Milwaukee Campaign Against Sleeping with Baby – Natasha Neal

Infant Mortality in Milwaukee, Wisconsin
Milwaukee, Wisconsin has higher rates of infant mortality in comparison to other areas of the United States and other parts of the world. Infant mortality is the number of infants that die during their first year of life (1). Milwaukee’s African-American infant mortality rate is ranked higher than at least 35 other countries, including some developing countries (2). The top four reasons for infant death in Milwaukee are complications of prematurity; congenital abnormalities and related complications; sudden infant death syndrome (SIDS), overlay, and accidental suffocation; and infections (2). In particular, Wisconsin is a state with one of the largest differences in infant mortality based on race. The gap between non-Hispanic white infants and African-American infants is quite large: for every five white infants that die prematurely, 14 African-American babies die (1). Based on the list of most common deaths in infants, the only cause that is preventable after birth is SIDS, overlay, and accidental suffocation.

In order to address the dismal situation, the City of Milwaukee’s Health Department created a Safe Sleep Awareness Campaign, in which they discourage the practice of co-sleeping, and more specifically, babies and adults sharing the same bed (3). They have used posters, as well as radio and television advertisements to get their point across to the public. To view the public health campaign advertisements, visit http://city.milwaukee.gov/SafeSleep (3). The public has perceived these advertisements with mixed views as they depict a small baby sleeping in a bed next to a large knife. The poster states: “Your baby sleeping with you can be just as dangerous.” Some responses have been supportive towards catching parents’ attention on an important matter; however, others feel that the City of Milwaukee is demonizing parents. These posters were created with the intention of grabbing the attention of parents that may bed-share. It is very unlikely that parents that co-sleep are consciously putting their babies in harm’s way, explaining the negative reactions of some parents.

Problems with Milwaukee’s Campaign Against Co-Sleeping

Despite correctly identifying the large racial disparity in infant mortality, Milwaukee’s campaign is unlikely to be successful in closing this gap. The Health Department has chosen to focus on a much narrower health behavior in the hopes that it will significantly reduce the rates of infant mortality. The advertisements used in the campaign overlook four important social behavioral models: Labeling Theory, Optimism Bias, the Law of Small Numbers, and Psychological Reactance. Furthermore, The City of Milwaukee’s Health Department has done a poor job of approaching such a controversial, and poorly understood health behavior.

The Health Department has been quick to pinpoint bed-sharing as the form of unsafe sleeping practice that results in sudden infant death syndrome (SIDS) or sudden unexpected death in infancy (SUDI). However, based on a study released in 2011, the major risk factors for SIDS also include inadequate prenatal care, low birth weight, premature birth, short interval between births, and maternal substance abuse (4). It becomes clear that many of these factors are uncontrollable, and are often completely independent from whether an infant sleeps in the same bed as an adult or not, except for maternal substance abuse. Therefore, even infants that sleep in their own bassinet or crib are at risk of SIDS. In some unfortunate cases, despite parents following the safest child-rearing practices, an infant will still experience SIDS. In combination with the disparity in infant mortality between races, it encourages one to question whether an ethnic community in particular is engaging or has a history of increased risk factors, in addition to bed-sharing. It is important to examine the situation in relation to different races as one of the goals is to narrow the gap between infant mortality rates in Milwaukee.

Data included in the City of Milwaukee’s Fetal Infant Mortality Review (FIMR) also does not concretely support their view on targeting co-sleeping. The FIMR stated that Singapore had the lowest infant mortality rates, despite approximately 70% of the population engaging in bed-sharing, showing that bed-sharing can be practiced safely (5). Armed with this knowledge, one must ask what specifically, during bed-sharing, is the cause for increased infant mortality in the United States versus Singapore. Research has been conducted on this point, and it has been found that there are often other factors playing a role. For instance, the risk of infant death during bed-sharing often occurs if a parent also engages in smoking or alcohol abuse (6). In addition to this, in other countries where bed-sharing is the predominant form of sleep practice, it is important to be aware that in these countries, families often sleep on firm mats instead of softer mattresses (7). Therefore, it is a combination of the risks mentioned previously, including premature birth and maternal substance use, combined with bed-sharing, that can increase the risk of infant death.

Another critical consideration of this intervention is the message that public health officials want to send. Research has shown that the risk of SIDS increases when babies sleep in a different room from parents (8). Despite this known fact, the advertisements do not include information indicating that although bed-sharing should not occur, room-sharing is important to the health of infants. The advertisements, while depicting the dangers of bed-sharing, contain little information on how to mitigate the risks. This information only appears on the website, and yet there is no guarantee that parents will spend the time going to the website. All information must easily reach parents in order for individuals to make educated decisions. The City of Milwaukee also ignores the positives that have been identified in literature regarding bed-sharing. These positive elements include making breastfeeding easier, allowing babies and parents to get more sleep, ensuring mothers are more responsive to the needs of the infant, and the practice encourages bonding and security between parent and infant (7). By purposely omitting this information, the public may feel as though the City of Milwaukee’s Health Department is trying to deceive or manipulate their behavior. This may be especially likely to occur in parents that are well-versed in the sleeping practices of other non-Western cultures.

