A Critique of The Basic Public Health Approach to the Development and Implementation of Obesity Interventions – Lynn Ibekwe
Obesity is currently the biggest health concern in the United States, with about 33.8% of U.S. adults and 16.9% of children and adolescents being obese (4,17). The trend continues to increase across the country. In 2009, nine states had obesity rates of 30% or more, when in 2000 there were no states was no states (4). Furthermore, these statistics have devastating implication on the health of the population and on U.S medical costs. Obesity-related conditions include heart disease, hypertension, stroke, type 2 diabetes, end stage renal disease, and certain types of cancer (15,22). In 2008, obesity-related medical costs were about $147 billion; the medical costs for obese individuals, paid by third-party payers, were $1,429 higher than those of normal weight (21).
In order to develop interventions to promote health or change behavior, public health practitioners look to theory to guide them in the interpretation of a situation and the design, implementation, and evaluation of interventions (18). With obesity being such a major health concern in the U.S., a comprehensive approach that can change individual nutrition and physical activity behaviors and the environments and policies that affect these behaviors would be most effective. Unfortunately, this is not the approach taken by a majority of public health practitioners (21).
Public Health’s Basic Approach in Developing Obesity Interventions and its Flaws
Social Science theories provide the basis for how public health practitioners assess and develop interventions for a particular problem. There are two things that can go wrong when creating public health interventions. First, the wrong social science model can be used for a particular situation. Second, a social science model can be applied in the wrong way for a particular situation. In addressing the growing obesity problem in the United States, public health interventions have largely fallen victim to both these. This can be seen in three major ways: in 1. its focus on education; 2. its disregard for social factors that impact behavior and behavior change; and 3. its tendency to create messages that takes control out of the hands of its target audience. Each of these flaws demonstrates how the obesity interventions in public health largely ignore the basic premises found in group level social science models created to address the major weaknesses found in traditional models. Any intervention that ignores these premises is more likely to fail when attempting to address an issue as complex as obesity.
The Health Belief Model
There are about five models that traditionally make up the basis of public health interventions. The oldest and traditionally the most widely used is the Health Belief Model. Like many of the traditional models, it is an individual level model many public health practitioners look to when addressing the increasing prevalence of obesity in the United States. The Health Belief Model looks at individuals’ approach to behavior as a rational weighing of costs and benefits that informs their decision to participate in a particular behavior. Its key components are that behavior is an outcome of perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (5). It consists of individual level factors operating under the assumption that once a person knows the risks of a certain behavior they will change their behavior. The Health Belief Model is a model that allows for self-reflection, its interventions are easy to measure, and is great for intervening in situations where people do not already know the health effects related to a behavior. The obesity issue, however, is so much more complex than what this model offers; interventions that utilize it and other individual level models are often met with the failures mentioned above.
How a message is presented is a very important part of how behavior change begins, and as we have discussed many times in class, the use of education, statistics, and facts can be very ineffective in encouraging behavior change. Education attempts to inform individuals about the risks of continuing unhealthy behaviors in an effort to persuade them to adopt healthy ones. With this method, largely rooted in the Health Belief Model, public health practitioners believe individuals will rationally weigh the costs and benefits of engaging in a particular behavior and change the behavior accordingly. This however only works when the goals of society are in line with those of the target audience. The benefits of behavior change must be attractive, immediate, low cost, and the target audience must feel as though they have the ability to change their behavior (self-efficacy) (8). The present strategy has many flaws, however, in terms of how a message is best presented, it ignores the group level model premise that behavior can be directly affected without necessarily working through attitudes and beliefs. It assumes that people behave rationally and that by spouting statistics and facts those individuals will change their behavior. According to analysis, this technique is based on the idea that health is an important concern or goal for most individuals and “cues to action” are common. It also, however, predicates that if these conditions are not present in the target population than the model is not likely to be useful in, or relevant to, explaining how they will respond to interventions (12).
In a study by Jeffrey J Hicks, researchers looked at the Florida Department of Health’s success in changing tobacco attitudes and use among Florida youth. They found that knowledge was not the problem when it came to youth use of tobacco. A great job had been done on explaining the dangers of tobacco. They found that a youth’s reason for using tobacco had “everything to do with emotion and nothing to do with rational decision making” (10).
