were common barriers to menu label use. For example, some participants mentioned that they go to fast food restaurants because they are hungry and choose their food items based on its ability to relieve hunger. One focus group participant mentioned, “I notice the calories, but if I’m really hungry…gimme that beef and potato, you know I’m looking for something to fill me. (14)” Other participants noted that the calorie count does in fact prompt them to weigh the risks and benefits of ordering the item, however they end up rationalizing ordering what they want. For example, one focus group participant came to the conclusion that “It [calorie label] doesn’t really affect what I eat because I’ll say, oh ok I’ll just run it off this week or in my sleep I’ll burn the calories. (14)” These focus group participants demonstrate that at times consumers may in fact go through a cost-benefit analysis when ordering food items, however they are not weighing it in relation to their health, rather in relation to other factors, like hunger.
Habits, consumer loyalty and marketing influences also play strongly on consumers’ inability to rationally weigh the health costs and benefits of a food item. In the Study by Schindler some participants mentioned that they know what food item they are going to buy before they even enter the food establishment (14). This demonstrates the influence of fast food marketing and its influence on consumer loyalty to a product. The pervasiveness of fast food marketing in America and its impact on consumer purchasing patterns has huge impactions on the ability of American consumers to make rational diet decisions. This policy falls short because it does not understand what consumers’ value and it overestimates consumers’ ability to make rational health choices at the point of purchase.
Flaw 2: The Cue to Action results in inaction
The calorie labeling policy is based on the fact that most consumers underestimate the number of calories and fat in foods they order away from home (2,3). According to the Health Belief Model (HBM), after an individual has undergone a cost-benefit-analysis, “cues to action” are needed to motivate an individual to act. In the case of the Calorie Labeling Policy, the calorie labels are meant to push or motivate consumers to make healthier food options. The fundamental problem with the “cue to action in this policy is that not all consumers understand the “cue”.
In a review of New York fast food restaurant boards, where calorie labeling has been in effect since 2008, it was found that calorie ranges for combination meals; flavor differences and customizations can vary substantially. This makes it difficult for consumers to determine the calorie content of a specific food item (17). Additionally, in a cross-sectional study by Pulos et al in Piece County, WA, it was found that 49% of customers did not understand the food labels (20). Schindler et al explains that not only are ranges confusing, but the relative value of the calories also present difficulties for consumers. Study participants mentioned confusion about the meaning of calories as well as presentation of large calorie ranges for combination meals was unclear. This confusion even led some focus group participants to distrust the label’s accuracy (14).
Though the policy attempts to help consumers understand the caloric significance of each food item by labeling each menu with the declaration that “2,000 calories a day is used for general nutrition advice, but calorie needs vary”, it is not sufficient enough to help consumers understand the calorie impact of their food. As demonstrated in the work of Schindler et al, often consumers do not know what the caloric value of their other daily foods are, so they might not understand how this one meal fits into their entire day (14). Additionally, the ambiguity of the statement “but calorie needs may vary”, may lead consumers to believe that they are an exception to the rule and therefor not use the calorie label to make their meal choice. Without providing clear tools for consumers to understand the calorie content of food items, this policy fails on “cuing” consumers to make healthier food choices.
Flaw 3: Intention does not lead to action
In a study by Ebel et al it was found that 27.7% of consumers in Philadelphia who saw calorie labels reported that it influenced their food choice, however when Ebel compared those customers to a control group in Baltimore, no changes were detected in the number of calories purchased (15). The empirical research thus far supports Ebel’s findings. Changes in consumer intention to purchase healthier options does not result in changes to their purchasing patterns (14, 18-20).
There is empirical evidence showing that there is often disconnect between intention and action with health related behaviors. In a review of 47 studies on social cognition models, like HBS, over two thirds of the studies found that a belief in ones ability to preform an action did not actually correspond to action (21). This is explained in the fact HBS and the Calorie Labeling Policy are based on the notion that behavior results from knowledge, desire and intent. The policy does not take into account the strong emotional and habitual nuances of human behavior. In the book Predictably Irrational by Dan Ariely he explains, “ We all systematically under-predict the degree to which [emotional] arousal completely negates our superego, and the way emotions can take control of our behavior. (22)” In terms of the Calorie Labeling Policy, labeling calories doesn’t work because eating is not only a physical need, but a social and emotional behavior. Food acts as comfort to individuals, it satiates our hunger both physically and emotionally. According to Ariely’s logic, this means that we cannot predict food choices or change them based on the acquisition of new knowledge on the number of calories in each portion.
This policy does not take into account human behavior or emotion, instead it takes a very simplistic view of behavior by assuming that exposure to caloric information on food and drink items will be enough to deter consumers from ordering high calorie items. In a New York Times article, George Lowenstein, a behavioral economist, enforces this point “There are very few cases where social scientists have documented that giving people information has changed their behavior very much…Changing prices and changing convenience have big impacts. Providing information doesn’t. (10)
Proposed Intervention
As an alternative to the Calorie Labeling Policy in food establishments, I propose a campaign to combat the influence of Big Food Corporations like Coca-Cola, McDonald’s, Pepsi, Burger King and other fast food conglomerates. The campaign would that use different group level behavior change tactics, like advertising and Theory of Diffusion Innovation to deter individuals from over-consuming high calorie dense foods. This campaign would involve a re-framing of the issue, the goal would no longer be prevent individual consumer behavior, but rather shift the blame and responsibility to the big food companies. This new frame would then be implemented through marketing and branding approach, using many of the theories and tactics of anti-tobacco campaigns like the “Truth” ads and targeted through school networks and media. The campaigns major objectives would be to impact the American population on an emotional level and expose the manipulation of the Big Food corporations and the consequences they have had on American families. This is in stark contrast to the rational choice model presented in the Calorie Labeling Policy.
Defense 1: The campaign focuses on freedom, not health
A frame is a method of packaging and arranging an issue so that it tells a certain story (23). One of the major flaws with the Calorie Labeling Policy is that it is framed in a way that places health as a core value and sends the message that it is the responsibility of the consumer to make rational, healthy options based on caloric information. The current Calorie Labeling Policy frame obstructs the idea of personal autonomy and life-style choices, when it should empower them. This proposed campaign would use fundamental American core value of individual freedom, a value that is deeply ingrained in American culture. According to Meashe and Siegel “although health is an important core value for the public and policy makers, personal freedoms, civil liberties and individual rights may be even more compelling values.(23)”
The core position of the proposed campaign would be that Big Food Corporations have manipulated Americans and thus caused negative effect of on American culture and that their advertising techniques have thwarted our ability to make independent choices. Images of individuals, particularly children, affected by obesity caused by Big Food would enforce our message and capture consumer emotion. By shifting the frame, we can shift the blame of the Obesity epidemic. Reframing the issue could have powerful effects not only on consumer behavior, but also on public health policy that gets to the route of the obesity problem.
Defense 2: The campaign fights fire with fire
An inherent flaw of the Calorie Labeling policy that it is based on the presumption that intention leads to action and that by empowering people with information, they will be able to overcome their predisposition for these convenient, high calorie, intensity flavorful and convenient food items. In his book Fast Food Nation, Eric Scholosser explains that (11);
McDonald’s spends more money on advertising and marketing than on any other brand. As a result it has replaced Coca-Cola as the world’s most famous brand. McDonald’s operates more playgrounds than any other private entitiy in the United States. It is one of the nation’s largest distributors of toys. A survey of American school children found that 96% could identify Ronald McDonald. The only fictional character with a higher degree of recognition was Santa Claus. The impact of McDonald’s on the way we live today is hard to overstate. The Golden Arches are now more widely recognized than the Christian cross. (11)
In a systematic review of 123 peer-reviewed studies by the Institute of Medicine, it was found that food marketing deliberately targets young children, who cannot distinguish advertising from truth, thus strongly motivating their food and drink preferences, requests and consumption (12,13). The study concludes that, “some forms of marketing increase the risk of obesity, cannot be rejected (12).” Fast food marketing is not exclusive to children, with decades of exposure the majority of American citizens have experienced of television, newspaper, magazine and environmental advertising, fast food companies have manipulated and continue to manipulate consumer choices regarding consumer choices and loyalties (6, 16).
In order to truly fight consumption of high calorie foods in chain restaurant establishments, Public Health Advocates and Legislatures need to fight fire with fire. Instead of simply attempting to educate consumers about the calories in their fast food choices, there needs to be a concerted effort to form marketing campaigns that fight against the presumptions made in fast food marketing. The proposed campaign will do this by using the same social marketing techniques employed by the anti-tobacco ‘Truth’ campaign.