Due to the vast majority and somewhat contradictory information available in regards to bed-sharing and co-sleeping, it becomes apparent that education must be the first step to behavior change. Parents are unaware of the pros and cons of different sleep practices. As well, many parents are misinformed about the definition of co-sleeping; some believe that co-sleeping is defined specifically as the practice of sharing the same bed with a baby; however, this is not true (3). Having a baby sleep in a bassinet or crib next to the parents’ bed is also a form of co-sleeping. Some experts have begun referring to room-sharing versus bed-sharing in order to clarify the difference in the two practices (3). One problem with the campaign is that the ads do not clarify this distinction. Therefore, the overall impression parents may be getting is that their babies need to sleep in a completely different room.

Labeling Theory and Racism's Effect on Health Disparities

Milwaukee’s Health Department has been quick to identify the difference in infant mortality rates between African Americans and non-Hispanic whites (2). However, one major flaw in their intervention was the obvious avoidance of addressing these differences in their campaign, other than including two versions of their ads, one featuring a white infant and the other featuring an African-American infant (3). It is important to consider the reasons behind why the rates of infant mortality differ so drastically between the two races, even when all other factors are similar. It has been reported that an African-American woman with a college degree has poorer infant mortality rates compared to a white woman with only a high school education (1). One contributing factor to this phenomenon may be due to labeling theory, and its relation to race. Institutionalized racism may play a huge role in the differences in infant morality rates between white and African-American infants. Differences in race are especially important as the City of Milwaukee is dramatically racially segregated (9).

One study has looked at biological differences between people of different races in order to determine reasons for such dramatic differences in health disparities in different populations of people. One study was conducted in order to identify why blood pressure can differ so drastically between black and white individuals (10). Researchers Krieger and Sydney concluded that when examining blood pressure, it was important to take into account how discrimination may affect health (10). Similarly, it is important to take into account the biological differences of African-American women in comparison to white women. African-American women typically have babies with lower birth weights and are more often born prematurely (9). Institutional racism, a form of racism that is not necessarily obvious, can result in African-American women having increased stress levels, perhaps due to the expectation that discrimination will occur in everyday life events (11). Increased stress levels may then lead to increased risk of premature births and low birth weight. It is important to help these women that must live with institutional racism overcome the hardships they may face, especially during pregnancy.

One other study looked at the differences in infant mortality between African-Americans and white mothers in relation to sleeping position. The study identified that the sleeping positions varied distinctly between the two races. African-American infants were more likely to sleep in the prone position, or on their stomachs, rather than the nonprone position (on the back or side) (12). The prone position is more highly associated with SIDS. This could be one reason why the disparity in infant mortality exists between the two races. The study also went on to find that African-American mothers more often recalled or were incorrectly told by health professionals that the prone position should be used (12). Here we see a form of institutionalized racism that impacts the mothers of different races, as it is unlikely physicians were purposely suggesting unsafe sleeping practices.

A separate study found that interpersonal racial discrimination experienced by African-American women a year prior to birth as well as over a lifetime was a risk factor for premature birth (13). Nancy Krieger defines interpersonal racism as “directly perceived discriminatory interactions” (14). The City of Milwaukee should consider examining whether members of the African-American community experience higher levels of interpersonal racism, in order to prevent this from occurring. In the study conducted by Rankin, David, and Collins, they found that using active coping behaviors to deal with interpersonal racism could weaken the association between the risk factor and premature birth (13).

Understanding the differences between African-American women and white women is one way to focus Milwaukee’s intervention and an important factor in determining how to reduce the infant mortality rate. Milwaukee’s campaign does not inform women that babies born prematurely or with low birth weights are at higher risks for SIDS, and the necessity to take more precautions. The racial segregation in Milwaukee can further impact the situation as areas with high populations of African-Americans may have fewer resources for pregnant and new mothers, such as clinics, primary care offices, and prenatal classes.

