Using Group Level Models to Tackle Inherent Flaws of the Let’s Move Program – Rohan Bakshi

Introduction – A federal report

Childhood obesity rates in the US are increasing at astronomical levels and more than a third of American children are now obese (1). According to a report published by the White House Task Force on childhood obesity Report to the President (2), “medical spending due to obesity amounted to approximately 40 Billion dollars. Obese children are at ten times the risk of becoming an obese adult as compared to non-obese children”(2). This report blames excessive junk food advertising, sugary beverages and decreased physical activity as the main cause for obesity (2). It also enlists the following interventions for addressing childhood obesity: empowering parents and caregivers, providing healthy food in schools, improving access to healthy food and getting children physically active (2). In short, this report suggests completely informational sessions provided through federal, state and private organizations to parents, potential parents, caregivers and hospitals (2).

Let’s move campaign

In response to this federal report, First Lady Michele Obama initiated the “Lets move” campaign that aspires to ‘America’s move to raise a healthier generation of kids (2). This campaign has focused on changing the environment around children into a one that is conducive towards healthy eating (3) and lifestyle habits (4). The knowledge provided to parents through this campaign has been strictly informational. Parents are described which behaviors are best suited for their children’s health (5). These behaviors include healthy diets, increased physical activity and decreased ‘screen time’, a phrase used to describe the amount of time children spend in front of a TV, computers and other electronic gadgets (2). Similarly, schools are asked to change their lunch offerings to a healthier diet, including the removal of vending machines (7). The Let’s Move program also appeals to political leaders of the county and city to make roads, parks and other public areas conducive and safe for physical activity (6). Even though the Let’s Go campaign is designed to address childhood obesity, direct messages to children are extremely limited and ineffective. According to an analysis of this program published by the New England Journal (1), Infants and pre-school age children could benefit more from being explicitly incorporated into the campaign. This is the first major weakness of the Let’s Move campaign.

1. Psychological Reactance Ignored

Majority of these efforts are routed through parents, school officials and political leaders. There is minimal focus on routing any information or messages directly to the children, the target population. The Let’s Move Campaign’s heaviest focus is on changing the immediate environment around children so that they have a healthier lifestyle. Parents(5), schools(7) and political leaders (6) are tasked with the job of increasing physical activity, introducing healthier school lunches and increasing access to healthy food. This is the second major flaw with the Let’s Move campaign. Everyone, including children cherish their freedom of diet and physical lifestyle, and will retaliate against any control being taken away from them. According to the chapter, ‘Phenomology of Reactance’ in the book, “Organizational change: A Comprehensive Reader”, “Although there is no assumption that a person will necessarily be aware of reactance, it should be true that she he is, he will feel an increased amount of self direction in regard to his own behavior”(8). This retaliation shall be in the form of increased intake of unhealthy food and sugary drinks, and more prevalent sedentary behavior and screen time. This retaliatory behavior is explained by the psychological reactance theory.

The psychological reactance theory explains the failure of many public health programs that have threatened to take away the target populations’ sense of freedom and control. According to the article, “Psychological reactance: examination across age, ethnicity and gender, “psychological reactance is a motivational state aroused when real or perceived freedoms are threatened, reduced or eliminated”(9). This model predicts a populations’ opposite reaction to ‘regain’ their freedom or control. When children realize that they are being directed or ‘managed’ towards a healthier lifestyle, they shall retaliate by choosing the exact opposite behavior – an unhealthy lifestyle (9).

The basis of this theory lies in the concept of freedom and control. “When a threat is portrayed as and believed to be serious and relevant, individuals become scared ... Their fear motivates them to take some sort of action- any action that will reduce their fear … they are motivated to control their fear and focus on eliminating their fear through denial, avoidance, or reactance (10). When children notice that they are being channeled into eating healthier food and doing more physical activity, they shall try and regain control by gaining access to unhealthy food at home and school, and intentionally limit their physical activity. Research carried out by Woller ET AL also proved that people below the age of 24 are most reactant as compared to the older population (9). Hence, we can be sure of a very strong reactance measure through the efforts of Let’s Move. This research paper also measured reactance among different races, and calculated that Asians, African Americans and Hispanics exhibited higher total, behavioral and verbal reactance than Caucasians and Native American-Indians (9). If we match this to data produced by New England Journal’s critique of the Let’s Move program (1), the results are particularly worrisome. According to this critique, African Americans, Mexican Americans and Hispanics have the highest child obesity rates (1). With the target population exhibiting highest reactance, the Let’s Move campaign might create unintended results of higher obesity levels amongst these racial groups.