The ‘Truth’ campaign looked for inspiration from the very population their campaign was targeting. They used focus groups and interviews to understand emotion behind smoking “we learned that a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making. (24)” Branding was also used to create an identity for those who opposed the tobacco industry, this helped to accumulate awareness and bolster loyalty to the cause (24). By using these same techniques and focusing on those individuals who are affected by obesity and/or big food and target our campaign messages on the emotional factors that influence fast food consumer behavior.
Defense 3: The campaign uses social innovations theory
An alternative approach to intervening with consumers at the point of purchase and relying on a ‘cue to action’ is to use the theory of diffusion innovation to influence consumer behavior before they even enter food establishments or vending machines. The proposed campaign will use the Theory of Diffusion Innovation primarily with children and adolescents. Children and Adolescence are more easily influenced by media and peers and, spend approximately $30 billion of their own money on fast food and junk food and have significant influence over the eating habits of their families (13). The Theory of Diffusion Innovations states that “adoption of a new idea, behavior, or product does not happen simultaneously in a social system; rather it is a process whereby some people are more apt to adopt than others (25).”
A key component of the Theory of Diffusion of Innovation is the targeting of innovators, or people who are willing to take risks and who ultimately take the risks and start the innovation. Since one component of our campaign is to target schools, we would assess the social environment of each school and identify individuals who have the most social influence among their peers. These individuals would become the “innovators” of the campaign and according to the Theory of Diffusion Innovation, these innovators would then influence their peers to join the campaign (25). This method of using both school popularity and media presents a more effective platform for influencing consumer purchasing behavior because it focuses on changing social norms as opposed to changing consumer knowledge.
Conclusion
The Calorie Labeling Policy has been implemented to educate consumers on the nutritional content of the food they are purchasing in chain restaurants and vending machines. Though there is nothing inherently wrong with consumer education, however the reality is that it does very little to impact consumer behavior. Obesity is epidemic in America and if Public Health Advocates want any chance at denting fast food and junk food consumption, new strategies that target the emotions and not the knowledge of consumers is needed. Public Health Advocates can no longer rely on consumers to value their health or act rationally when making daily food choices. I propose a campaign that focuses on changing consumer behavior through emotion and taking the blame off of the individual and onto the shoulders of the Big Food corporations. This comprehensive campaign uses mass media and school advocacy to change the way that Americans not only view their food choices, but view the entire food system.
References
1) Centers for Disease Control and Prevention. Overweight and Obesity. 2013. http://www.cdc.gov/CDCTV/ObesityEpidemic/
2) U.S. Food and Drug Administration. Press Release: FDA finalizes menu and vending machine calorie labeling rules. 2014. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm423952.htm
3) Centers for Disease Control and Prevention. Adult Obesity Facts. 2014. http://www.cdc.gov/obesity/data/adult.html
4) U.S. Food and Drug Administration. Labeling Nutrition. 2014 http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm248732.htm
5) Jennifer L. Pomeranz & Kelly D. Brownell, Legal and Public Health Considerations Affecting the Success, Reach, and Impact of Menu-Labeling Laws, 98 AM. J. Public. Health. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2509596/
6) Kriegar J, Saelens BE. Impact of Menu Labeling on Consumer Behavior: A 2008-2012 Update. Minneapolis MN: Healthy Eating Research.2013.Available at: http://healthyeatingresearch.org.
7) National Cancer Institute. Theory at a Glance: A guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21
8) Rosenstok I., Strecher V., Becker M.Social Learning Theory and the Health Belief Model. Health Education Q. 1988 Summer;15(2):175-83. http://deepblue.lib.umich.edu/bitstream/handle/2027.42/67783/10.1177_109019?sequence=2
9) Barton S, Creyer E, Kees J, et al. Attacking the Obesity Epidemic: The 27. Potential Health Benefits of Providing Nutrition Information in Restaurants. American Journal of Public Health, 96(9): 1669–1675, September 2006.
10) Tavernise S. The New York Times. Calories on menus: Nationwide Experiment Into Human Behavior. 2014. http://www.nytimes.com/2014/11/27/upshot/calories-on-menus-a-nationwide-experiment-into-human-behavior.html?_r=0&abt=0002&abg=1
11) Schlosser. Fast Food nation: The Dark Side of the All-American Meal. New York, Ny. First Mariner Books edition. 2011
12) McGinnis JM, Gootman JA, Kraak VI, eds. Food marketing to children and youth: threat or opportunity? Washington, D.C.: National Academies Press, 2006
13) Nestle. Food marketing and Childhood Obesity-A Matter of Policy. New England Journal of Medicine. 2006; 354:2527-2529. http://www.nejm.org.ezproxy.bu.edu/doi/full/10.1056/NEJMp068014#ref1
14) Schindler J., Kiszko K., Abrams C., Islam N., Elbel B., Environmental and Individual Factors Affecting Menu Labeling Utilization: A Qualitative Research Study, Journal of the Academy of Nutrition and Dietetics 2013; Volume 113, Issue
15) Elbel B., Kersh R., Victoria L., Brescoll, Dixon L., Calorie Labeling and Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs. 2009; vol. 28 no. 6 w1110-w1121 http://content.healthaffairs.org/content/28/6/w1110
16) J Harms and D Kellner, Toward a critical theory of advertising, University of Texas Illuminations website, n.d., viewed 27 August 2010, http://www.uta.edu/huma/illuminations/kell6.htm
17) Cohn EG, Larson EL, Araujo C, Sawyer V, Williams O. Calorie postings in chain restaurants in a low-income urban neighborhood: Measuring practical utility and policy compliance. J Urban Health. Aug 2012;89(4): 587-597.
18) Pulos E, Leng K. Evaluation of a voluntary menu-labeling program in full-service restaurants. Am J Public Health. Jun 2010;100(6):1035-1039.
19) Thunström L,Nordström J.Does easily accessible nutritional labelling increase consumption of healthy meals away from home? A field experiment measuring the impact of a point-of-purchase healthy symbol on lunch sales. http://bit.ly/ZL8yqz.
20) Tandon PS, Wright J, Zhou C, Rogers CB, Christakis DA. Nutrition menu labeling may lead to lower-calorie restaurant meal choices for children. Pediatrics. Feb 2010;125(2):244-248.
21) Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003;22:424-428
22) Ariely D., Predictably Irrational: The Hidden Forces that Shape our Decisions. New York Ny. HaperCollins. 2009.
23) Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues-United States, 1985-1996.Journal of Health Communication 1988; 3(4):307-325.
24) Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5
25) Boston University School of Public Health. Behavioral Change Models: Diffusion of Innovation Theory. Boston, MA: Boston University School of Public Health. http://sphweb.bumc.bu.edu/otlt/MPHModules/SB/SB721Models/SB721-Models4.html
Approximately one in three of American adults and one in six American children are obese (1). The rise of obesity in America is a result of a verity of complex factors, one of which is the way that Americans eat has changed (1). Americans now consume approximately one third of their calories outside of the home and spend almost half of their annual food budget outside of the home (2,3). These restaurant and fast foods are typically higher in calories, sugar and fat and their calorie content is usually underestimated by the consumers (2,3). On November 25, 2014 the Food and Drug Administration (FDA) finalized two rules under the 2010 Patient Protection and Affordable Care Act to address this issue of lack of awareness and overconsumption of calorie dense food (4). The rules require that chain restaurants, similar food establishments and vending machines with 20 or more locations must clearly list calorie information on menus and menu boards next to the name or price of the item. The objective of the rules is to help consumers make informed and healthy diet choices for themselves and for their families (2, 4). Although some states and restaurants have already implemented calorie labeling on menus, this new legislation sets a uniform standard for all states (2). In order to help patrons recognize the significance of the calorie information menu boards will display this statement “2,000 calories a day is used for general nutrition advice, but calorie needs vary” (2).
The theory behind menu labeling is that if consumers are confronted with the calorie content of their food at the point of purchase, they may adjust their purchasing pattern and by doing so, may influence food localities to offer healthier options (5). The design of the Calorie Labeling Policy follows a Health Belief Model (HBM), which does not align appropriately with the target population, consumers. The objective of the Calorie Labeling Policy is to present consumers with facts, in this case, calories about their food options when eating out, thus “cueing” them to choose healthier food options. In addition to this cost-benefit analysis, “cues to action” are used to “push” individuals to act; in this case, the calorie labels are a “cue to action” (7).