What many in the public health field also fail to realize is that when individuals engage in a behavior—no matter how unhealthy—they feel a type of ownership over that behavior and value it. However, based on the concept of cognitive dissonance, once a person is doing a behavior that does not match their attitudes, something must change; the change is usually in their attitudes (7). As seen in one of our class discussions, Simon Sinek discusses how great leaders and organizations inspire action. It is not through education but through emotion. Very few people know why they do what they do. They do not buy what you do; they buy why you do it. It is a strategy that acts directly on the part of the brain that drives behavior (20). This is why it would be more effective to focus on changing individuals’ behavior; with that we can then change attitudes and knowledge.
Another flaw of the public health approach to obesity is its narrow focus on physical activity and healthy eating, ignoring the social factors that influence individuals ability to engage in these behaviors. It ignores the premise that behavior is often unplanned, out of control, and dynamic. This flaw is also largely based in the utilization of the Health Belief Model, ignoring concepts that were introduced as early as the theory of planned behavior. The approach primarily focuses on individual decisions. It does not address social and environmental factors, believing that decisions of health behavior are a weighing act in that it looks at how an individual values possible outcomes and the strength of that value. It also however fails to look at the social norms that come into play when individuals make a decision about health behavior. In reality, individuals typically take into consideration what other people think depending on how important these people are to them. After weighting these options, it dictates an individual’s intention to do a behavior and then if that individual believes they can do the behavior (self-efficacy), it is carried out (5). Many interventions assume that by providing individuals with the necessary knowledge and by changing their attitudes towards a specific behavior, their attitudes will inform their intentions and play out into actions. This view, however, ignores the concept of self-efficacy. It does not take into account social factors that may affect a person’s decision to engage in a behavior; this can be seen in failed interventions such as the 5 a day and the Fat Chance billboard campaign.
Taking such a narrow view, ignores the very root causes of obesity, such as SES, of many affected. “Conventional approaches are the least effective as they consist of passive dissemination of messages from experts to the public in the hope of motivating people to change their behaviors” (6). In this sense the problem is not the lack of knowledge among individuals, as the Health Belief model would suggest, rather it is the lack of resources needed to engage in physical activity and a healthy lifestyle. For example, a large number of the obese population is made up of minorities and low SES individuals. Many of these individuals live in unsafe neighborhoods with little to no access to healthy food. In these areas there is a shortage of grocery stores that sell fresh fruit, vegetables, and various other healthy food options. Even when these stores are available, they tend to be more expensive than if they had access to other options. We demonstrate this in one of our class discussions, that even in the area near BUSPH, it was hard finding the most basic fruits and vegetables.
Additionally, in regards to physical activity, it can be hard for many families who live in neighborhoods with high crime rates to find a safe place to exercise or for children to even play. The stress that can come from living in such an environment has a significant correlation with negative attitudes and beliefs and in turn decrease health-promoting behaviors (14). Developing interventions that bring parks and create sidewalks in a neighborhood does nothing to increase physical activity when the issue of safety is not also addressed.
The general public health approach to obesity has a tendency to launch interventions that take control out of people’s hands. People do not like feeling like control is being taken out of their hands. When people perceive that their freedom is being taken away, they resist and, more often than not, they do the opposite of what you are trying to get them to do. Again we can find this concept displayed in the research done by Hicks. The fact that tobacco killed was the unique selling proposition for youth. Generations of social marketers aggressively blared anti-tobacco messages over airwaves, stressing the fact that tobacco kills. To the profit of tobacco industry, these groups did not understand that it was the very risk associated with tobacco that made it more appealing to youth (10).
In a study by Hornik et al, researchers found that the National Youth Anti-Drug Media Campaign, implemented between 2000 and 2004, had “no favorable effects on youths’ behavior and that it may even have had an unintended and undesirable effect on drug cognitions and use” (11). The concept we see playing here is based in the theory of psychological reactance. Public health interventions, especially messages related to obesity, are typically looked at as taking away someone’s freedom. This is also another case of ownership. Individuals do not respond well when they feel something they value is being threatened. When people think that a freedom is threatened they experience reactance, a motivational state aimed at restoring the threatened freedom (3). One way individuals seek to reinforce a threatened freedom is to exercise that freedom. Essentially, individuals show “boomerang effects” and seek out the behaviors they are advised against (19). When you tell someone not to do something not only are you threatening their freedom you are increasing the value of the behavior. What is needed is an approach that takes into account the complexities that come with addressing obesity.
Obesity is the biggest health concern in our country today. As addressed above, if we continue to rely on an approach that relies so heavily on education, ignores social and environment influences, and incites reactance, it is very unlikely that we will be able to take hold of this ever-increasing epidemic. A comprehensive approach that develops obesity interventions that can change individual nutrition and physical activity behaviors, can change the environments and p0lices that influence unhealthy behaviors, and gives individuals a sense of control is an approach worth considering-- and the approach I am proposing.
