Challenging Dogma - Fall 2011

Wednesday, December 21, 2011

We Can! Develop A Successful Public Health Campaign to Combat Childhood Obesity – Andrew Stewart

In the past, having fat a fat child was seen as a blessing. This meant that you had a healthy child and that you did not have to concern yourself with malnourishment. This has not been the case in the past decade. Childhood obesity has arguably become the number one health problem affecting today’s youth (1). The term obesity should not be confused with the term overweight. The term overweight refers to extra body weight from muscle, bone, fat, and water (2). The term obesity refers only to having extra body fat (2). Being obese is associated with a number of health complications over the entire body. The most prevalent of these is Type II diabetes. In many populations, close to half of all Type II diabetes diagnoses may come from children under the age of 18 (1). The prevalence of diabetes alone at least doubles your risk of developing heart disease and stroke later on in life (3). Other risk factors for cardiovascular disease present in obese children are high blood pressure, high cholesterol, and hyperlipidemia (1,4). Currently, 70% of obese youth have at least one of these risk factors (4). Obese children are also at increased risk for respiratory problems, joint problems, social and psychological problems (1,4).

Even with the breadth and severity of these health concerns, the number of children who are obese continues to rise. The percentage of obese children aged 6-11 has risen from 7% in 1980 to over 20% in 2008 (4). Similarly, the rate of obese adolescents has risen from 5% to 18% over that same time period (4). Although this has been the trend worldwide, the United States is drastically leading the way in childhood obesity rates (1). There are many factors that contribute to this. There have been five genes that have been demonstrated to show a link to obesity (1). However, more of the influence comes from nutrition, physical activity, and family factors (1). These factors have been the focus of most public health campaigns battling obesity.

One of these campaigns is the We Can! campaign that was launched by the National Institutes of Health. We Can! (Ways to Enhance Children’s Activity and Nutrition) is a science-based national education initiative that was launched on June 1, 2005 (5). Their strategy is to educate parents and caregivers about healthy nutrition, physical activity, and reducing screen time (6). They do this through community, national, and corporate partnerships. These partnerships allow them to not only provide research and educational materials to families, but also to gain feedback from users, hospitals, parks, public health departments, schools, and worksites (6).

In theory, We Can! is a great program with good intentions on a serious problem; however, there are some major flaws in the way the program attempts to get its message across:

Misuse of Psychological Reactance Theory

The nutritional portion of this program focuses on removing many of the sugars and fats from diets. They utilize what is known as a “GO, SLOW, and WHOA” food chart, in which they tell people how much of a particular food they can eat (7). A program such as this may cause a “boomerang effect” where individuals will attempt to protect the freedom that is being threatened (8). In this sense, freedom is used to mean behavioral freedoms. Each individual behavioral freedom can be lost without having an impact on other behavioral freedoms. Losing one particular freedom while retaining all others will make the lost freedom increasingly desirable to that individual (9). This effect has been demonstrated in studies comparing anti-smoking ads that were put out by large tobacco companies such as Phillip Morris where, after viewing the anti-smoking ad, adolescents tended to have more favorable viewpoints toward the large tobacco company (10).

The program does a poor job with this theory in the active portion of their strategy as well. Instead of discussing the benefits of being active like enjoying a morning jog or having a good body image, the program focuses on what a person should not do. It focuses on time spent inactive while sitting at a desk at or work or school and compounding that with time spent sitting during your free time. The program states “fight the urge to slouch on the couch” (11). Presenting the program in this manner may make the individuals think about activities they will be missing out on, such as their favorite television programs. This in turn makes these programs more desirable (9). Individuals adding importance to these programs can have a compounding effect in where they begin to add importance to activities they previously did not perceive to be important (12). The increased importance placed on these activities will cause the person to justify actions that they normally would not have (12).

This affect is generally on an unconscious level. People do not perceive that their freedoms are being threatened, but they may still respond to minor requests in a magnified manner if it is framed incorrectly (9). The program suggests that a person do simple things such as park further away, take the stairs, or go for Saturday or Sunday walks (11). These by themselves are small requests, but they can be magnified by individuals due to a threat to their freedom of time. People may justify taking the elevator or driving around for a closer parking spot because they tell themselves they don’t have the time to spend walking when, prior to this threat to their freedom, they wouldn’t have given it a second thought. If the people behind the We Can! program had framed the way they attempt to motivate individuals to be active, they may have been able to avoid this effect.

The program does attempt to counteract the boomerang effect of psychological reactance theory by providing positive effects that can arise out of being physically active. Unfortunately, like many other public health intervention programs, they fail by improperly using the Health Belief Model.