There are multiple flaws within the design of the Calorie Labeling Policy. To begin with, the policy assumes that consumers undergo a rational weighting of health costs and benefits when making food choices at the point of purchase. In fact consumers often prioritize taste, convenience, price and hunger over health when making food based decisions. Additionally, the policy uses calorie labeling on menus to inform and influence consumer behavior, however this may confuse consumers more than it helps them. Finally, the policy assumes that by informing consumers on the nutritional content of their food, they motivate them to make healthier food choices. The problem is that intention doesn’t always lead to action. These fundamental flaws in the policy prevent it from accomplishing its objectives.
Flaw 1: Assuming that consumers make rational choices.
The Calorie Labeling Policy assumes that by increasing consumers awareness on calorie content will allow consumers to make a rational cost-benefit-analysis about what food item to choose in relation to how it will impact their health and or weight (6-9). This model, like other individual level models, is flawed because assumes that individuals always undergo a rational weighing of cost and benefits when making a health related decision. In the context of the Calorie Labeling Policy, it also assumes that consumers value their health and nutrition and will use the calorie labels to weigh the costs and benefits of choosing an item in relation to how it will affect their health. The use of this model underestimates the strength of other factors consumers are confronted with when deciding what food to order. Taste, price, convenience, along with the bombardment of media and advertising influences are likely play heavily in consumer behavior (6).
In a qualitative study by Schindler et al of 105 low-income New York City residence it was found that the majority of participants had noticed or heard of menu labels, but had not used them (14). The study found that habitual ordering, confusion over labels, price and hunger were common barriers to menu label use. For example, some participants mentioned that they go to fast food restaurants because they are hungry and choose their food items based on its ability to relieve hunger. One focus group participant mentioned, “I notice the calories, but if I’m really hungry…gimme that beef and potato, you know I’m looking for something to fill me. (14)” Other participants noted that the calorie count does in fact prompt them to weigh the risks and benefits of ordering the item, however they end up rationalizing ordering what they want. For example, one focus group participant came to the conclusion that “It [calorie label] doesn’t really affect what I eat because I’ll say, oh ok I’ll just run it off this week or in my sleep I’ll burn the calories. (14)” These focus group participants demonstrate that at times consumers may in fact go through a cost-benefit analysis when ordering food items, however they are not weighing it in relation to their health, rather in relation to other factors, like hunger.
Habits, consumer loyalty and marketing influences also play strongly on consumers’ inability to rationally weigh the health costs and benefits of a food item. In the Study by Schindler some participants mentioned that they know what food item they are going to buy before they even enter the food establishment (14). This demonstrates the influence of fast food marketing and its influence on consumer loyalty to a product. The pervasiveness of fast food marketing in America and its impact on consumer purchasing patterns has huge impactions on the ability of American consumers to make rational diet decisions. This policy falls short because it does not understand what consumers’ value and it overestimates consumers’ ability to make rational health choices at the point of purchase.
Flaw 2: The Cue to Action results in inaction
The calorie labeling policy is based on the fact that most consumers underestimate the number of calories and fat in foods they order away from home (2,3). According to the Health Belief Model (HBM), after an individual has undergone a cost-benefit-analysis, “cues to action” are needed to motivate an individual to act. In the case of the Calorie Labeling Policy, the calorie labels are meant to push or motivate consumers to make healthier food options. The fundamental problem with the “cue to action in this policy is that not all consumers understand the “cue”.
In a review of New York fast food restaurant boards, where calorie labeling has been in effect since 2008, it was found that calorie ranges for combination meals; flavor differences and customizations can vary substantially. This makes it difficult for consumers to determine the calorie content of a specific food item (17). Additionally, in a cross-sectional study by Pulos et al in Piece County, WA, it was found that 49% of customers did not understand the food labels (20). Schindler et al explains that not only are ranges confusing, but the relative value of the calories also present difficulties for consumers. Study participants mentioned confusion about the meaning of calories as well as presentation of large calorie ranges for combination meals was unclear. This confusion even led some focus group participants to distrust the label’s accuracy (14).
Though the policy attempts to help consumers understand the caloric significance of each food item by labeling each menu with the declaration that “2,000 calories a day is used for general nutrition advice, but calorie needs vary”, it is not sufficient enough to help consumers understand the calorie impact of their food. As demonstrated in the work of Schindler et al, often consumers do not know what the caloric value of their other daily foods are, so they might not understand how this one meal fits into their entire day (14). Additionally, the ambiguity of the statement “but calorie needs may vary”, may lead consumers to believe that they are an exception to the rule and therefor not use the calorie label to make their meal choice. Without providing clear tools for consumers to understand the calorie content of food items, this policy fails on “cuing” consumers to make healthier food choices.
Flaw 3: Intention does not lead to action
In a study by Ebel et al it was found that 27.7% of consumers in Philadelphia who saw calorie labels reported that it influenced their food choice, however when Ebel compared those customers to a control group in Baltimore, no changes were detected in the number of calories purchased (15). The empirical research thus far supports Ebel’s findings. Changes in consumer intention to purchase healthier options does not result in changes to their purchasing patterns (14, 18-20).
There is empirical evidence showing that there is often disconnect between intention and action with health related behaviors. In a review of 47 studies on social cognition models, like HBS, over two thirds of the studies found that a belief in ones ability to preform an action did not actually correspond to action (21). This is explained in the fact HBS and the Calorie Labeling Policy are based on the notion that behavior results from knowledge, desire and intent. The policy does not take into account the strong emotional and habitual nuances of human behavior. In the book Predictably Irrational by Dan Ariely he explains, “ We all systematically under-predict the degree to which [emotional] arousal completely negates our superego, and the way emotions can take control of our behavior. (22)” In terms of the Calorie Labeling Policy, labeling calories doesn’t work because eating is not only a physical need, but a social and emotional behavior. Food acts as comfort to individuals, it satiates our hunger both physically and emotionally. According to Ariely’s logic, this means that we cannot predict food choices or change them based on the acquisition of new knowledge on the number of calories in each portion.
This policy does not take into account human behavior or emotion, instead it takes a very simplistic view of behavior by assuming that exposure to caloric information on food and drink items will be enough to deter consumers from ordering high calorie items. In a New York Times article, George Lowenstein, a behavioral economist, enforces this point “There are very few cases where social scientists have documented that giving people information has changed their behavior very much…Changing prices and changing convenience have big impacts. Providing information doesn’t. (10)
Proposed Intervention
As an alternative to the Calorie Labeling Policy in food establishments, I propose a campaign to combat the influence of Big Food Corporations like Coca-Cola, McDonald’s, Pepsi, Burger King and other fast food conglomerates. The campaign would that use different group level behavior change tactics, like advertising and Theory of Diffusion Innovation to deter individuals from over-consuming high calorie dense foods. This campaign would involve a re-framing of the issue, the goal would no longer be prevent individual consumer behavior, but rather shift the blame and responsibility to the big food companies. This new frame would then be implemented through marketing and branding approach, using many of the theories and tactics of anti-tobacco campaigns like the “Truth” ads and targeted through school networks and media. The campaigns major objectives would be to impact the American population on an emotional level and expose the manipulation of the Big Food corporations and the consequences they have had on American families. This is in stark contrast to the rational choice model presented in the Calorie Labeling Policy.
Defense 1: The campaign focuses on freedom, not health
A frame is a method of packaging and arranging an issue so that it tells a certain story (23). One of the major flaws with the Calorie Labeling Policy is that it is framed in a way that places health as a core value and sends the message that it is the responsibility of the consumer to make rational, healthy options based on caloric information. The current Calorie Labeling Policy frame obstructs the idea of personal autonomy and life-style choices, when it should empower them. This proposed campaign would use fundamental American core value of individual freedom, a value that is deeply ingrained in American culture. According to Meashe and Siegel “although health is an important core value for the public and policy makers, personal freedoms, civil liberties and individual rights may be even more compelling values.(23)”
The core position of the proposed campaign would be that Big Food Corporations have manipulated Americans and thus caused negative effect of on American culture and that their advertising techniques have thwarted our ability to make independent choices. Images of individuals, particularly children, affected by obesity caused by Big Food would enforce our message and capture consumer emotion. By shifting the frame, we can shift the blame of the Obesity epidemic. Reframing the issue could have powerful effects not only on consumer behavior, but also on public health policy that gets to the route of the obesity problem.