Additionally, reactance leads to mistrust and poor psychosocial health among the target population, especially in children and teenagers (9). These are the last values we want to instill in children when trying to convince them to adopt a healthier lifestyle. Hence, the Let’s Move program suffers multiple flaws that can be explained by the psychological reactance theory.

2. Use of Health Belief Model

This informational aspect of the Let’s Move campaign uses the health belief model to convince parents, schools and political leaders to change their own and more importantly, their children’s behavior towards a healthier lifestyle (11). They are told about children’s increased risk to several diseases due to obesity - perceived susceptibility, along with obesity-reducing meals, behavior and activity. According to the health belief model, an individual shall decide to forgo a behavior by assessing their susceptibility to negative effects of the behavior, and compare it to their perceived benefit or sensation of changing or foregoing the behavior. If the individual believes that his/her susceptibility and negative effects of the behavior outweigh the benefits of the behavior, he/she is predicted to forgo this behavior. On the other hand, if the individual believes that the cost of foregoing the behavior, withdrawal for example, outweigh the benefits, the individual is predicted to continue with this particular behavior.

In this application, the health belief model is applied indirectly to children through parents, schools and political leaders. The health belief model states that this decisions shall have to be made on a daily basis, which implies that decisions such as parents buying healthy food, schools serving healthy lunches and arranging for more physical activity, and political leaders making the roads more jogger and cyclist-friendly on a daily basis. This is one of the major flaws of the health belief model; daily decision-making towards healthy behavior does not work for decisions of such magnitude and duration. In her research paper, “Critique of the Health Belief Model”, Linda W. Thomas (12) “Attempts to holistically examine motivators of and barriers to health promotion have failed using the Health Belief Model. In another study conducted to measure the effect of the health belief model, investigators educated mothers of obese children about increased risks of their children being obese, and the results run parallel to our prediction of the health belief model (13). They found that 44 percent of patients they surveyed had never intended to even comply… Among complying mothers, they found that initial response to the health belief model can be strong, but with time and concurrent experience with the diet and weight-change outcomes, other variables such as socio-economic and social perception may become important as well (13). In its conclusion, the study also noted that the “HBM (heath belief model) itself suggests no particular strategy for altering beliefs” (13).

FAILURE TO INCLUDE SOCIAL FACTORS – Parents and Weight-Bias

The third major flaw of the Let’s Move campaign is the failure to include social factors that influence children’s and their parents’ decisions to adopt a healthier lifestyle. As we have established before, the Let’s Move campaign relies heavily on the health belief model. Being an individual level theory, the health belief model does not work for this application with the target population as large as American children because it ignores any social factors that interfere with the decision-making among children and their parents. In her paper, “Critique of Health Belief Model”, Linda W. Thomas notes that the “Health Belief Model’s failure has been in part to the model’s inability to allow for the inclusion of the relationship between health status and historical, social and political structures” (12).

The Let’s Move campaign fails to address social norms, affects and stigmas in the life of obese or overweight children. In a study that tried to calculate the correlation between the family characteristics such as family adversity, maternal depression and attachment insecurity predict long-term success in children’s weight reduction (13). This study involved overweight and obese children between the age of 7 and 15 years old. The focus of this study was not only behavior among children, but also in their immediate environment – their family (13). Factors such as BMI, depression, adversity such as disease and attachment insecurity among family members was measured and correlated with success in children’s weight reduction (13). The study concluded that family obesity maternal attachment insecurity and depression, along with alcohol use and smoking predicted a decreased success rate in weight loss among children (13).

Admittedly, the Let’s Move campaign has correctly appealed to children’s social network, namely their parents and schools. The issue here is regarding the type of information that is conveyed to them. Through its comprehensive website, the campaign has cited possible harms and risks of childhood obesity, and suggested parents and schools to create an environment around children that is conducive towards a healthy lifestyle. As described earlier, there are several problems that arise from this pure informational campaign in the form of reactance. It is imperative for the campaign to keep parents and schools within the effort, but the type of information provided is crucial. Risk factors for child obesity include parental fatness, low socio-economic status (14), maternal attachment and depression, alcohol use and household smoking (13). Childhood obesity is directly related to parental behavior such as bottle-fed instead of breastfed, maternal obesity (15) additional research has proven that “dirty and neglected children had a much greater risk of adult obesity than averagely groomed children (16).

