Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Thursday, May 7, 2009

Limitations of Restaurant Nutrition Labeling in Promoting Healthier Choices and a Proposal for Increasing Its Effectiveness – Stacey Kokaram

An increasing number of cities and towns across the US are requiring restaurants to provide nutrition information for their menu items (1, 2). Currently, the Nutrition Labeling and Education Act (NLEA) gives the Food and Drug Administration (FDA) the authority to require and regulate nutrition labeling for most food products regulated by the Agency (3). Over the past years, several pieces of legislation have been introduced in Congress to expand the FDA’s authority to also require nutrition labeling in restaurants (4). A recent observational study published in the American Journal of Public Health, showed that only 0.1% of patrons entering four popular fast-food restaurants referenced in-store available nutritional information (5). The study did not analyze whether the information had an effect on the food choices of these consumers. Nutrition labeling in restaurants would provide information for consumers to make healthier food choices but is only a small component of what is necessary to promote and support healthier eating among consumers.
This paper explores three key limitations that prohibit restaurant nutrition labeling from leading to healthy eating behavior. These limitations include: 1) the amount and accuracy of information posted; 2) the belief that intent to eat healthier will lead to healthy eating behavior; and 3) the lack of access to healthier food alternatives.

Nutrition Labeling Requirements & Accuracy
Many of the current restaurant nutrition labeling regulations require restaurants to post minimal nutritional information. The labeling requirements in King County, Washington require chain restaurants with 15 or more establishments to include total number of calories, grams of saturated fat, grams of carbohydrate, and milligrams of sodium for all standard menu items (2). This amount of information is not adequate in order to promote healthy dietary habits. Additionally, variability in nutritional content of foods requires that additional steps occur in order to make the available information useful to consumers.
The American Dietetic Association (ADA) convened the Task Force on Restaurant and Nutrition Labeling Research to analyze the effects of restaurant nutrition labeling using scientific principles tested through research and to identify gaps in the available research (6). The task force, comprised primarily of public health officials and registered dieticians, raised a key concern about the unintended consequences potentially caused by nutrition labeling. The concern is that by posting minimum caloric information, consumers will make choices based solely on calories and not on other nutritional values. Overall nutrition is particularly important for children and adolescents whose bodies need nutrients and who tend to eat at fast-food restaurants most frequently.
Another concern raised by the ADA’s task force is the accuracy of nutritional analysis programs. The task force reports that nutritional information can vary significantly in packaged foods, which are produced in tightly controlled environments, therefore the probability is high that even greater amounts of variability will occur in restaurant nutrition labeling. Steps should be taken to reduce this variability and this variability information should accompany any labeling initiatives to ensure that the information provided to consumers is accurate. Providing inaccurate information to consumers would counter the intentions of the restaurant nutrition labeling initiative.

Healthy Eating Intent vs. Behavior
Restaurant nutrition labeling initiatives follow the principles of the health belief model (7,8). The principle most affected by these initiatives is the consumer’s perception of the severity of eating unhealthy foods. These initiatives assume that most people know that high calorie foods are bad for them and will avoid eating foods they know are high in calories. Like the health belief model, restaurant nutrition labeling erroneously assumes that because a person intends to eat healthy foods, they will actually eat healthy foods.
The United States Department of Agriculture’s (USDA) Economic Research Service (ERS) conducted a study in which the researchers analyzed consumer food choices based on the consumer’s long-term health objectives and immediate visceral influences, such as hunger and stress (9). The analysis used behavioral economics to develop models to predict the effects of time pressures and hunger and compared these models to results from the 1994-96 Continuing Survey of Food Intake by Individuals and the Diet Health and Knowledge Survey. The results found that those under stress and those who had gone longer without eating were more likely to eat more calories per meal than those who were not under these influences when faced with immediate food choices. These results remained true even for those who had long-term health goals.
Another key limitation of using the health belief model for this initiative is the assumption that people will make rational food choices. Even if a person is presented with accurate nutritional information, knows the severity of eating unhealthy foods and is not under stress, there are still other factors that could lead the person to choose unhealthy foods over healthier options. A study challenging the notion that intention leads to behavior was published in the Journal of Marketing in 2003 (10). This study found that health claims and nutrition information generally had an effect on consumer’s attitudes towards food items but for many, this evaluation did not actually influence the consumer’s actual consumption behavior.
Consumer’s attitudes towards taste of healthy foods can play a significant factor in their decision to choose either the healthy item or the unhealthy item. A study conducted by Horgen and Brownell (11), suggests that consumers may associate the term healthier foods with bad taste. The study looked at the effects of price decreases, health messages and the combination of the two methods on consumer choice of targeted food items. Although the combination of price decreases and health messages produced an increase in sales of the healthy items, the results suggested that the perception of the taste of healthier foods attenuates the effect of price decreases alone in these healthier food choices.