Using Scientifically Based Educational Campaigns

Like much of the rest campaign, We Can! attempts to justify being physical activity by providing health benefits. The Health Belief Model is not a bad model to attempt to change behavior. In fact, the Health Development Agency recommends much of the model to be used in creating an effective public health campaign (13). They recommend increasing knowledge and awareness of risks and health benefits in order to prevent disease (13). While this is a good model that is utilized widely throughout public health campaigns, it should not be used as a major model, rather as supplement. This model assumes that people will weigh perceived relative benefits and risks of certain behaviors and ultimately take action according to those perceptions (14) The Health Belief Model also relies on the assumption that the person also believes that he or she is susceptible to the perceived threat (15) This is counter-acted by the Optimistic Bias Theory which states people tend to underestimate the chances of themselves experiencing a negative health effect (16).

If people acted rationally, the Health Belief Model would be a great model for public health campaigns. Unfortunately, people tend to have greater responses to campaigns aimed at core values than scientific, health based data. This is illustrated in advertising theory which states that a successful campaign will appeal to an individual’s emotions and values instead of providing scientific data (17). We Can! comes very close to doing this in justifying their exercise program, but they need to take it one step further. In an attempt to justify increased exercise, they make references to making “active time family time” (11), but they need to take it one step further. Instead of merely saying make active time family time, they should talk about the additional time that they will be able to spend with their children, and how it will make them closer as a family. This will appeal to the family values that many parents strive for.

Yet another problem with the way that they framed the Health Belief Model is the manner in which they framed this program as an educational program. They might be more successful in attempting to change behavior directly and having the beliefs follow the change in behavior. This is well illustrated in self-efficacy theory which states that if you are able to change an individual’s behavior, their beliefs will follow in order to justify their actions (18). Instead of focusing on changing behavior, this program focuses on educating parents on eating habits and physical activity for both them and their children, which leads to the third critique.

Poor Use of Messenger

We Can! quotes research saying that parents are the primary influence on this age group (6). It focuses its efforts on educating parents on healthy lifestyles assuming that these effects will trickle down to the children. They are basing this assumption on Social Cognitive Theory, which is one of three theories this program is based on along with Community Organization Theory and Diffusion of Innovations Theory (5). Social Cognitive Theory states that if you surround an individual with a certain environment and certain behaviors, the individual will ultimately begin to model the behavior themselves (19). Once again, this program leaves out the effect of Psychological Reactance Theory.

One aspect of Psychological Reactance Theory states that one way to increase compliance and reduce resistance to an intervention is to have the messenger of that intervention be as similar to the individual you are attempting to reach as possible (20). Individuals who were presented with threats to particular freedoms but associated with the communicator felt less threatened by the proposed intervention than ones who did not associate with the messenger (20). By laying the burden on the parent or caregiver to implement the new behavior, the program is eliminating any possibility that the children will associate with the messenger.

This also holds true for the parents. The parents are merely provided with educational information on better eating habits and ways to become physically active. They are encouraged to speak with other members in the community, but they are never in direct contact with a representative from We Can! (5). Studies have found that people are more likely to accept and implement behavioral changes if they are delivered socially rather than solely as text (21). By delivering the message socially, the individual receiving the message feels at least some connection to the messenger which in turns decreases psychological resistance (20). As previous studies have found, any decrease in psychological resistance can have profound effects (9,12).

We Can! 2.0

The We Can! project is a good project aimed at a serious problem here in America; it just has a few flaws that need to be addressed. The project does have a wide base that it is able to reach out to and is set up well in many communities. It receives national funding from the National Institute of Health, so it is able to implement its programs (5). If we reshape this project, it could prove to be very effective and instrumental against the fight against childhood obesity.

First, the project needs to break away from its heavy reliance on the Health Belief Model and move toward another more encompassing theory such as advertising theory. This would allow it to appeal to core values instead of simply supplying people with factual information and hoping that they make rational decisions for themselves. This will not only evoke stronger feelings toward the project, but it may also decrease much of the psychological reactance that is associated with the current methods they are employing.

Second, the project needs to be framed in a different way. It is a good idea to get the parents involved in the project as well, but they need to be cautious of rebellion on the children’s part if they perceive this program as another task their parents are ordering them to do. Also, it would help to deflect some of the psychological reactance if other children in the age range they are looking to implement the change in behavior in are presented in this campaign as well.

Third, the very nature of this project will evoke psychological reactance. Instead of attempting to fight and deflect the reactance, they can actually alter their campaign to embrace psychological reactance in a positive manner. Some of the material provided in the campaign comes close to accomplishing this, but they can take it one step further and embrace it.

Incorporating these three things, they can develop a new campaign that is centered on family values for parents and fun for kids. Sure, some scientific evidence can be used to support the promise of fun and togetherness for families, but it will merely supplement the main message. The program needs to show that being active and eating right is a way to a more fun lifestyle, not a way to a healthier lifestyle. Instead of passing out brochures filled with scientific data, they should have pictures of kids playing soccer together and families out on works. Rather than conducting educational programs in communities, they should have families representing the program in communities. This way families can see for themselves and model the behavior of them. The program claims to utilize Diffusion of Innovations Theory (5), but it does so in a poor way. In order for Diffusion of Innovations Theory to be successful, a families who are seen as respected and of high social status need to adopt the theory (22). Once they adopt the theory, it can trickle down to the remaining families until it hits the point of inflection where it will spread quickly throughout the community. This would prove to be a much more effective method of altering behavior.