Optimistic Bias and the Law of Small Numbers

The Health Department has overlooked the roles that the theory of optimistic bias in combination with the law of small numbers may play in this campaign. The Law of Small Numbers is the theory that people will often associate their risk with one positive case despite substantial information contradicting this (15). For example, a smoker will doubt that smoking increases the risk of cancer despite the vast evidence supporting this simply because they have a family member who smoked their entire life and never developed cancer. Optimism bias refers to the fact that an individual will know the risks of a particular behavior, but will underestimate their own risk (16). The campaign against bed-sharing emphasizes the dangers through the use of the knife and tombstones in the ads (3). While this may communicate the risk of bed-sharing with the public, individuals may believe that they will be the exception to the statistics. In the television ad depicting a mother that tosses and turns while sleeping, the overall impression is that bed-sharing may lead to a parent or adult suffocating their child. However, based on optimistic bias, people viewing the ad may think that while suffocation of a child may happen to others, it will not happen to them – they will be the exception to the rule (16). This becomes especially important for parents who already have had a child, and who practiced bed-sharing without any incidence of SIDS or SUDI. Based on their previous experience, they are likely to experience the law of small numbers, and be confident they can bed-share with smaller risks than the general public, although this may not necessarily true (17). Another factor to consider is the social networks of people, and the different sleeping practices friends and families engage in. One study found that at 2 weeks of age, 42% of parents shared a bed, at 3 months 34% shared a bed, and 28% at a year of age (18). These statistics show that bed-sharing is not rare and many people likely know of other parents that sleep in the same bed as their infants. The knowledge of others that have bed-shared successfully can lead people to believe in the Law of Small Numbers - that those people that have successfully practiced bed-sharing are in fact the norm. These individuals will question the veracity of the ads in conjunction with having an increased risk of infant death, especially if these parents believe that bed-sharing is a better parenting technique. Combined with optimistic bias, knowing others that successfully bed-share make it unlikely that these ads will be effective in changing the behavior of parents that co-sleep in the same bed, especially those that have never known someone whose child suffered from SIDS or SUDI.

Psychological Reactance and Pushback Against the Ads

It is very important to gauge how the public perceives the advertisements. Psychological reactance occurs when people feel their control is being taken away (19). It becomes particularly important in the issue of co-sleeping because parents have differing opinions on the pros and cons of bed-sharing based on the literature available and the cultural norms of different populations. Therefore, when advertisements tell people that their method of child-rearing is incorrect or unsafe and should not be practiced anymore, it is in effect taking away the freedom for people to decide how they want to raise their children, and what they believe is best for their child’s development. In a study conducted, investigators found that countercultural parents in the US were more likely to also be “pronatural.” This group of parents was interested in following “natural parenting” and often follows practices more common in non-Western countries, such as breast-feeding rather than formula use, bed-sharing, and using only organic foods (20). However, they may be unaware that in non-Western countries, firmer mats instead of softer mattresses are used. These parents believe that they are practicing the best form of parenting, and will therefore not heed the warning, and they will perceive a loss of control over their style of parenting. When people experience psychological reactance, they will often engage in the prohibited behavior much more strongly (19).

Solutions for Co-Sleeping and High Infant Mortality Rates

It is important to consider the root causes of high infant mortality. Despite perhaps not being the largest cause of SIDS and SUDI, proper co-sleeping may lower the rates of infant mortality in Milwaukee. However, identifying the differences in racial groups will also be impactful if addressed in the intervention. A new intervention is being proposed that will effectively remove the barriers in the already existing intervention.

The new intervention will consist of various different platforms: it will use television advertisements as well as offering educational programs in the community. This new intervention is based largely on three models useful for changing behavior: the Theory of Planned Behavior, Social Expectations Theory, and Advertising Theory. In combination, these will overcome the problems seen in Milwaukee’s current campaign, and will hopefully reduce the number of deaths that can be attributable to unsafe sleeping practice, as well as reducing the number of SIDS and SIDU deaths in general in Milwaukee.

New television advertisements will be created for the intervention. The advertisements will depict images of the important milestones in a child’s life: first birthday, first steps, first day of school, graduation, marriage, and then the birth of a grandchild. Following the images, a parent who experienced the death of an infant due to SIDS or SIDU will speak out. More specifically, the parent will emphasize the point that they were unaware of the importance of safe-sleep practices, that they missed out on so many of the milestones they expected to experience, and they will encourage parents to seek out new information regarding safe sleep practices. They will also suggest ensuring children sleep in an environment without blankets or pillows, to avoid the risk of suffocation, and that parents always place their babies on their back or supine position to sleep (8). If parents are concerned about moving in their sleep, the ad will go on to explain that the safest place for a child is in a crib or bassinet. However, it will emphasize the importance of infants sleeping in the same room as a parent.

In addition, the new intervention will have nurses available at churches, clinics, or community centers for expecting and new mothers. These nurses will be concentrated in African-Americans communities, where clinics and services may be harder to come by and where infant mortality rates are much higher – in particular, the zip codes of 53206, 53210, and 53233, which have the highest rates of infant mortality in Milwaukee (2). The nurses will act as educators, talking about the increased risk of SIDS for premature or low birth weight babies. They will ensure that African-Americans have strategies in place to deal with any type of discrimination they may face. They will describe common safe sleep practices outlined in the report by the American Academy of Pediatrics, such as always placing an infant in a supine position, using a firm mattress, avoiding pillows and blankets near the infant, encouraging breast-feeding, encouraging room-sharing over bed-sharing, and encouraging the avoidance of exposure to tobacco smoke, alcohol, and illegal drugs (8).