Access to Healthier Alternatives
In a 2006 study of fast-food restaurant patrons, 87.2% indicated that price was an important factor in their food choice while only 57.9% indicated that nutrition was an important factor (12). While cost is a factor in food choices for most people, for some cost is THE deciding factor. Restaurant nutrition labeling may provide consumers with the information to make healthier food choices but the labeling initiative does not go far enough to ensure that those who want to make healthier choices have the resources to follow through with their intention. Even if these individuals know the nutritional information related to the food they’re purchasing, there may not be a cost-effective alternative available for them to purchase. Several studies have been conducted which show that diet-related health outcomes are worse in areas with less access to supermarkets and more access to convenience stores and fast-food restaurants than in areas with large supermarkets (13,14) The populations that live in the areas with less access to large supermarkets in general have a lower socioeconomic status than those who live in areas with accessible grocery stores (15).
An earlier study mentioned in this paper, showed that price decreases on food items had a more significant impact on the purchase of these items than did the inclusion of health messages promoting the items (11). If prices for healthier food options were decreased, this suggests that the likelihood of consumers purchasing these items would increase.
Finally, healthy food options available at restaurants need to increase in order to assure that people have choices in what they can eat. Glanz, et al (16) evaluated the major factors that influence restaurant chains to plan their menus. They found that growing sales and increasing profits were not surprisingly the most important consideration, with health and nutrition much less influential. Several respondents to the survey noted that healthier food options have been offered in order to prevent loss of business from certain health advocacy groups. The study suggested that consumer demand is likely the major factor that will influence major chains to include and keep healthier food options on their menus. Additionally, the researchers suggest that public health and government agencies should work towards increasing chain restaurant perceptions of consumer interest and also incentives for restaurants to offer healthier food options. The availability of healthier food options will help reduce a potential barrier consumer’s face while trying to adopt healthier eating habits.

Restaurant nutrition labeling initiatives have the potential to provide valuable information to some consumers who wish to improve their dietary health. These initiatives facilitate healthy eating among those who already perform healthy eating behaviors but do little to promote healthy eating behaviors among those who do not regularly make healthy food choices. Strategies to expand the benefits of restaurant nutrition labeling to wider audiences must include other components that affect food choice behavior and reduce barriers to healthier food choices.

Counter-Proposal for Intervention
The three limitations of the restaurant nutrition labeling program presented above can be remedied. The remainder of this paper will present a modification to the program which will address these three main limitations. The redesigned restaurant nutrition labeling program should be comprehensive and include multiple public health campaign components rather than simply providing information to the public. A committee at the Institute of Medicine “strongly suggests that interventions need to use multiple approaches (e.g. education, social support, laws, incentives, behavior change programs) and address multiple levels of influence simultaneously (i.e., individuals, families, communities, nations)”(17). The proposed campaign has three key components that improve upon the previous intervention. The first component is for restaurants to provide more complete and accurate nutrition information to the public using a system that allows consumers to easily identify healthier menu items. Secondly, the campaign would use social sciences theories to promote the use of the system to consumers so hey could make healthier food choices. Finally, the campaign would focus on making restaurants that used these labeling systems easier to access for those who would like to make healthy food choices.