Defense 2: The campaign fights fire with fire
An inherent flaw of the Calorie Labeling policy that it is based on the presumption that intention leads to action and that by empowering people with information, they will be able to overcome their predisposition for these convenient, high calorie, intensity flavorful and convenient food items. In his book Fast Food Nation, Eric Scholosser explains that (11);
McDonald’s spends more money on advertising and marketing than on any other brand. As a result it has replaced Coca-Cola as the world’s most famous brand. McDonald’s operates more playgrounds than any other private entitiy in the United States. It is one of the nation’s largest distributors of toys. A survey of American school children found that 96% could identify Ronald McDonald. The only fictional character with a higher degree of recognition was Santa Claus. The impact of McDonald’s on the way we live today is hard to overstate. The Golden Arches are now more widely recognized than the Christian cross. (11)
In a systematic review of 123 peer-reviewed studies by the Institute of Medicine, it was found that food marketing deliberately targets young children, who cannot distinguish advertising from truth, thus strongly motivating their food and drink preferences, requests and consumption (12,13). The study concludes that, “some forms of marketing increase the risk of obesity, cannot be rejected (12).” Fast food marketing is not exclusive to children, with decades of exposure the majority of American citizens have experienced of television, newspaper, magazine and environmental advertising, fast food companies have manipulated and continue to manipulate consumer choices regarding consumer choices and loyalties (6, 16).
In order to truly fight consumption of high calorie foods in chain restaurant establishments, Public Health Advocates and Legislatures need to fight fire with fire. Instead of simply attempting to educate consumers about the calories in their fast food choices, there needs to be a concerted effort to form marketing campaigns that fight against the presumptions made in fast food marketing. The proposed campaign will do this by using the same social marketing techniques employed by the anti-tobacco ‘Truth’ campaign.
The ‘Truth’ campaign looked for inspiration from the very population their campaign was targeting. They used focus groups and interviews to understand emotion behind smoking “we learned that a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making. (24)” Branding was also used to create an identity for those who opposed the tobacco industry, this helped to accumulate awareness and bolster loyalty to the cause (24). By using these same techniques and focusing on those individuals who are affected by obesity and/or big food and target our campaign messages on the emotional factors that influence fast food consumer behavior.
Defense 3: The campaign uses social innovations theory
An alternative approach to intervening with consumers at the point of purchase and relying on a ‘cue to action’ is to use the theory of diffusion innovation to influence consumer behavior before they even enter food establishments or vending machines. The proposed campaign will use the Theory of Diffusion Innovation primarily with children and adolescents. Children and Adolescence are more easily influenced by media and peers and, spend approximately $30 billion of their own money on fast food and junk food and have significant influence over the eating habits of their families (13). The Theory of Diffusion Innovations states that “adoption of a new idea, behavior, or product does not happen simultaneously in a social system; rather it is a process whereby some people are more apt to adopt than others (25).”
A key component of the Theory of Diffusion of Innovation is the targeting of innovators, or people who are willing to take risks and who ultimately take the risks and start the innovation. Since one component of our campaign is to target schools, we would assess the social environment of each school and identify individuals who have the most social influence among their peers. These individuals would become the “innovators” of the campaign and according to the Theory of Diffusion Innovation, these innovators would then influence their peers to join the campaign (25). This method of using both school popularity and media presents a more effective platform for influencing consumer purchasing behavior because it focuses on changing social norms as opposed to changing consumer knowledge.
Conclusion
The Calorie Labeling Policy has been implemented to educate consumers on the nutritional content of the food they are purchasing in chain restaurants and vending machines. Though there is nothing inherently wrong with consumer education, however the reality is that it does very little to impact consumer behavior. Obesity is epidemic in America and if Public Health Advocates want any chance at denting fast food and junk food consumption, new strategies that target the emotions and not the knowledge of consumers is needed. Public Health Advocates can no longer rely on consumers to value their health or act rationally when making daily food choices. I propose a campaign that focuses on changing consumer behavior through emotion and taking the blame off of the individual and onto the shoulders of the Big Food corporations. This comprehensive campaign uses mass media and school advocacy to change the way that Americans not only view their food choices, but view the entire food system.
References
1) Centers for Disease Control and Prevention. Overweight and Obesity. 2013. http://www.cdc.gov/CDCTV/ObesityEpidemic/
2) U.S. Food and Drug Administration. Press Release: FDA finalizes menu and vending machine calorie labeling rules. 2014. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm423952.htm
3) Centers for Disease Control and Prevention. Adult Obesity Facts. 2014. http://www.cdc.gov/obesity/data/adult.html
4) U.S. Food and Drug Administration. Labeling Nutrition. 2014 http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm248732.htm
5) Jennifer L. Pomeranz & Kelly D. Brownell, Legal and Public Health Considerations Affecting the Success, Reach, and Impact of Menu-Labeling Laws, 98 AM. J. Public. Health. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2509596/
6) Kriegar J, Saelens BE. Impact of Menu Labeling on Consumer Behavior: A 2008-2012 Update. Minneapolis MN: Healthy Eating Research.2013.Available at: http://healthyeatingresearch.org.
7) National Cancer Institute. Theory at a Glance: A guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21
8) Rosenstok I., Strecher V., Becker M.Social Learning Theory and the Health Belief Model. Health Education Q. 1988 Summer;15(2):175-83. http://deepblue.lib.umich.edu/bitstream/handle/2027.42/67783/10.1177_109019?sequence=2
9) Barton S, Creyer E, Kees J, et al. Attacking the Obesity Epidemic: The 27. Potential Health Benefits of Providing Nutrition Information in Restaurants. American Journal of Public Health, 96(9): 1669–1675, September 2006.
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A Critical Look at the Don’t Be a Lab Rat Campaign on Marijuana Use Prevention Efforts Among Teenagers – Kara Sewalk
With the evolving legalization of marijuana in the United States, public health professionals, lawmakers, politicians and community members have raised concerns of marijuana use in the United States, particularly focusing on the youth of America. The Official State of Colorado Website for Retail Marijuana Information and Resources maintains that, “according to the 2011 Healthy Kids Colorado Survey, approximately 55 percent of youth tried marijuana at least once by the time they reached 12th grade. The percentage of youth that perceive marijuana use as dangerous is declining” (1). This concern is being addressed in the Don’t Be a Lab Rat campaign, a $2 million campaign funded by the state of Colorado that the city of Denver launched in the summer of 2014, which markets the adverse effects of marijuana use to teenager’s 12 to 15 years olds (2). The Don’t Be a Lab Rat campaign premise is simple: to dissuade teens from smoking marijuana, the argument is made that not enough scientific evidence is available to show the true effects of the drug on the human brain, particularly on the developing brain of teens. Therefore, teenagers who smoke marijuana become the test subjects for future studies on adverse effects of the drug. The campaign is backed up with human-sized rat cages placed in areas around the city of Denver where teens frequent to give a visual on what it is like to be a test rat. Television advertisements are also run which state the possible consequences of marijuana use among teenagers, the data of which, while mostly speculation, comes across extremely frightening to viewers. The full campaign can be explored at www.dontbealabrat.com.
Marijuana use among teenagers is a widely recognized public health concern; however, this intervention is a flawed approach to address the issue. The campaign targets individual viewers and does not take into the account social influences on marijuana use, the negative imagery associated with the campaign is adversely affecting it’s own success, and finally the campaign is flawed in the delivery of the anti-marijuana message to the target audience.
Critique Argument 1: Flaws in Targeting the Individual
The Don’t Be a Lab Rat campaign relies on perceived threats to health by the individual. The campaign, targeted to teenagers 12 to 15 years old, assumes that those who see the campaign will learn that marijuana is potentially extremely dangerous, particularly to developing teenage brains and therefore one should not experiment with the drug. The campaign implements the health belief model to get this message across. The health belief model is one of the most widely used traditional interventions in health education and promotion and has six steps that individuals undergo to motivate themselves to act out or refrain from a particular health behavior. The core of the theory includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy (3). There are a number of flaws in relying on the Health Belief Model in the Don’t Be a Lab Rat campaign. The greatest weakness of implementing this model is that it focuses on the individual person’s internal drive to reduce a health behavior. It assumes that a teenager exposed to this campaign will perceive him or her-self as being at high risk to being exposed to marijuana. The campaign also assumes that teenagers will recognize the “laundry list of troubling side effects [such as] schizophrenia, permanent IQ loss and stunted brain growth” (2) as severe threats to health. In addition, the target audience will make the rational decision that marijuana use has no benefits while the perceived benefits of not smoking marijuana will be a healthier life, free of becoming a test subject in future studies on adverse effects of the drug use among teenagers. The campaign could be identified as the cue to action to get teenagers to not experiment with marijuana, because of the potential troubling side effects. There is a major flaw in relying on individualized interventions and assuming a rational thought process in behavior change. Currently, the perceived risk of marijuana use is quite low among teenagers (4) which explains this campaign aims to drastically increase how teens view smoking the drug. However, the need to boost the perceived severity of the behavior does not necessarily equate to the behavior change, which is what this campaign assumes. Using the health belief model, the campaign assumes that teenagers will value their future health and that the potential adverse effects for using marijuana are too high to pick up the drug. What the campaign does not acknowledge is that health is an extremely weak core value, particularly among teenagers. It may be difficult for teenagers to see the perceived benefits of health, particularly when the study acknowledges that these risks are only speculated. Health is generally undervalued and often taken for granted. The health belief model is an ineffective tool in the Don’t Be A Lab Rat campaign because it relies too heavily on the assumption that individual teenagers will rationally make the decision that the potential side effects of using marijuana are too high a threat to experiment. However, it does not address the social or environmental factors that are even more influential to a teenager’s behavior (3). The advertisements of this campaign are specifically designed to induce fear into the target audience. Often the decision to try marijuana happens in social settings, which has much stronger influence over behavior change than an individual’s personal knowledge of harm that may (or may not) result. For this reason, an individualized perspective to behavior change is a flawed mechanism for the effectiveness in reducing teen marijuana use in Colorado.