Finally, the City of Milwaukee should start a program where parents can donate cribs or bassinets once they are no longer needed. These will be provided to parents of newborns that are interested in room-sharing rather than bed-sharing, but that may not have the means to purchase these items.

Social Expectations Theory for Community-Based Interventions

The Social Expectations Theory suggests the importance of examining individuals based on the community they live in and the values they hold (21). As Milwaukee is racially segregated, this theory would be very helpful in addressing the differences in community norms and values. This theory, and its examination based on a community level, will help overcome weaknesses due to the Labeling Theory and racism. Do mothers in the African-American communities place more importance on bed-sharing or sleeping in the prone position? Does this belief stem from the norms and values of their culture? Is there a way to educate these mothers on safer methods of co-sleeping that may reduce risk of smothering and suffocation?

It is also important to focus on the issue of infant mortality among African-Americans in general, as this population has the highest rates of infant mortality in the city. The first step would be to identify the resources available to new and expecting mothers. Placing more resources in these lacking communities may have a profound effect on infant mortality. Finally, it will be important to examine the communities, and in particular, the African-American communities, for indicators of excess stress levels mothers may encounter due to discrimination and racism. If these two issues can be combatted, perhaps the number of premature or low birth weight cases will decrease. Following this identification, if the City of Milwaukee can take a more active role in the resources available to pregnant women combatting discrimination, perhaps Labeling Theory and racism can be overcome, in turn decreasing the number of cases of premature and low birth weight babies, and in turn decreasing the number of cases of SIDS or SIDU.

The Theory of Planned Behavior

The first step to effecting behavior change, especially in regards to a topic that individuals may not be familiar with, is education. Using the Theory of Planned Behavior, one can begin to develop a new intervention that may be more effective in reaching people that currently do not practice safe sleep techniques. The Theory of Planned Behavior is based on the fact that individuals weigh their attitudes and social norms against expected outcomes when engaging in a particular action (22). An important factor is their perceived behavioral control, also known as self-efficacy, in carrying out a particular behavior (22). This theory, with a focus on education, can be used to overcome optimism bias and the law of small numbers. In order for this to occur, it is imperative that individuals are educated on the safest sleeping practices for children from birth to the age of one.

If prenatal classes are available in the community and are well attended, the City of Milwaukee should ensure that expectant mothers are educated about safe sleeping practices during these classes. This allows mothers to be exposed to the information, and they can include it during their decision process. If prenatal classes are not offered, programs will be created in churches, community centers, and clinics in the community, which will be free of charge. By basing these educational events in a group setting, new social norms are being created around safe sleeping practices. These safe-sleeping practices can be geared towards room-sharing over bed-sharing.

The information presented in the sessions will include information about the pros of co-sleeping, the definitions of co-sleeping, room-sharing, and bed-sharing and the pros and cons of each. Classes will encourage parents to use bassinets or cribs that can be close to the bed, which are completely empty except for the mattress. For parents that are determined to bed-share, it is important to portray a safe way to do so – by placing blankets and pillows away from infants, by placing infants on their backs to sleep, and by ensuring that the parents are not restless sleepers that tend to move in their sleep. It is important, on the part of the educators, not to give the impression that parents are being told how to raise their children. By using education rather than commanding or ordering parents to engage in a particular behavior, we are allowing parents to make their own decisions on child-rearing practices. This will help mitigate psychological reactance because we are not taking away individuals’ sense of control (19). Instead, we are giving control to parents – they are now in control of making safe and smart decisions when choosing a particular sleep practice based on all of the information available.

One important addition to the Theory of Planned Behavior is the component of self-efficacy (22). Parents must be made to feel as though they can actually change their behavior and be successful. One barrier to self-efficacy in the context of room-sharing may be that the parent does not have access to a bassinet or a crib, due to financial circumstances. Therefore, this needs to be addressed in the intervention. It is unreasonable to institute a campaign encouraging mothers to practice safe-sleeping techniques if they are unable to afford the necessary requirements. The program involving crib and bassinet donations from the public will allow parents to obtain these needed items when financial limitations exist. By using donations, Milwaukee’s Health Department will not need to worry about financial constraints.