Complete and Accurate Information System
The information that restaurants are required to post should take into account nutrients rather than just calorie count and fat content as some restaurants have done (1,2). By providing only calorie count and fat content, people may not be making the healthiest food choices. According to the ADA, posting of calorie and fat information without additional nutrient information could take the focus away from healthy eating and put the focus on calorie counting alone (6).
Comprehensive posting of nutritional information, however, may become burdensome for both the restaurant and the consumer if there are lots of items on a restaurant’s menu. An alternative strategy for condensing prominent displays of nutritional information while still providing complete nutritional information for patrons could be done using two components. The first should be a pamphlet with complete information on all products the restaurant serves. This gives the customer the option of seeking out specific amounts of various nutrients in foods if, for example, they are diabetic and need to watch their sugar intake or if they have high blood pressure and need to limit their sodium intake. The majority of consumers would use the second component which would be a nutritional posting similar to the “DDSMARTTM” menu used by Dunkin’ Donuts (18). This type of menu creates a visual way for consumers to more easily identify foods that are the healthiest on the restaurant’s menu. This menu would allow consumers to see which items are healthiest in the restaurant and would allow them to make smarter food choices without having to analyze the nutrition content of every item served by the restaurant. According to a study by Malhotra (19), consumers have finite ability to absorb and process information given a short amount of time. If given too much information in a short time, consumers can actually make poorer decisions than they would if they didn’t have as much information. This theory supports concise but accurate restaurant labeling which could serve as a compromise to promote healthier food choice and prevent restaurants from being overburdened by extensive menu labeling. Nutritional standards would have to be developed by agency enforcing the restaurant labeling regulation in order for foods to make it on to the “healthy options menu.”

Promoting the Labeling System
Once an acceptable system is established to identify the healthiest items on restaurant menus, the system needs to be marketed to consumers. If a consumer can easily identify a brand to mean healthier food, without having to process lots of information at the point of purchase, then they would be more likely to make a healthier food choice than if they had to process lists of nutritional information (19). Branding theory is based on analyzing a target audience to create a brand that has attributes with which the audience can identify (20). Once this identity and sense of shared attitude is established, consumers will recognize the brand and may become loyal to it (21). The association by consumers of healthier foods with bad taste suggested by the Horgen and Brownell (11) study could be combated by this branding campaign. This type of branding and brand loyalty would make it easier for consumers to choose items from the menu with which they were familiar. The branding would have to include a visually appealing and easily recognizable menu design that consumers could identify once in the restaurant. The simple act of being able to identify healthy choices without sorting through nutritional information will increase the likelihood that people who intend to eat healthy will eat healthy. The simplification of the choice reduces an irrational barrier that prevents people from following up their intent to eat healthy with the actual behavior (19).

Increase Availability of Restaurants With Labeling System
Finally, once the labeling system is in place in the restaurants and is made easily recognizable for consumers through the promotion process, policy makers should ensure that consumers have access to get to these restaurants. The labeling policies in both New York City (1) and King County (2) both had limitations on which type of restaurants had to comply with the labeling law. If an area does not have a high quantity of restaurants that must comply with the regulation, then the labeling system would be virtually useless to the consumers who lived in that area. Policy makers should ensure that the majority of restaurants must comply with the regulation or that the restaurants that do have healthier menus are more accessible within neighborhoods.

Although current restaurant nutrition labeling programs in various cities have good intentions, the programs do not go far enough to ensure that the labeling program itself is effective. By assuming that providing more information will lead consumers to make healthy behavior changes, policy-makers are erroneously designing interventions based on the Health Belief Model (7,8). While having more information may change consumer intentions, their behavior at the point of purchase in these restaurants is what should be addressed in order to truly promote healthier food choices.