The Let’s Move campaign fails miserably in addressing other social influences on children fighting with being obese and overweight. It ignores any outer social stigmas and biases that might affect the decision making of overweight children and parents to change their lifestyle. Other than the above-mentioned familial and household factors, social influences in school and among their peer group also play a large role in their perception of obesity reducing programs. The paper Childhood obesity: Issues of weight bias (16), introduces and explains the concept of weight bias. The paper’s author, Dr Washington, Chief Medical Officer, Rocky Mountain Hospital for Children, explains Weight Bias as “the inclination for unreasonable judgment based on a person’s weight” (16) He supports this by citing decreased teacher perception, lower college admission rates and increased refusal of physicians to take care of obese patients. Dr Washington is certain that public health programs that address childhood obesity shall have a higher success rate when accompanied with a parallel effort that advocates for obese children and to fight against weight bias (16).

In his analysis, Dr Washington notes that obese children are seen as untidy and unsuccessful by their teachers; rated more negatively during employment interviews and rating; non-compliant, hostile, dishonest and hygienically untidy by health providers (17). This can be explained by the behavioral theory of Labeling. According to this model, an individual shall behave in a way that they are labeled or stereotyped. During socialization, individuals learn the attitude of the community toward many behaviors, objects, and attributes, and internalize these attitudes to replicate them (18). Hence, as a society exhibiting extreme weight bias as depicted by Dr Washington, we are instead reinforcing the stereotype and stigma associated with obesity, encouraging obese people to behave in unhealthy and unhygienic ways. Not surprisingly, in-depth research has also cited stigmatization and labeling as important sources of failure in school organized obesity prevention programs (19). The inherent flaw the Let’s Move campaign lies in its inability to make a change in society’s attitudes in response to the labeling theory.

In such a way, the Let’s Move campaign correctly identified parents as one of the target groups for their campaign to reduce child obesity, yet is greatly flawed as they provided ineffective informational and statistical evidence; and interventions that apply to the ‘wrong target group’. It also fails to soften the society’s apparent strong negative view of obese children and young adults.

PROPOSED INTERVENTIONS

Due to the large, encompassing scale of the Let’s Move program, this paper suggests 3 separate, yet very specific interventions that could be used by the campaign. These interventions address the above-mentioned flaws with this campaign to reduce the prevalence of childhood obesity in the US.

1. Changing target population’s perception of freedom and ownership: This intervention addresses the problem of psychological reactance suffered by the Let’s Go Campaign. The intervention shall be an advertisement that is directed specifically to children aged 5 to 17 years old. It shall depict a successful group of socially and romantically desirable 19 to 30 year olds, and then tracing them back as non-obese, physically fit children.

2. Appealing to children’s core values through an advertised story line: This intervention replaces the Health Belief Model used by the Let’s Go campaign by the Advertising model. Intervention: Advertisement with Child narrating a story that depicts junk and soft-drink companies recruiting children into an undesirable generation of young adults.

3. Appealing to biological and behavioral effects by parents: Intervention is an advertisement directed exclusively at would-be or current parents, depicting a similarly aged-couple giving up TV hours for romantic memories, and restaurant runs for outdoor activities with their happy, well-tended and attractive family.

1. Changing children’s perception of freedom and ownership.

The psychological reactance model demonstrated the predicted repercussions of using parents, schools and political leaders to bring change in children’s habits. This might seem logical as mostly everything else in children’s lives are shaped and modeled by these ‘authorities’, but since the Let’s Move campaign’s effort, perhaps inadvertently curtails children’s freedom and autonomy, shall not be greeted with much enthusiasm or respect by the target population – obese or overweight children. “Because perceived control is important to their well-being, people strive to maintain a sense of control and are motivated to restore control that has been threatened … Reactance theory, for example, proposes that, when freedom is threatened or lost, people behave in ways that protect or restore the specific freedom in question” (20).

To overcome the reactance generated by the Let’s Move campaign we can either use psychological reactance for our benefit, or to eliminate it. According to a research paper concerning consumer reactance, “the more important the freedom, the more reactance is generated due to personal or impersonal threats” (21). The authors of this paper recommend using ‘the importance of freedom’ as a mediator to reactance (21). If a campaign can manipulate the amount of perceived importance placed on freedom amongst our target population, reactance can be used to the campaign’s benefit. In our case, the Let’s Move campaign should attempt to reduce the amount of importance placed on children’ freedom of diet and physical lifestyle, and increase the importance placed on their freedom of being successful, socially desirable and physically capable. A possible example of this could be in the form of a television advertisement that depicts a successful group of individuals who are socially and romantically desirable, then tracing this group back in time, as non-obese children. As per the authors of the consumer reactance theory, similar advertisements shall shift the target population’s perception of freedom on values set by the organizers of the campaign (21). This particular approach shall align both parent’s and their children’s perception of freedom with those of the Let’s Go campaign.