Advertising Theory and Connecting to the Community

Advertising theory should be considered when reaching out to the target population. Advertising theory is composed of three main components: the promise, core values, and support. These work together to reach the public on an emotional level (23). Therefore, advertisements need to be created which touch individuals on all three components. The promise the new set of advertisements will offer to viewers is the possibility of being a part of all important milestones in a child’s lifetime: first steps, first birthday, graduation, wedding, and the birth of their first child. These are all experiences that parents will treasure over the course of their child’s life, and will reach a wider target. These images will support the promise of experiencing life’s many milestones, and will play on the values of love, family, and aspirations. In order to overcome the law of small numbers, following the images, a parent will speak about how they missed out on all of these important life events because they were unaware of safe sleep practices, and therefore, they suffered the death of a child. They will show a picture of their baby that passed away due to SIDS. This overcomes the law of small numbers because people can now relate to someone who has experienced SIDS rather than knowing someone that has successfully bed-shared. Advertising Theory has proven successful in an intervention known as the Truth Campaign in Florida (24). This campaign was able to build a brand based on values, and resulted in decreased rates of high school and middle school students smoking (24). Similarly to this campaign, Milwaukee’s safe-sleeping campaign will place most attention on life’s important milestones for a parent, and the values of love and family, in order to connect with parents and change behavior.

Conclusion

Milwaukee is a city that is unique in its mortality rate differences based on ethnicity. It is critical to narrow the gap, and decrease the infant mortality rate. Milwaukee has correctly identified one potential area that may reduce the rates of infant mortality – the incidence of bed-sharing, but by basing their intervention on fear alone, they are unable to make an emotional connection with viewers that will encourage parents to change their behavior. Using the Social Expectations Theory, The Theory of Planned Behavior, and Advertising Theory for the basis of a new intervention, Milwaukee will be more successful in reaching their target population, and lowering the rates of infant mortality due to SIDS and SIDU.

References:
1. City of Milwaukee. Infant Mortality. Available at: http://city.milwaukee.gov/InfantMortality.htm. Accessed December 12, 2011.
2. City of Milwaukee Health Department. 2010 City of Milwaukee Fetal Infant Mortality Review (FIMR) Report: Understanding and Preventing Infant Death and Stillbirth in Milwaukee. Milwaukee, Wisconsin: City of Milwaukee Health Department; 2008.
3. City of Milwaukee Health Department. Safe Sleep for Your Baby. City of Milwaukee. Available at: http://city.milwaukee.gov/SafeSleep. Accessed December 14, 2011.
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Boston Combats Adolescent Obesity Through “Fat Smack” Campaign: A Critique – Alicia Charleston

Obesity in America and Boston

Adolescent obesity continues to be a growing problem in the United States, particularly among youth and adolescents. As childhood and adolescent obesity often leads to overweight adults, it is an issue that needs be addressed at a young age (1). The Center for Disease Control {CDC} estimates 12.5 million youth, ages 2-19, in America are obese (2). The city of Boston, Massachusetts is no different. In its effort to combat both obesity and type II diabetes, in 2011 Boston’s Mayor Thomas Menino with the Boston Public Health Commission introduced the “Fat Smack” campaign (3).

“Fat Smack” as a youth intervention

“Fat Smack” is a youth and adolescent centered campaign. In a city with 57,500 public school students (4) and roughly 40% are overweight or obese (3), an intervention to reduce this problem is necessary. For teens 12-19 years old, the American Heart Association recommends 4.5 teaspoons of sugar daily, but a 20-ounce bottle of soda contains almost four times that recommendation, 16 teaspoons (3). Each additional serving of sugary drinks increases the frequency of high Body Mass Index {BMI} counts. While soda consumption is not entirely to blame for the increasing prevalence of obesity, it is certainly a contributing factor (5).

Parents do recognize the need for weight management in their children but barely 50% of those surveyed felt confident in their abilities to change the behaviors of their kids. Parents indicated that the most important method of weight management is physical activity. However the elimination of soft drinks fell fourth on the list, after portion control and increased consumption of fruit and vegetables. The survey indicates that parents also need to be educated regarding consumption of sugary beverages (6), and “Fat Smack” should work to educate a more broad population. Mayor Menino hoped the campaign would stretch across all demographics, including parents and young adults to take responsibility in making healthier choices (7). “Sugar Smarts” was created to fill the gap between adolescents and parental knowledge (8).

The Boston Public Health Commission is following suit of other major U.S. cities with their anti-soda campaign. They are attempting to lower obesity in part through decreasing the amount of sugary beverages consumed. These unhealthy drinks not only increase ones likelihood at becoming obese, but also it takes away from the consumption of healthy beverages, like milk and water. The city of Boston took a step in 2004 to reduce consumption of sugary beverages by banning sales in public school vending machines (9), but there continues to be a rise in obesity. Rather than taking on all causes of obesity, like improved nutrition habits or exercise behaviors, the campaign focuses on a single action: decreasing the consumption of regular soda, sports drinks, sweet teas and other beverages with added sugar. Mayor Menino rolled out this aggressive campaign about a month before his policy to pull sugary beverages from municipal buildings went into effect.