Critique Argument 2: Flaws in the Visual Images
One aspect of the Don’t Be a Lab Rat campaign that undermines the success of the intervention is the use of rat cages throughout the city. The purpose of the human-sized rat cages placed outside the Denver Public Library and local Colorado skate parks where teens frequent is to give the harsh visual of what is it actually like to be inside a rat cage. The effect is also intended to have a high shock value. With the ability to let people walk inside a giant rat cage, the campaign hopes to express the vulnerability and suffocation of what being a lab experiment subject is truly like. The use of such a visual is intended to bring a harsh reality check to teens that those who use marijuana are indeed lab rats for future studies. However, this is a crude and unnecessary representation that has flawed the intervention. The core message of the campaign is, at this point in time there is inconclusive data on the harmful effects of marijuana use on developing brains. The rat cages do not have any purpose but to patronize and induce fear into those who use or are thinking about using the drug. This is an ineffective method to reduce the rates of teens using marijuana and ineffective in creating awareness of potentially dangerous effects of the drug. Fear as a core message in any intervention will not be met with success, particularly among teenagers (9). The entire message is overshadowed by the immense and dramatic delivery through the human-sized rat cages. In addition, the visual display is not respected in the city as it had quickly been vandalized with the words, “Smoking weed saved my life” and “Scientists can’t wait to see the positive effects it has on your brain” (6). The reason why the use of rat cages is a flaw to this campaign is due to the social reaction theory and the communications theory. The social reaction theory, also known as the labeling theory states that when a person does a behavior, they are defined by the behavior and consequently finds a personal identity in the label given to them by the behavior, which reinforces the repetition of said behavior (8). In the Don’t Be a Lab Rat campaign, teens that have used marijuana are labeled as “Lab Rats” and are stigmatized to become merely test subjects that have no hope but to await future studies to tell them more conclusive data on what adverse health effects to expect. The label of being a “Lab Rat” would therefore become the identity of those who currently use marijuana, which will reinforce the behavior. While the campaign is designed to scare off teenagers from experimenting with the drug, it has no premise for those who have already. The campaign offers no advice or help for teenagers who have experimented with marijuana but do not want to become “lab rats”. Rather, it leaves teens to become the identity they are labeled as which is a major flaw in the implementation of this campaign. The communication theory is the basic principle that people respond better to persuasive messages when they have a connection with the object delivering the message (7). While it should matter what the message is, such as potential adverse effects of teenage marijuana use, it is really how well liked or how well received the delivery is. In the case of the Don’t Be a Lab Rat campaign, the delivery of the message through the use of rat cages is not effective. There is no familiarity of the audience to the image of being a rat in a cage because this visual is not relatable. There is no sense of self-represented in a human-sized rat cages. This campaign works directly against communications theory because the use of rat-cages is the polar-opposite of what any person can relate to. The campaign demeans the audience because teenagers are not rats and they are not test subjects, which results in the message not effectively working on the target demographic, a major flaw in the construction of this campaign.
Critique Argument 3: Flaws in the Delivery of the Message
The delivery of the Don’t Be a Lab Rat campaign is the greatest flaw. The campaign runs fear-inducing messages to prevent teenagers from using marijuana. The campaign has a number of troubling statistics presented to the teenage demographic, that are designed to frighten the audience out of doing the behavior. Dramatized statistics used in this campaign include, “Teens who smoke pot at risk for later schizophrenia, psychosis”, “Who’s going to risk their brains to find out once and for all what marijuana really does?”, “You can’t escape the negative effects weed has on the teenage brain”, “Legal pot might make America’s kids stupider, say researchers”, “Smoking, vaping, the teenage brain can’t tell the difference”, “Weed can drop a teen’s IQ from average to the bottom 30%. Are you good with 70% of the world being smarter than you?”, and lastly “Care to volunteer for further research?” (2). The intimidation tactic is a direct use of the fear appeal theory. Fear appeal theory is a type of communication used in campaigns that attempts to bring fear to the audience as motivation to protect them from a particular behavior (9). The metaphor of being a lab rat is comparable to the failed “This is your brain on drugs” campaign, which also used the fear appeal theory to prevent substance abuse. “These campaigns are based on the assumption that by vividly demonstrating negative and life-endangering consequences of risk behaviors, people will be motivated to reduce their current risk behavior and adopt safer alternative behaviors”(9). However, studies have found that provoking fear as an intervention method is not successful in creating behavior change about the perceived health threat. Fear may actually result in “defensive reactions such as risk denial, biased information processing and allocating less attention to the health promotion messages, thus rendering threatening health information an ineffective behavior change method” (9). The delivery of fear in the Don’t Be a Lab Rat campaign is an ineffective tool to create the intended behavior change to prevent teens for using marijuana. The tone conveyed in the message is condescending to the target audience and has the potential to have the defensive reactions to the risk of the behavior, which is exactly of what the campaign was intended for. Additionally, according to the ideas of the psychological reactance theory, telling the audience not to do something will actually provoke them to engage in the behavior (8). And in the case of the Don’t Be a Lab Rat campaign, the title itself is ordering the audience of teenagers not to use marijuana and become a “Lab Rat”, which has great potential to establish a reactance among teenagers to do the exact opposite. This psychological reactance actually promotes what the campaign is designed against, making this a major flaw in the design of this intervention.
Articulation of proposed intervention:
The core goal of this intervention is not just to reduce the rates of teenage use of marijuana. The overarching aim of the Don’t Be A Lab Rat campaign is to increase awareness of the potential adverse effects of using marijuana on developing teenage brains. Among teenagers, there is not much recognition that marijuana has adverse affects (1), particularly with the developing government legalization or decriminalization of the drug throughout the nation. With proper knowledge of the risks of using marijuana, teenagers can actively decide whether to use or not to use the drug. Increasing awareness of the risks of marijuana use among teenagers can have a positive effect on decreasing the rates of teenagers that use marijuana. While there is much debate on the true nature of harm that marijuana causes, the Don’t Be Lab Rat campaign focuses on the risk considering the speculated data provided. While there is no hard evidence marijuana actually causes schizophrenia, decreased IQ levels or stunted brain grown, in the next thirty years there could be. Basing an intervention on speculation and fear does not have the basis to be a successful public health campaign. Three interventions that should be considered to improve the campaign’s aim to improve the awareness of adverse affects of the drug and subsequently reduce rates of teenagers using marijuana include: Focus on social influences rather than individual behavior change; Create a model for behavior change; And finally, redesign the delivery with youth involvement. These interventions, based on social behavioral principles and theories, will improve the reception and effectiveness that the Don’t Be A Lab Rat attempts to have in improving teenage awareness of marijuana effects and subsequent use of the drug.
Defense of Intervention 1: Focus on Social Influence
The flaws in targeting individual behavior change through the Health Belief Model used by the Don’t Be a Lab Rat campaign could be improved if the focus shifted to the group level rather than the individual. There is much power held in social influences at the group level that can be used in changing the attitudes and behavior use of marijuana, particularly among teenagers. In fact, teenagers often base their decisions on what they think their peers do. The social norms theory could have a positive influence on reducing the rates of teenage marijuana use and perception. The Don’t Be a Lab Rat campaign does have the exaggerated statistics that could be beneficial. However, instead of targeting the individual’s perception of the drug, target the group level using the social norms theory, which uses misconceptions about changing behavior to push people in a better direction. For example, Montana developed an educational campaign to reduce alcohol use among college students by advertising that “most” students have less than 4 drinks each week (13). By suggesting to the audience what seems to be the social norm, a campaign can effectively change behaviors of the individual, because the group will act how they think those around them are acting. In the case of reducing the rates of teen marijuana users, the campaign should focus on the declining rates of marijuana use in the state of Colorado. Bringing attention to how the group behaves can have an influence on an individuals own behavior change. For example, if the campaign advertisements said, “Most Colorado teens don’t use marijuana” those teens who see the advertisements today would think it’s the social norm around their peer group not to use marijuana, so they may not either.