The above-mentioned article on consumer reactance advocates eliminating psychological reactance by depicting a perceivable absence of freedom amongst current obese or overweight children (21). Current approaches used by the Let’s Go campaign that propose a healthy diet and increased physical activity is, in essence instilling a sense of freedom of diet and sedentary life in children and their parents, leading to a strong psychological reactance. Conversely, if the campaign can eliminate this false sense of ‘unhealthy’ freedom, it can eliminate the problem of reactance among the target population.

2. Appealing to children’s core values through an advertised story line
The advertising model is a group-level theory that appeals to the target populations’ core values. Communication’s researchers at the University of Minnesota have ascertained that “persuasion is primarily a communication process and most definitions of advertising classify it as a form of communication” (22). The advertising model predicts that the use of non-causal arguments such as those employed by the Let’s Go campaign are ineffective in changing people’s behavior. Non-Causal arguments use statistics and probabilities, information that is unnecessary for a highly persuasive campaign (23). The advertising model uses causal arguments to change people’s behavior. Causal arguments in public health explain the scientific process and causality that connects the behavior to a specific health issue, and are more effective in changing the target audience’s behavior.

When using the advertising model, we employ three concepts: Promise, Core Values and Support. The campaign needs to promise something that is close to the population’s core values. Core values are those that are kept at utmost importance among the target population, and hence, play a much larger part in an individual’s decision-making process when compared to simple reasoning by providing statistics, probabilities or likelihood of an event occurring. The core values used by the advertising theory include love, freedom, acceptance, attractiveness, etc (21). Unfortunately, good health is not among these core values and cannot be used effectively in a health campaign such as the Let’s Go campaign (22). The third and final concept introduced by the Advertising model is support in the form of stories that appeal to the target group.

Applying the advertising model to the Let’s Go campaign will need to make a valid promise to the target population’s core values, at the same time providing ample support in the form of a storyline. The advertising model also advises public health campaigns to implement a peer messenger – using someone from the target population in the advertisement (21). Core values that can be applied here are social desirability, attractiveness and success. We can also incorporate aspects of the psychological reactance theory as discussed earlier. A potential campaign advertisement that meets all these requirements could be the following: A child narrating a story that depicts junk food and soft-drink companies recruiting children into a group of socially undesirable, unsuccessful and unattractive young adults. This kind of advertisement satisfies recommendations made by the advertising theory as well as the psychological reactance theory.

3. Appealing to biological and behavioral effects by parents

Addressing social factors that increase obesity and decreasing society’s weight bias requires a two-pronged approach, appealing to parents and the society (17). Parental behaviors in terms of health, attitude and social preferences are accurately reflected in children (14). Instead of asking and convincing parents to modify their children’s behavior, the Let’s Move campaign should instead target pre-conception couples and current parents to change their own behavior. Children who were bottle-fed seem to more at risk of obesity later in childhood than those who were breast-fed (15). Similarly, excessive prenatal and postnatal parental TV, especially bedroom TV use, restaurant meals, intake of sugary-drinks, etc lead to higher rates of obese and overweight children. It is imperative to note that these behaviors are especially predictive during the pre-conception period (15).

To address this fallacy, a suitable adaptation that the Let’s Move campaign can incorporate is asking current and to-be parents to change their behavior for the their own and their children’s benefit. Keeping the advertisement theory and psychological reactance in mind, we would have to appeal to the parent’s core values such as social acceptability, desirability and success (22). Research also shows that neglected children are more likely to develop obesity as an young adult. A potential intervention could be an advertisement that shows an average young couple avoid restaurants for an enjoyable outdoor activity with their family and loved ones, replace a bedroom TV for more intimate bedroom moments and hence, raise a well-tended, happy, attractive and socially desirable family. This intervention addresses all of the above-mentioned risk factors to childhood obesity by appealing to core values of most young-couples and avoiding redundant and ineffective statistics and probabilities.

Conclusion

To briefly conclude, Michele Obama’ Let’s Move program suffers a few flaws in the form of the self-belief model, psychological reactance and improper information imparted to parents. These flaws can be corrected by using a few theories including the advertising theory, psychological resonance theory and labeling. The obvious preference in these corrections is to use group-level theories, which use strategies that have proven successful in public health and many other marketing and advertising campaigns in a variety of settings.

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