“Fat Smacks” print campaign features four attractive, non-white, adolescents attempting to drink sodas or sport drinks but instead they get hit in the face by a yellow ball of a gel-like substance, presumably fat. The statement “Don’t Get Smacked by Fat. Calories from sugary drinks can cause obesity and Type 2 diabetes” accompany the pictures of adolescents. The advertisements are prevalent throughout public transportation in the city of Boston. Alongside the print campaign are television advertisements, radio and a social media campaign via Facebook encouraging teens to take the pledge to no longer drink sugary beverages.

The campaign attempts to send an important message to youth and adolescents that drinking sugary beverages can adversely impact one’s health, specifically through weight gain and increased risk of diabetes. However, the campaign as it stands is not effective. It first uses silly and unrealistic print ads to attract the population rather than appealing to the core values of the target audience. Second, it attempts to engage youth through a media campaign but it is falls short of creating a movement led by youth. In marketing to teenagers, the campaign should make a stronger effort to change social norms. Teens who associate with peers that engage in risky behavior are more likely to do so themselves (10). There also tend to be misconceptions about the percentage of people who do engage in such behavior. Accurate evidence about the local population’s actions would improve assumptions about the social norms (11). If adolescents had an accurate representation of the percentage of their peers who drink sugary beverages on a regular basis, they might be better poised to influence the social norm. Finally the campaign fails to address the socio-economic disparities that are prevalent throughout Boston.

Print campaign: “Gross”

It gets your attention, but does it make you give up your soda addiction? The recent “Fat Smack” campaign released by the Boston Public Health Commission shows adolescents who are hit in the face with airborne yellow blobs of fat while attempting to drink sodas or sport drinks. The campaign has been effective in getting the attention of the local population and has been discussed on blogs and local magazines (12, 13). However the attention does not come from the reduction of sugary beverage consumption, mostly the attention is because the campaign is “kind of gross” (12) and induces fear in young people (13). The rise in obesity is an ongoing concern and youth do understand that one must exert more energy than they take in. The campaign attempts to fill in the knowledge gap that sugary beverages also contribute to their calorie count (14). Since teens consume twice as much soda as they do milk, this surge in weight-gain is understood (3).

The link between consumption of sugary beverages and weight gain is well documented. Specifically, it was found in a long-term study of female nurses that women who went from drinking one or less soft-drinks weekly to one or more daily documented weight gain as compared to women who did not. It was also noted that study participants who consumed greater numbers of sugary beverages were also less physically active and more likely to smoke (15). While it is clear that campaigns to reduce the consumption of sugary beverages are needed, there are better ways to raise awareness than throwing globes of fat at teenagers.

The “Fat Smack” campaign is relatively new, and long-term impacts of the campaign have not yet been reported. The campaign is aimed at adolescents to attempt behavior change at a young age. Since overweight youth and adolescents are more likely to be overweight or obese adults (2), attempting to change behavior in school-aged youth is a promising start.

But instead of creating a youth movement empowering adolescents to take on the producers of sugary beverages, the campaign uses fear to show the risks of consuming sugary beverages. Based on the ads it appears that any consumption of sugary beverages will automatically make a person fat, rather than the idea of everything in moderation.

Inducing fear, rather than fostering self-efficacy, does not always give the desired response. The print campaign does not increase one’s knowledge of how much sugar is actually contained in these beverages. It does not help teens make the choice to consume less sugar in their beverages. Rather the scare tactic causes people to perceive greater susceptibility to the undesired outcome at hand (16). Instead of inducing fear of weight gain through silly advertisements; the print campaign should be modified to appeal to adolescents desire for freedom and making their own choices (17, 18). It should give people the option to choose what they prefer to drink, like a cup of soda or a cup of raw sugar, allowing greater ownership of their choice not to consume sugary beverages.

Social networking campaign expected to engage youth

“Fat Smack” is not limiting itself to the traditional advertising methods of print, radio and television. In an attempt to connect with the Internet generation, “Fat Smack” set up a Facebook page, where someone interested in taking the Free from Sugary Drinks pledge is able to do so. The page has 634 people who stated they ‘like’ the page (19). But for a campaign aimed at the roughly 630,000 residents of Boston (20), to only have 0.1% of the population recognizing the campaign on the networking website is not enough. Improved use of the site could influence a larger population of people by building on the Social Network Theory. It can be a powerful tool in changing an entire groups behavior rather than focusing on an individual, as the theory uses the groups one associates with, such as family, friends, classmates and co-workers, to influence one another (21). The theory has been applied successfully in weight loss programs and smoking cessation program, and could likewise be practical to reduce consumption of sugary beverages.