Breaking Away From the Health Belief Model

People have historically had a tendency to act irrationally, so why expect them to react any differently to a public health campaign (23). Thus, a public health campaign would be most effective and reach a broader audience by utilizing advertising theory in the mass media.

We Can! has made a feeble attempt at this by producing a YouTube video that is still scientific evidence based. They need to separate themselves from that. Instead of passing out brochures and providing education for families on specific activities and the health benefits associated with them (11), the program should direct its focus to a mass media campaign that appeals to core values of the families they are trying to reach.

They can do this using the three principles of advertising theory (17). They can make an ad that promises that a change in physical activity and diet will not only give them greater independence and happiness, but it will also bring them closer together as a family thus giving them more love. Once the promise to the core value has been made, this new campaign has the advantage of being able to support that evidence with information that is actually true. This is where the scientific evidence plays a role. Studies have shown that people who routinely perform physical exercise are generally more happy and independent than their sedentary counterparts (24).

Proper Framing

Once the ad has been established, they need to ensure that it is framed the correct way. This is not only in terms of how they are using advertising theory, but also in who they are using to deliver the message. Currently, the program has no specific messenger and is only making an attempt to appeal to the parents and caregivers. It would be more effective for them to make appeals with proper messengers to everyone whose behavior they are trying to change.

The first messenger that needs to be included in this is the initial messenger providing information to the parents. By not having the face of any messenger in this situation, the program is losing out on a large part of the acceptance process by being able to associate oneself to the messenger (20). They also claim to utilize social cognitive theory (5), but, without any messenger to associate with, the parents have no one to model their behavior after (19). This is why it would be helpful to portray families that are similar to target audiences in the ad campaign.

Parents are not the only ones that this program is attempting to reach. This program makes no attempt to appeal to the children it is designed to help. This is the second messenger needed. Since the program is aimed at a wide range of ages of children, it would be helpful to accomplish this using multiple messengers. Children age 6 might have a tough time identifying with a messenger who is 12 and vice versa (20). By having messengers that these children are able to associate with, the program is able to eliminate much of the psychological reactance that it may evoke.

Turning Psychological Reactance on Itself

Having psychological reactance in a program doesn’t necessarily have to be a bad thing. As a matter of fact if it is framed properly, it can turn out to be advantageous. This program evokes a lot of psychological reactance, but in a negative way by taking freedoms away from people. The program should be redirected to seem as if the health benefits were being taken away from people.

Now that we have our advertisement that is appealing to the core values of family and has the proper messengers, the advertisement can also incorporate in one additional factor: reverse psychological reactance. It can do this by beginning the commercial appealing to these core values and showing the advantageous aspects of diet and exercise, and end the advertisement on a note asking “Could you imagine yourself without such freedoms”. The advertisement may then depict what life would be like without such things such as walks in the park with your family or enjoying a nutritious home cooked meal. By doing this, the viewer may feel that his or her freedoms to do such things are being threatened by their unhealthy lifestyle. In this manner, the psychological reactance that goes hand-in-hand with this campaign can be turned around and used favorably.

Combining these three factors allow for the creation of an effective public health campaign that We Can! was close to achieving before. By using theories such as advertising theory and deflecting and reversing psychological reactance, a much stronger and effective campaign is created to combat the problem of childhood obesity that is currently plaguing the United States.


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  2. National Heart Lung and Blood Institute. What Are Overweight and Obesity?. National Institute of Health.

  3. National Diabetes Information Clearinghouse. Diabetes, Heart Disease, and Stroke. National Institute of Health.

  4. Adolescent and School Health. Childhood Obesity Facts. Center for Disease Control and Prevention.

  5. National Heart Lung and Blood Institute. We Can!. National Institute of Health.

  6. National Heart Lung and Blood Institute. We Can!. National Institute of Health.

  7. National Heart Lung and Blood Institute. We Can!. National Institute of Health.

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  17. Vaughn, Richard. How Advertising Works: A Planning Model. Journal of Advertising Research. 1980. 20: 27-33

  18. Schunk, Dale. Self-Efficacy Theory. (34-52). In: Wentzel, Kathryn. Handbook of Motivation at School. New York, NY: Taylor & Francis. 2009

  19. Luszczynska, Aleksandra. Social Cognitive Theory. (127-170). In: Predicting Health Behavior: Research and Practive with with Social Cognition Models. New York, NY. University Press. 2005.

  20. Silvia, Paul. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. 2005. 27:277-284.

  21. Roubroekes, Maaike. Does it make a difference who tells us what to do?: Exploring 2009. the Effect of Social Agency on Psychological Reactance. Persuasive Technology.

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  24. Warburton, Darren. Health Benefits of Physical Activity: The Evidence. Canadian Medical Journal. 2006. 174.

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