1. Board of Health Vote to Require Chain Restaurants to Display Calorie Information in New York City. New York City Department of Health and Mental Hygiene Web site. Available at Accessed on April 5, 2009.
2. Trans fat and nutrition labeling in King County. King County Public Health Web site.
Available at Accessed on April 5, 2009.
3. Nutrition Labeling and Education Act. %20OF%20NUTRITION
4. HR. 1334
5. Roberto C, Agnew H, Brownell KD. An Observational Study of Consumer’s Accessing of Nutrition Information in Chain Restaurants. Am J Public Health, 2009;99:xxx-xxx.
6. American Dietetic Association. Task Force Report on Restaurant Nutrition Labeling Research.
7. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones & Bartlett Publishers, 2007.
8. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN 39(3) 128-135: 1991.
9. United States Department of Agriculture. Is Dietary Knowledge Enough? Hunger, Stress and Other Roadblocks to Healthy Eating. ERR, 2008; 62.
10. Kozup JC, Creyer EH, Burton S. Making Healthful Food Choices: The Influence of Health Claims and Nutrition Information on Consumer Evaluations of Packaged Food Products and Restaurant Menu Items. J Marketing, 2003; 67:19-34.
11. Horgen KB, Brownell KD. Comparison of Price Change and Health Message Interventions in Promoting Health Food Choices. Health Psych, 2002;21(5):505-512.
12. O'Dougherty M, Harnack L, French S, Story M, Oakes J, Jeffery R. Nutrition labeling and value size pricing at fast-food restaurants: A consumer perspective. A J Health Promot. 2006;20:247-250.
13. Morland KB, Evenson KR. Obesity Prevalence and the local food environment. Health & Place. 2008;15:491-495.
14. Larson NI, Story MT, Nelson MC. Neighborhood Environments: Disparities in Access to Healthy Foods in the US. Am J Prev Med, 2009; 36(1):74-81.
15. Morland K, Wing S, Roux AD, Poole C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. Am J Prev Med, 2002; 22(1):23-29.
16. Glanz K, Resnicow K, Seymour J, et al. How Major Restaurant Chains Plan Their Menus: The Role of Profit, Demand and Health. Am J Prev Med, 2007; 32 (5): 383-388.
17. Institute of Medicine. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academies Press, 2000.
18. DDSMART Nutrition Advisory Board. .
19. Malhotra NK. Information Load and Consumer Decision Making. Journal of Consumer Research, 1982; 8 (4): 419-430.
20. Huhman M, Heitzler C, Wong F. The VERBTM Campaign Logic Model: A Tool for Planning and Evaluation. Preventing Chronic Disease: Public Health Research, Practice and Policy. 2004; 1(3): 1-6.
21. Evans WD, Wasserman J, Bertolotti E, Martino S. Branding behavior: the strategy behind the truth® campaign. Soc Marketing Q. 2002;8(3):17–29.

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Why 5 A Day Fell Short And Alternative Solutions in the form of Community Supported Agriculture– Jacquelyn Murphy