Defense of Intervention 2: Modeling Behavior
An important aspect of the Don’t Be a Lab Rat campaign that has sparked controversial debate is the terminology of defining those who use marijuana. Labeling marijuana users as “Lab Rats” is an ineffective approach to influence teens not to use marijuana. According to the psychological reactance theory (12), This label stigmatizes those who use the drug and could possibly influence those who use to continue using as they have already been deemed “Lab Rats.” In order to support the aim of reducing rates of teen marijuana use, a more effective tool to use would be a positive label that would influence teens to join the cause, rather than be patronized by it. The labeling theory looks at how groups “create and apply definitions for deviant behavior” such as marijuana use among teenagers (9). Instead of using a negative label of what teenagers can become by using marijuana, the intervention should focus on a positive label that encourages teens to choose not to use the drug. The positive label will enforce healthy behavior, and give teenagers the control over deciding to become a marijuana-free individual. Creating a label that teens can positively identify with allows them ownership of their decision, rather than being told not to engage in the behavior. Additionally, the modeling theory should be applied in this intervention to give a good example of what marijuana-free teens can aspire to be. The modeling theory “refers to the process whereby people learn through the experiences or credible others, rather than through their own experiences” (14). Using the modeling theory, the campaign can promote well-respected teens throughout the communities in television advertisements and ad campaigns around the city where teenagers typically visit, including but not limited to schools, libraries, youth centers, outdoor sporting areas and shopping malls. Providing young teenagers a role model (in their community or a well-respected teen celebrity) as an example on how to make health-conscious decisions, encourages teens to make the choice not to smoke pot. The campaign would show teens it is the popular thing to not use marijuana and very much socially acceptable to stand up for their right to health. Positive influences would have more of an effect in increasing negative labeling and provoking statements that could actually cause the reverse reaction to marijuana use (15). Empowering the youth to actively seek knowledge on the risks of marijuana use, giving them ownership of their actions, and to be apart of a new movement for marijuana-free teens would be much more effective in reaching the target audience for this intervention than the Don’t Be a Lab Rat campaign.
Defense of Intervention 3: Redesign Delivery with Youth Involvement
When designing a campaign and how to portray the message it is imperative to know the audience the campaign is trying to reach. In the Don’t Be a Lab Rat campaign, the target demographics are teenagers between the ages of 12 to 15 years old. A successful campaign to strive towards in reducing teen marijuana use is the national Truth campaign, directed towards reducing teen tobacco use. The Truth campaign is exemplary in showing how to target youth in health promotion campaigns. In the research done on this campaign there was an overall consensus that youth do not like to be told what to do and that they “want the facts, and then want to be left to make their own educated decision…Tobacco [much like marijuana] was a significant, visible and readily available way for youth to signal that they were in control” (10). Additionally, research done for the Truth campaign found that humor rather than harsh realities are more effective in reaching younger people. It would be beneficial to model a campaign aimed to reduce teen marijuana use to the Truth campaign, particularly in a state like Colorado where the selling marijuana is now legal. Further steps to explore can be modeled after the Truth campaign involving the youth, using humor in advertisements rather than fear, and making a brand of the campaign. While the creative design team for the Don’t Be a Lab Rat campaign “talked to dozens of teens, in groups, on the street, and at concerts” (4), an annual youth summit and youth review boards, much like what the Truth campaign implemented would be most beneficial to create, in order to truly know the audience the campaign is attempting to reach. The involvement of youth in how they would be most receptive to advertisements and messages would greatly impact the success of this campaign.
While the Don’t Be a Lab Rat campaign intervention is successful in that it has sparked the conversation of teen marijuana use, it certainly has flaws that inhibit the campaign from effectively reaching the target demographic. With recommendations that include social influences, modeling techniques and involving the youth for a youth-related intervention, the state of Colorado could improve the efforts to increase the knowledge on potential adverse effects of marijuana use among teenagers.
REFERENCES:
(1) Colorado Marijuana [Internet]. [cited 2014 Dec 11]. Available from: https://sites.google.com/a/state.co.us/marijuana/
(2) Don’t Be A Lab Rat [Internet]. [cited 2014 Dec 11]. Available from: http://104.131.228.16/
(3) Edberg M. Social and Behavioral Theory in Public Health. Essentials of Health Behavior. Jones and Bartlett; 2007. p. 35–49.
(4) 8 JDA, 2014. New Colo. marijuana ad campaign captures unknown health impact on teens [Internet]. Colorado Public Radio. [cited 2014 Dec 11]. Available from: http://www.cpr.org/news/story/new-colo-marijuana-ad-campaign-captures-unknown-health-impact-teens
(5) Vandals Don’t Take Long To Hit Rat Cages Used In Anti-Pot Ad Campaign [Internet]. [cited 2014 Dec 11]. Available from: http://denver.cbslocal.com/2014/08/11/vandals-dont-take-long-to-hit-rat-cages-used-in-anti-pot-ad-campaign/
(6) Ruiter RAC, Kessels LTE, Peters G-JY, Kok G. Sixty years of fear appeal research: current state of the evidence. Int J Psychol. 2014 Apr;49(2):63–70.
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(9) Broadhead RS. A Theoretical Critique of the Societal Reaction Approach to Deviance. The Pacific Sociological Review. 1974 Jul 1;17(3):287–312.
(10) Hicks J. The Strategy behind Florida’s “truth” campaign. Tobacco Control. 2001(10):3–3.
(11) Woller KMP, Buboltz WC, Loveland JM. Psychological Reactance: Examination across Age, Ethnicity, and Gender. The American Journal of Psychology. 2007 Apr 1;120(1):15–24.
(12) Silvia P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. 2005;27(3):277–84.
(13) Thaler R, Cass S. Following the herd. Nudge: Improving Decisions about Health, Wealth, and Happiness. p. 53–71.
(14) Theories and Applications, part two. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute; p. 9–21.
(15) Brooks-Gunn J, Donahue E. The Power of Positive Marketing. The Future of Children: Children and Electronic Media. 2008;18(1):181–204.
Pouring on the Pounds Ad Critique and Intervention – Jen Hawkins
Introduction
In August 2009 the New York City Department of Health and Mental Hygiene announced a new campaign to reduce the consumption of sugary drinks (1). This ongoing campaign consists of TV spots and printed advertisements placed on subway cars, and is supplemented by information posted on their website. Most of the ads and videos contain a hashtag with the phrase “Pouring on the Pounds” or the question, “Are you pouring on the pounds?”
The Pouring on the Pounds (POP) ad campaign was initiated to help decrease sugary drink consumption, thereby reducing the rates of obesity and diabetes—and related complications— among both children and adults. While some of the ads were powerful with the necessary shock factor needed to engage a public audience, others failed to have the impact that they could have. This paper critiques certain POP ads as ineffective because 1) they are fear based, 2) they rely on the health belief model without providing strong cost-benefit elements, and 3) they fail to acknowledge the role of herd influence and social conformity.
Critique 1: Fear Based Advertising
Several of the POP television ads focus on scaring people into compliant behavior – drinking fewer sugary drinks. One ad in particular explains how overconsumption of sugary drinks “eventually can bring on obesity and diabetes and its serious complications,” which can then lead to blindness, amputations, and even death (2). Part of the ad shows an image of two bandaged feet with toes missing, followed by an open body that is being operated on with the sound of a heart monitor beeping in the background. The machine switches from regular beeping to a high-pitched continuous beep, signaling that the patient has flat-lined and died. While it is true that poorly controlled, untreated diabetes can lead to death, linking sugary drinks to death in a 30 second ad is a bit extreme and unlikely to promote behavior change, as is supported by research on fear based health appeals.
According to Soames Job, a professor and researcher at University of New South Wales, fear based appeals are often met with little success in health promotion campaigns. An effective campaign, however, “allows for the desired behavior to be reinforced by a reduction in the level of fear…This entails five requirements: 1) fear onset should occur before the desired behavior is offered; 2) the event upon which the fear is based should appear to be likely; 3) a specific desired behavior should be offered as part of the campaign; 4) the level of fear elicited should only be such that the desired behavior offered is sufficient to substantially reduce the fear; 5) fear offset should occur as a reinforcer for the desired behavior, confirming its effectiveness” (3).