“Fat Smack” has some youth involvement, specifically the Youth Media Council. Prior to launching the print campaign, the group “Warriors Against Sugar” hit the streets of Boston to educate people about the amount of sugar in beverages. They lured in passer-bys by offering free drinks on a hot summer day. The beverages offered were Sobe, Twister, Sunkist and Arizona Iced Tea. Rather than actually passing out these sugar-loaded drinks, the clientele were offered the equivalent amount of sugar in pie, ice cream, whipped cream and breakfast cereal. They filmed the street campaign to use as a marketing tool on their blog, and it shows the public interest in the information. The peer group “Warriors Against Sugar” should be more active in the community to increase the success of social network theory as a useful tool in the campaign (3).

In addition to the improved social networking and youth-led movements, social norms will not change if the greater population does not follow suit. Looking at Diffusion of Innovations, theorized by Dr. Everett Rogers, the change will occur in three phases (17). The “early adaptors” will initiate the behavior change, followed by the vast majority of the population and finally the lagers will take up the change. “Fat Smack” has early adaptors, as seen by their Facebook status and youth group. But it is not until the idea “tips” (22) that the majority of the population follows suit. However, there is no easy way to predict when the tipping point occurs. The tipping point can be triggered by a single person and can be an overnight success. In the same respect, it can also take years for behavior change to occur. In order to increase the success of continuing to lower the amount of sugary drinks consumed by youth and adolescents, the early adaptors will need to continue to force the topic into the public sphere. Early adaptors continued efforts to decrease soda consumption combined with efforts of Social Learning Theory, Social Network Theory and improved marketing will change the social norms of sugary beverage consumption (23).

Inequalities in obesity across socio-economic and racial groups

There is a disparity in obesity when comparing populations from different socio-economic backgrounds. At-risk and low-income populations in the United States tend to have greater levels of obesity and type II diabetes. In Boston roughly 25% of Latinos and 20% of African-Americans in the area live in poverty compared to 7% of Whites (24). Hispanic boys and black girls are more likely to be obese than their white counterparts (2). “Fat Smack” does understand these disparities and targets their campaign to these high-risk populations, by working directly with them in youth councils and reproducing the advertisements in Spanish (3).

Despite the efforts to focus the campaign on the low-income populations, sugary beverages remain more affordable than their healthier counterparts. They can be less expensive and more accessible than more nutritious options. So regardless of one’s knowledge of the harmful health effects, the continued consumption is often a matter of affordability.

To increase consumption of healthier drink options, New York City suggested coupling education and public health campaigns with a restriction on food stamps, banning the purchase of sugary drinks with food stamps. Los Angeles county Public Health director and chair of the CDC Prevention’s Task Force on Community Preventative Services, Jonathan E. Fielding, stated that education alone is not enough to change behavior; incentives and disincentives need to be in place as well (25). Banning food stamp purchases of sugary beverages could potentially adversely impact behavior if the affected population sees the policy as a loss of freedom. Psychological Reactance Theory causes a person to do the opposite of what is being advised (26). In this instance, the campaign would want to continue to drink sugary beverages but would purchase them elsewhere. The negative reaction could be accounted for if the price of sugary beverages increased while healthier beverage options became more affordable, encouraging the purchase of healthier options for low-income people instead of restricting someone’s perceived freedom to drink a sugary beverage.

Improving the “Fat Smack” campaign

For behavior change campaigns to be successful, it is necessary to combine behavior change theories. To reduce the consumption of sugary beverages on a larger, long-term scale, the social norms need to be changed as well. Cigarette smoking in bars and restaurants has changed in the recent past as a result of combining behavior change theories and a constant battle by public health professionals and policy makers. To successfully change behaviors of consuming sweetened drinks, “Fat Smack” campaign leaders should look at modeling the anti-smoking legislation by combining numerous behavior theories.

Reduced sugary beverage consumption through social expectations

The campaign first needs to update the marketing strategy to something more realistic. Then the campaign should also better utilize the theory of social networking to influence behavior of the population. A good print campaign is not enough to do this, especially when there is the continued bombardment of advertisements by Coca-Cola, Pepsi and the like. The campaign should appeal to youth and adolescents through a marketing approach that appeals to teens freedom, ability to choose and giving the target population a sense of ownership over their choice to consume water and natural juices. The campaign should be framed in a way that teens will take the campaign seriously. In addition, “Fat Smack” needs to get on the media agenda and work to influence policy.

Childhood and adolescent obesity is a serious health concern, just as smoking and drug use is. It increases one’s risk of type II diabetes, heart disease, high blood pressure and cholesterol, joint problems, psychological issues associated with discrimination and poor self-esteem (2). It is well documented that consumption of sugary beverages can increase one’s risk of weight gain.

Common in public health interventions, self-efficacy is necessary for success. If a person does not think they are capable of doing what is being asked of them, they are unlikely to succeed. A weight-loss study demonstrated this when the intervention group had greater overall weight-loss compared to the control group. The intervention group received support through social learning (27). The theory is built around the idea that a person’s environment, their own self-efficacy and their behaviors influence actions. It also takes into account reciprocal determinism, where one’s behavior and self-belief influence one another (18). “Fat Smack” should use Social Learning Theory to change individual behavior, but as stated before, “Fat Smack” should simultaneously attempt to change the social norm.