Changing the Basic Public Health Philosophy in the Development of Obesity Interventions
The first thing we must realize in public health and ingrain in to our minds before the development of an intervention is that obesity is complex. No single strategy has been determined most effective due to this very fact. Rather than continuing to base obesity-related interventions on the traditional public health approach described above, we must look to a more comprehensive approach and make that the new basic philosophy. Recently, The Surgeon General’s Vision for a Healthy and Fit Nation 2010 and the 2010 report of the White House Task Force on Childhood Obesity stressed the need for such a comprehensive approach. Their reports stress the need to address “both nutrition and physical activity; work across multiple settings and multiple sectors; and change individuals behaviors as well as the environments and policies that affect those behaviors” (21). In planning comprehensive health promotion programs, different theoretical approaches are essential and make a stronger impact, especially when multiple levels of a health problem need to be addressed (18). As I will describe using the 5-a-day campaign as a demonstration of my proposals, this very well can be achieved by some addressing the flaws of the basic approach to obesity interventions.
Incorporating Marketing and Framing Theory
So if not with education, how do we get individuals to change their behavior? We must use the concept of cognitive dissonance to change individuals’ behaviors first, in order to change their attitudes and knowledge and stimulate long term behavior change. In developing interventions that effectively utilize cognitive dissonance and that counteract the effects of statistical numbing, it would be beneficial to the utilize Marketing Theory and Framing Theory.
Marketing Theory is a broad paradigm that encourages the use of advertizing and communication techniques to sell a product or idea to consumers. Interventions should be thought of like campaigns, and any campaign needs the proper research to be effective in selling their product. The theory asks us to look at what people want and use that knowledge to shape their behavior. In order to do this, like any successful marketing company, the core values that dictate behavior must be identified (8). The Public Health Paradigm focuses on the product that people should want; attempting to sell the desire for health. Marketing theory, however, reverses this logic and focuses on a set of core values by framing health as something that can be obtained in the pursuit of a set of basic values.
Framing is how the information in a message is packaged so an important strategy in this effort is to change the way messages are framed in public health. This is essential because Public Health is all about who can frame the facts most effectively. Certain framing techniques can appeal to a person’s values and beliefs so how a message is framed can change people’s opinions in one direction or another. What makes this theory so effective is that people are irrational, and people engage in most negative behaviors because they are irrational. This creates a problem for public health practitioners because the traditional philosophy is that if we provide information to people they will behave differently (23).
Providing information has been largely unsuccessful; advertisements that promote the negative behaviors we are trying to combat aim at people’s emotions so we must take a similar approach. If we can predict how people will behave irrationally, we can take advantage of that by hitting them with highly emotional messages. The message should be on a societal level rather than an individual one. The art of public health is learning how to effectively frame facts, because how you frame information has major implications on what you can do about the problem.
The Eighty Four Campaign, The Crush Campaign, and The Hula Hooping for Health Campaign have all been successful in avoiding the use of strictly education to change behavior. These interventions include messages that bring everyone together for a common cause, addressing the values of its target population. A similar approach would be useful in all obesity-related interventions.
Branding and imagery are very important parts of the process and by incorporating a strategy such as that into a campaign such as the 5 a-day campaign, a greater response can be elicited from target populations. By appealing to a group’s ideas about freedom, love, acceptance, etc, a creative message—like the Barbie-When I Group Up commercial (2)—could present the concept of eating 5 fruits and vegetables a day and health as a movement or a cause in actualizing a sense of love and freedom. In a sense, if the same commercial with a few additions could be presented with instead the 5-a-day campaign logo, you would have a very compelling and effective nutrition campaign. Again, as discussed by Simon Sinek, very few people know why they do what they do; they are inspired by something (20).
There are no right or wrong methods to framing, there are just effective and ineffective ones. A key aspect to remember in intervention development is what the overall message conveys to the audience. If a message focuses on blaming the victim, their behavior is not likely to change; however, if the message is geared toward societal influences that effect behavior, they are more effective in changing behavior. This is important when addressing issues of self-efficacy.
When thinking about why individuals engage in unhealthy behaviors, we must look at the whole picture; with this, Maslow’s Hierarchy of Needs is a useful resource. Maslow’s Hierarchy of Needs is theory that speaks to what motivates people’s behaviors. At the bottom of the hierarchy—in a sense the most important level—are physiological needs. These are things like food, breathing, and sex. Next is safety, which would be the security of one’s acute health, family, etc; love and belonging; esteem and confidence; and finally, self-actualization in terms of morality, creativity, and acceptance of facts. People will not meet the needs at the top without first feeling secure in their most essential needs (13).