The ad described above does not meet all of these requirements. To proceed numerically, the ad does meet the first requirement by describing the terrible complications that can accompany diabetes before proposing that limiting sugary drink consumption can reduce the likelihood of developing diabetes. Criterion two, however, is not met. While it is true that drinking too many sugary drinks can contribute to becoming obese, which can then contribute to developing diabetes and further lead to amputations or death, the feared outcome is a result of a poorly treated medical condition that usually takes many years to develop and is a result of many prior health issues. A person does not become obese or diabetic overnight and does not develop a severe foot infection that requires amputation quickly either. Frankly, the allusion that sugary drinks lead to amputation and death is a stretch and is not likely for most individuals, particularly not in the immediate future.
Criterion three is met as reducing sugary drinks is a proposed solution to prevent obesity, diabetes, and related complications. Criterion four, however, is unlikely to be met because a) most people will not be fearful of amputations and death as previously discussed and b) those who are afraid of these complications, perhaps because they are obese or diabetic are unlikely to see reducing sugary drinks as sufficient to reduce this fear. I make this assertion because many people know that reducing sugary drinks can have a positive impact on weight and diabetes control, but this single change is unlikely to have a major impact on someone’s health without other significant changes in diet and exercise, especially if a person’s health is poor enough to warrant this fear.
Proceeding to criterion five, fear offset is unlikely to reinforce the desired behavior. As with criterion four, most people will either be unafraid or will be in such poor health that simply reducing sugary drinks will not reduce their fear. Consequently, based on Job’s research, this ad is unlikely to lead to significant behavior change.
Further research supports this assertion. Doctors Witte and Allen also did a meta-analysis of fear appeals in relation to public health. While they found that strong fear appeals are more persuasive than low fear appeals, “strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses” (4). I believe this research is in concordance with Job’s conclusions. This ad utilizes a very strong fear appeal—amputation and death are severe complications of diabetes. However, reducing sugary drink consumption does not seem like it will prevent these complications independently, thereby making it a low-efficacy message. Thus, individuals who drink excess sugary drinks may be prompted to defend their choice, either asserting that such extreme complications are unlikely and will not happen to them, or if they are overweight and/or diabetic, perhaps blaming their medical conditions on genetics or some other comorbid health issue that they do not believe they have any control over. It is also possible that individuals who consume many sugary drinks may justify such behavior as something that brings them joy, which may be difficult to come by if they experience a reduced quality of life due to obesity and/or diabetes.
The impact and effectiveness of fear based health promotion messages has been studied and is only effective in certain circumstances. This particular ad, however, fails to meet the necessary criteria needed to positively impact behavior change as the feared outcome highlighted is so extreme that it will not induce fear in many viewers, and may cause those who actually are morbidly obese or have poorly controlled diabetes to either simply ignore the message because reducing sugary drinks does not seem like it will have a large impact or defend their choice to drink sugary beverages. Additionally, such individuals are likely to feel stigmatized by this ad, further raising their defenses.
Critique 2: Health Belief Model – Cost Benefit Analysis May Not Lead to Desired Results
The health belief model is based on the idea that people make health decisions by doing a cost-benefit analysis (5). The perceived severity and susceptibility to a disease is weighed with the perceived benefits and costs of taking a certain action. The ad previously described utilizes the health model by insinuating that anybody who drinks too many sugary drinks is susceptible to becoming obese and developing diabetes, from which severe complications may result, such as amputation or even death. The ad further implies that the action needed to prevent this is simply to switch to water, seltzer, unsweetened tea or fresh fruit. With this “simple” switch, one can be healthy and avoid severe complications. However, for those individuals who do base their behavior on a simple cost-benefit analysis using this ad, the cost of giving up sugary drinks might be too great to warrant replacing them with less sugary alternatives and/or the perceived benefits might not be great enough to warrant the change.
First, individuals feel ownership over their behavior and giving up a particular behavior can be costly, especially if the behavior is automatic and provides a sense of normalcy and comfort, as may be the case when it comes to drinking sugary drinks (6). This concept is related to choosing to partake in identity-related experiences and behaviors, which can lead to personal happiness (7). While it is easy to tell someone to drink more water and fewer sodas, people often feel a loss when they give up a behavior that plays a recurring part in their life, making it difficult to change that behavior. For example, one study found that teens who planned to be abstinent often were not when faced with temptation. The core idea behind telling people to just say no “assumes that we can turn off our passion at will, at any point, whereas our study shows this assumption to be false” (8). This is likely true of sugary drink consumers as well; just telling them what to do is unlikely to be effective and giving up a favorite beverage may simply be too costly, especially if someone identifies as, say, a Pepsi drinker as opposed to a Coke drinker.
Beyond the cost, this ad portrays amputation and death as the worst outcomes that may arise from obesity and poorly controlled diabetes. Most people who view this ad are not going to view themselves as highly susceptible to either of these outcomes—because they aren’t. Even the average person with diabetes only has roughly a 0.28% chance of having an amputation in any given year, and that includes those who make no effort whatsoever to control their condition (9). While the severity of these outcomes is high, the lack of perceived susceptibility undermines that severity as a force to help people change behavior.
Similarly, the benefits of limiting sugary drink consumption are presented as the avoidance of obesity, diabetes, and resulting complications. However, this ad primarily targets those who do not already have these conditions by saying that over time drinking sugary drinks can lead to such complications, and therefore healthier beverage consumption should start now. However, the perceived benefit of preventing a condition that the person does not have is not very strong. As explained by two university researchers, Resnick and Siegel, “The person is more likely to choose a benefit he or she will obtain immediately…The delay associated with the long-term benefit results in the person discounting that benefit’s value” (10). In other words, the POP ad would have been much stronger if the benefit presented could be experienced or obtained in the present.
Overall, this ad is presented in such a way that the cost of giving up sugary drinks is unlikely to be greater than the benefits, and therefore does not utilize the health belief model in an effective way.
Critique 3: Health Belief Model – Doesn’t Account for Environmental Factors
While the health belief model relies on individuals doing a cost-benefit analysis when they make decisions, many individuals do not do a cost-benefit analysis because they are influenced by environmental factors, such as affordability, accessibility, herd mentality and social conformity. (It is also likely that some individuals do a cost-benefit analysis, but are swayed to make decisions that conflict with the health based analysis due to the social determinants listed above.)
Studies have shown that many individuals choose to drink whatever is convenient, accessible, and affordable. For example, an observational study conducted among 13 schools in Massachusetts found that 71% of sixth and seventh graders who used vending machines available at school purchased a sweetened beverage (i.e., Frutopia, tea, sports drinks, etc.) or regular soda in the previous 7 days (11). Following sweetened beverages other than soda, water was the most frequently purchased beverage. Had sweetened beverages been absent from these vending machines, it is likely that students would have consumed fewer sugary beverages and more water simply because the sweetened beverages would have been more difficult to obtain during the school day. Thus, availability, an environmental factor, can lead to greater behavior change than solely relying on an individual to perform a cost-benefit analysis.
In addition to purchasing drinks that are accessible, individuals also fall victim to herd mentality and social conformity, which are not accounted for by the health belief model (12, 13). Herd mentality and social conformity involve making decisions based on what others have done, leading people to change their opinions and make choices that help them coalesce with the group. Herd mentality occurs when individuals do whatever the group is doing without really thinking about it. For example, when “the wave” goes around a sports stadium the sports fans are engaging in herd mentality. They raise their arms because many people before them have done it. Most do not think about why they are raising their arms or the pros and cons of such a decision—they simply act.
Social conformity is similar in that people do things to fit in and avoid being perceived as “different.” This can be an intentional decision or something that happens quickly on a subconscious level. Let’s imagine a young adult at a dinner party. The hostess asks five people what they want to drink before her and they all ask for Pepsi. When the young lady, the sixth person in line, is asked, she quickly replies, “Pepsi, please.” Perhaps she is conforming intentionally; it is also possible that she answers quickly simply because everyone else had said Pepsi and it is easy to give this reply.
The dinner party scenario parallels findings from research studies and likely represents how many individuals make beverage choices on a day-to-day basis. For example, this fictional scenario is supported by the Asch line study in which a participant is shown a line and verbally asked to choose which of 3 different lines is the same length (13, 14). This task, however, is completed in a room with four confederates who all choose a line before the participant, often giving the incorrect answer. Each participant completed 12 line judgments and approximately 75% of these participants gave the incorrect answer at least once when the majority of the confederates gave the incorrect answer first. Also, “an average of 35 percent of the overall responses conformed to the incorrect judgments rendered by Asch’s accomplices” (13). When performing this task alone, participants almost never erred.