Youth-led movement, modeled after Truth’s anti-smoking campaign

“Warriors Against Sugar” is a youth-led program that works with “Fat Smack” to educate and combat sugary beverage consumption in Boston. However, they have failed to gain the large following of youth to really impact behavior change. Following a large settlement by tobacco companies in Florida, the then governor earmarked settlement funds for a youth-focused anti-smoking campaign. The anti-smoking campaign in Florida, “Truth”, began in 1998 (28).

The most important aspect of the youth centered campaign is involving youth. “Truth” brought 500 youth together to discuss what they felt would be successful, and worked around their ideas. The campaign stayed away from negative or preachy messages and focused on the facts. They worked to not impede on the target audiences freedoms or pass judgment on their choices. The campaign also created a brand. They had a public relations tour hitting 10 cities and a “truth truck” that made stops at major concert venues, beaches and raves. The brand “Truth” gave the youth a sense of identity in a similar fashion to other major brands, like Nike (28).

“Truth” was found to have a substantive impact on lowered cigarette usage and intention to use among youth following implementation of the campaign (29). It was also suggested that these decreases in smoking among youth were more likely to carry into smoke-free adults. Modification of the “Truth” campaign to fit the anti-soda and sports drink campaign led by “Fat Smack” will likely have greater success than its current campaign. It is unrealistic for “Fat Smack” to have the same availability to funds, but they can use a similar model to better engage youth.

As stated before, “Fat Smack” does have some of the ideas from the “Truth” model in place. However, in order to be successful it needs to be scaled up. The youth focus group needs to expand and their ideas needs to be considered for marketing materials. “Fat Smack” also needs to build up their brand. At this early stage in the campaign “Fat Smack” is primarily a print campaign. Print campaigns, as a sole marketing technique, is not an effective mean of engaging youth. In order to connect with the targeted youth, the “Fat Smack” brand should “surprise and lead”(28) the audience. While the current marketing campaign does surprise people by a blob of fat striking a person, it is not something that leads the audience away from sugary beverages.

Increased costs of sugary beverages to reduce consumption

Scaring people into not drinking sugary beverages because of weight gain will not be enough on its own to change behavior. Making healthier drink options more accessible and affordable will help, as will increasing the price of sugary beverages. A five-phase study at Brigham and Women’s Hospital in Boston showed that education alone did not reduce consumption of sugary drinks. The hospital cafeteria enacted a 35% price increase on regular {non-diet} soft drinks and saw a 26% decrease in those sales. The hospital then implemented an educational component in addition to the price increase and saw an additional 10% drop in sales. Following completion of the educational program, the hospital decreased the price of regular soft drinks by 18% to test the effectiveness of the program. Despite the price drop of regular soft drinks, there was not an increase in sales (30). The study was completed on a small-scale looking at the cafeteria in a single hospital, and further research needs to be conducted to determine generalizibility. It does give reason to believe that the educational component of “Fat Smack” when combined with a price increase will reduce the overall consumption of sugary beverages.

Instead of merely increasing the prices of sugary beverages, enacting a national sales tax on these drinks is a preferred option. Forty states already have small taxes on such beverages, but New York and Maine have proposed even higher taxes. The tax will be a simple revenue generator for states, giving them opportunity to subsidize healthy food options. Taxes on tobacco and alcohol products have been effective, which gives reason to believe that taxes on unhealthy beverages will do the same (31).

Higher prices and introducing or raising taxes on sugary beverages will help to deter people from consuming the unhealthy beverages while bringing in revenue for the state at the same time. All of these tactics have been completed in other public health interventions and have proven successful. “Fat Smack” has already laid the foundation for a solid public health intervention to reduce obesity by involving youth and getting some media attention.

“Fat Smack” on its way

“Fat Smack” as a campaign to reduce consumption of sugary drinks in youth and adolescents is an important public health intervention, especially given the rise in childhood and adolescent obesity. The campaign has many good ideas, but in practice they are not effective. A campaign aimed at youth and adolescents should actively involve members of the target population, getting them to join the movement against unhealthy beverages. The campaign does have “Warriors Against Sugar” but they have been unsuccessful in increasing the size of the movement. The environments of public schools municipal buildings in Boston have already changed no longer allowing sales of sugary beverages in vending machines. However the most visible aspects of the campaign, print and television ads, have received little attention. And most of that attention comes from the campaign being “gross” rather than changing attitudes and behaviors regarding consumption of sugary beverages. At the very least, the campaign has gotten the public discussing the consumption of sugary beverages. The campaign is a step in the right direction, but more needs to be done if it is going to be successful in changing attitudes and behaviors about consumption of sugary beverages.

References

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