This is important to remember when developing interventions that target the populations that are most affected by the obesity epidemic—low SES and minority populations. As discussed, narrowing interventions to only address issues of physical activity and nutrition ignores the root issues—such as neighborhood safety and healthy food availability—related to why these populations engage in unhealthy behaviors in the first place. By recognizing these issues of self-efficacy, interventions such as the 5-a-day campaign can make greater impacts on the obesity epidemic.
To improve the 5-a-day campaign, an added initiative could be incorporated into the campaign to addresses issues of self-efficacy. The organization could create a board that focuses on how to bring fresh fruits and vegetables at a low cost to communities where resources are scarce. Projects such as these are possible. In Boston, Mattapan has the highest obesity rate of any community in the state, and has no full service grocery store within its boundaries. There are several projects under the Mattapan Food and Fitness Coalition that try to address these issues such as, the Healthy on the Block Corner Store Project in Mattapan and East Boston. They work with farmers markets and a bounty bucks program that allows individuals to use food stamps at farmers markets. They encourage gardening with the Boston Natural Areas Network, Mattapan Branch Library, Clark-Cooper Community Garden, Kennedy Garden, The Food Project, and work with local restaurants to improve nutrition in the community (16).
Besides providing strategies to increase physical activity, they could partner with an organization such as the Association of State and Territorial Health Officials—a national non-profit organization dedicated to formulating and influencing sound public health policy (1) – to work on issues within policy change that create safer neighborhoods for families to participate in physical activity. This partnership would also include a partnership with the most vulnerable populations and work with community members on exacting those changes.
Even on a smaller scale, the campaign could provide suggestions (for example, on their main website) to community members on ways to increase physical activity that takes into account the possibly of living in unsafe, exercise unfriendly neighborhoods such as walking school buses for children, etc (9). If the 5-a-day campaign, which is a national campaign, where to incorporate efforts such as this in their intervention they could have a great impact on obesity, especially among those most vulnerable.
Control is such an important fact in people’s lives so building a campaign that incorporates control or some kind of ritual that people can take part in can help to give people a sense of control and provide for effective messages. As previously discussed freedom is a core value among individuals; congruent with reactance theory, a large literature shows that social influence is more successful when it does not threaten important freedoms (19).
Psychological Reactance is the phenomenon that occurs when people perceive that their freedom is being taken away. As discussed above, public health interventions are typically looked at as taking away freedom. When people feel their freedom is being threatened, they develop the urge to obtain what is threatening to be withheld (3). This is the exact opposite response desired from a public health intervention; however, many times this is what happens.
As a basic philosophy before implementing an intervention, psychological reactance needs to be measured. In this case we must enact strategies to deflect reactance such as decreasing dominance, increasing reason in the sense of support of the claim, and using a source of similarity to deliver the message (19). Methods based on deflecting reactance, would present an effective intervention that would frame a message with messengers that are similar to the target audience exacting the coveted core values—such as freedom—and demonstrating how this freedom could be threatened—that is through poor health. In this way, the audience can see themselves in the message and instead of feeling as though they are losing control by changing unhealthy behaviors, they absorb the message that they can exact these same core values through the pursuit of health. As a basic approach to the obesity issue, public health practitioners must be able to repackage interventions to make people feel like they are gaining control.
Using this theory to improve upon the 5-a-day campaign, a message similar to that of the Barbie commercial would assess the potential for reactance and implement a message, depending on the target population, that features messengers similar to the target population and core values that could be obtained through healthy eating. In the 5-a-day commercial, in order to sell their product, the message would appeal to core values of today for the target population but would avoid threatening their freedom by telling them what to do or what they are doing wrong. Instead they provide these images, a heart-warming song, and flash a relevant message that would in a sense suggest that nutrition would ensure the actualization of these goals.
The final intervention would consist of a campaign that does not focus on education but utilizes the theories of appeal (marketing and framing) to inspire, enhances a sense of self-efficacy (environment and policy change), and gives individuals control over how to be in line with their basic values, through health.
Interventions that address issues of self-efficacy, deflect psychological reactance, and affect change without relying solely on education based messages are more effective in facilitating behavior change than interventions implemented under the traditional public health approach. With this “new” approach for developing obesity-related interventions, a larger proportion of the obese population can be reached in an effort to ignite behavior change.
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