The point is that people are not doing cost-benefit analyses every time they make a decision. They are also influenced by herd mentality and a human tendency to conform to what others are doing around them. Therefore, the health belief model is inadequate to promote major behavior change for an activity that is often done in public, such as drinking a beverage.
Intervention Strategy
I propose changing three major aspects of the POP campaign. First, the ads based on scare tactics needs to be removed entirely and replaced with ads that use marketing theory and feature people similar to the target audience. Second, school vending machines need to stop selling sodas and sweetened beverages. And third, corner stores need to place unsweetened beverages at the front of stores, in more prominent locations.
An ideal ad could consist of two teenage friends at a vending machine. One asks the other what she wants to drink. We see a quick flashback of her on the cheerleading squad taking a sip of water after completing a complicated stunt. We also see her walking her dog with her brother, water bottle in hand. Upbeat music plays in the background. Back in real time, she asks for water. Her friend says, “Really? There’s soda in here too.” “Really,” she replies. “I don’t want to end up on the sidelines because I drank too much sugar.” “Good point,” her friend says. “I guess I’d rather not pour on the pounds either.” The friend then purchases two waters and they walk off happily together.
Defense 1: Replace Fear-Based Appeals with Advertising Theory
As explained in the first critique, fear appeals are often unsuccessful. I propose removing them entirely and replacing them with ads that take advantage of advertising theory, a model successfully used by corporate America to sell billions of dollars of product every year, ranging from cosmetics and clothing to cars and electronics. There is no reason why such tactics cannot also be used for health promotion.
Advertising theory has three major components: a promise, support, and core value (15). A well-done ad must tie all of these elements together in way that has universal appeal. The ad described above successfully accomplishes this. First, it promises that drinking water will both enable people to be included with their peers and family, and maintain a lifestyle they already enjoy. This message has a universal appeal because human beings are hardwired to seek social acceptance and support. For example, adults older than 65 who had impaired perceived social support had 3.86 times the mortality risk compared to adults in the same age group with unimpaired perceived social support (16). It is also common knowledge that teenagers give in to peer pressure in order to fit in and feel accepted. One retrospective study found that, “One-third of both genders identified peer pressure as one of the hardest things they had to face as a teenager” (17).
This ad also has strong support and core values. The flashback images are very positive and supported by positive music. They are intended to evoke an “I want that too!” response in the viewer. This ad tells the viewers that drinking water instead of sugary beverages will give them the freedom to live the life they want, surrounded by friends and family, unhindered by excess weight. As freedom and inclusion are very strong core values, this ad is likely to be successful.
Defense 2: Strengthen Cost-Benefit Elements
Some individuals do indeed do a cost-benefit analysis when making decisions. As previously discussed, the cost of giving up sugary drinks will be too high for many people, especially if they do not perceive themselves as being susceptible to the horrible complications that can result from untreated diabetes. The ad described above, however, has lowered the cost of cutting out sugary beverages by using speakers with whom the viewer can relate. Additionally, the implied outcome of consuming sugary drinks has been changed to something more realistic, therefore increasing perceived susceptibility. In the immediate future, individuals are more likely to become winded while walking their dog or have trouble playing sports due to weight gain. Having an amputation or dying as a result of diabetes complications is far less likely and difficult for most people to relate to (18).
By delivering the message by people who are similar to the viewer, the new ad utilizes communication theory and reduces reactance. According to communication theory, people relate and respond more positively to messengers that they can relate to. Research suggests that, “Similarity can increase the positive force toward compliance by increasing liking for the communicator” (18). This is why the ad features average teenagers, as opposed to an unseen narrator as used in the critiqued POP ad. Similar versions of this ad can be made to addresses other target populations, such as working mothers or children.
Psychological reactance theory, on the other hand, explains that people will hold onto something tighter when they perceive that it will be taken away (18). This is why the ad focused on the girl maintaining what she had: positive, fun interactions with her team, brother and dog. Instead of taking away her freedom (to drink sweetened beverages), avoiding sugary drinks allows her to keep it. Additionally, since this girl is an average teenager her similarity can help reduce reactance among teenage viewers. Again, research shows that, “similarity can reduce the negative force toward resistance by fostering positive interpretations of the communicator’s actions, particularly the degree of threat in the message” (18). Based on these theories, having a similar speaker who focuses on the benefits of drinking water will help lower the perceived cost of limiting sweetened beverage intake.
Defense 3: Change Behavior First
It is possible to use herd mentality to help further a public health cause. The key is to change behavior first. If people change their behavior, their beliefs will follow because people experience discomfort when their actions are not aligned with their values, leading to cognitive dissonance (19).
The diffusion of innovations theory involves getting a few people to adopt a behavior, which, upon reaching a tipping point, will lead to many people adopting that behavior (20). This theory also applies to schools and companies, not just individuals. Once a few schools remove sugary drinks from vending machines, more schools are likely to follow, and some people will drink fewer sugary drinks and come to value that decision as a result of cognitive dissonance. The same is true of placing sugary drinks in less prominent store locations and moving unsweetened beverages to the front of the store. As more and more people adopt this healthier behavior, it should catch on and become more commonplace.
It is also important to discuss how to convince schools and corner stores to make this change. Ideally, either a law would be passed or the schools and corner stores would receive a financial incentive, perhaps from the government or an NGO, to offer healthier options. However, if this was not the case, successfully lobbying even a few schools and corner stores could make a huge difference and lead to a diffusion of innovation. Once these few schools and stores change to emphasize the purchase of unsweetened beverages, it is likely that more will follow. For instance it is plausible that health conscious parents will advocate for healthier vending machine options in their own children’s schools upon hearing of this innovation at other schools. As a result, an increasing number of schools might jump on the bandwagon, thereby leading students to change their behavior, accomplishing the whole point of the intervention.
Overall, improving the ads, removing sweetened beverages from school vending machines, and placing unsweetened beverages in prominent storefront locations will bring the Pouring on the Pounds Campaign increased success.
References
1. The New York City Department of Health and Mental Hygiene. Press: New Campaign Asks New Yorkers if They’re “Pouring on the Pounds.” http://www.nyc.gov/html/doh/html/pr2009/pr057-09.shtml
2. The New York City Department of Health and Mental Hygiene. Pouring On the Pounds Ad Campaign Archive. http://www.nyc.gov/html/doh/html/living/sugarydrink-media-archive.shtml
(* Ad cited is the first one on the above page)
3. Soames Job, R. F. Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health 1988; 78(2):163–167.
4. Witte, K., & Allen, M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Education & Behavior 2000; 27(5):591–615.
5. Edberg, M. Individual health behavior theories (pp. 197-211). In: Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.
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8. Ariely, D. The influence of arousal (pp. 119-138). In: Ariely, D. Predictably Irrational. New York, NY: HarperCollins, 2009.
9. American Diabetes Association. Statistics About Diabetes. http://www.diabetes.org/diabetes-basics/statistics/
10. Resnick, E., Siegel, M. Introduction to Marketing Principles (pp. 87-111). In Resnick, E., Siegel, M. Marketing Public Health. Burlington, MA: Jones and Bartlett Learning, 2013.
11. Wiecha, J. L., Finkelstein, D., Troped, P. J., Fragala, M., & Peterson, K. E. School vending machine use and fast-food restaurant use are associated with sugar-sweetened beverage intake in youth. Journal of the American Dietetic Association 2006; 106(10):1624–1630
12. Thaler, R., Sunstein, C. Following the herd (pp 53-73). In: Thaler, R., Sunstein, C. Nudge. United States: Caravan Books, 2008.
13. Aronson, E., Aronson, J. Conformity (pp 13-58). In: Aronson, E., Aronson, J. The Social Animal. New York, NY: Worth Publishers, 2007.
14. Asch, S. E. Effects of group pressure upon the modification and distortion of judgment. In: Guetzkow H, ed. Groups, Leadership and Men. Pittsburgh, PA: Carnegie Press, 1951.
15. Resnick, E., Siegel, M. Marketing Public Health. Burlington, MA: Jones and Bartlett Learning, 2013.
16. Blazer, D. G. Social support and mortality in an elderly community population. American Journal of Epidemiology 1982; 115(5):684–694.
17. Brown, BB. The extent and effects of peer pressure among high school students: A retrospective analysis. Journal of Youth and Adolescence 1982; 11(2): 121-133.
18. Silvia, P.J. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3):277-284.
19. Aronson, E., Aronson, J. Self-Justification (pp 181-252). In: Aronson, E., Aronson, J. The Social Animal. New York, NY: Worth Publishers, 2007.
20. Rogers E. Diffusion of Innovations Fifth Edition. New York, NY: Free Press, 2003.
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