Fruits and vegetables are an important part of everyone’s diet. They provide vitamins, fiber, and few calories, which are all things anyone, especially most Americans, could benefit from. With these things in mind, the National Cancer Institute and the Produce for Better Health Foundation teamed up to found a nutrition program, entitled 5 A Day for Better Health, in 1991 (4). The 5 A Day program very simply encourages people to eat five servings of fruits and vegetables every day as part of a low-fat, high-fiber diet, marking packages of acceptable fruits and vegetables with the small trademark symbol (2). On the Center for Disease Control and Prevention Website, there are recipe ideas to incorporate servings of fruits and vegetables into meals as well as tips on how to reach the five servings, such as having fruit or vegetables for in-between meal snacks. In 1991, when the program first began, and in 1997 after six years of spreading the “5 A Day” message and pouring millions of tax dollars into raising awareness on this critical nutrition issue, there was no significant difference in fruit and vegetable consumption after researchers adjusted for demographic shifts (4). The 5 A Day program is flawed in that it is based on the Health Belief Model and thus the assumption that people act rationally, it lacks consideration for environmental factors, and it advertised poorly. These flaws could account for part, or all, of the lack of response after millions of dollars were spent on increasing awareness of the 5 A Day for Better Health program.
Based on assumptions of Health Belief Model.
The 5 A Day program is based entirely on the idea that if people are educated about what actions they should take to optimize their health, in this case eat at least five servings of fruits and vegetables daily, then they will do it. Like many public health interventions based on the Health Belief Model, it is limited in various ways and assumes a few different things. Many individual level models assume that people act rationally and plan their behavior. The Health Belief Model is no different. In general, the Health Belief Model is based on increasing perceived susceptibility or perceived severity, or both, of the consequences of performing or not performing a certain action (3). From here, people determine the perceived benefits of adhering to guidelines set by the intervention, as well as barriers preventing them from following the guidelines of the intervention outlined by the Health Belief Model. Finally, they come to a conclusion and determine their intention, which they then carry out through their behavior, which is both planned and rational (3).
Specifically, the limitations and assumptions of the Health Belief Model come into play in a few different ways in the 5 A Day nutrition campaign. First, this campaign gives people information about what they should be doing, eating five servings of fruits and vegetables per day. From there, it assumes they will change their behavior to eating five or more servings of fruits and vegetables just because they know it is beneficial to their overall health. The campaign does not take into consideration that people oftentimes do not care about their health, or care about it enough to give up their unhealthy, but perhaps tastier, habits, such as eating a cookie instead of an apple. People value their health as much as they do not want to be sick or feel poorly, but many people do not think about their actions’ impact on their long term health. They usually invest their thought in other things, such as appearing attractive or being well-liked, rather than spending their time thinking about their slightly increased chances of certain types of cancer years down the road due to poor nutritional choices.
Secondly, and somewhat deviating from the limitations of the Health Belief Model, this campaign does little to raise people’s perceived susceptibility or severity of the consequences of not eating five servings of fruits and vegetables, which is a trademark of interventions based on the Health Belief Model. If the campaign was more strictly based on the Health Belief Model, it would incorporate more information about the negative repercussions of their lack of eating at least five servings of fruits and vegetables in order to scare people into action. However, this campaign tries to get people to eat five servings of produce without the aspect of increasing people’s perceived susceptibility or severity of potential negative consequences.
Thirdly, since it assumes that people’s behavior is rational, it obviously does not capitalize on the ways in which the behavior of most people is irrational. There are three main facets to irrational behavior, as discussed in this lecture January 29, 2009. The first is that people have expectations of how things should be, and their experiences impact their expectations. The second is that people enjoy owning things and have an aversion to losing the things they own. The third aspect of irrational behavior is that people generally do not have as much self-control as they think they do. Rather, they are mostly lazy procrastinators. The 5 A Day campaign mostly disregards the second of the three features of irrationality in that it did not take into account the strength of people’s habits. They own their unhealthy eating habits, and they will only relinquish these unhealthy habits and practice self control, another feature of irrational behavior not taken into account by the 5 A Day campaign, if they think they will be rewarded with a result that they deem to be worthy of their sacrifice and effort to change their behavior.
Lacks consideration for environmental factors.
Another reason that there was such an insignificant change in the amount of fruits and vegetables people ate before and after the implementation of the 5 A Day nutrition campaign is the lack of consideration for environmental factors. Barriers to consuming the recommended five servings of fruits and vegetables, according to a survey of single mothers included cost, lack of availability, time and effort required to prepare produce, a preference for other foods instead and habit (6). Some of these environmental factors were discussed in the experiments performed during the first seminar meetings on January 22, 2009. Groups went to grocery stores in Roxbury and the South End, two different neighborhoods near the Boston University Medical Campus. The groups that went to the South End, the wealthier of the two neighborhoods, found plenty of full-sized grocery stores, such as Trader Joe’s and Whole Foods, which contained many varieties of fruits and vegetables, usually including a lot of organic produce as well. On the contrary, groups that went in search of produce in Roxbury could only find small and overpriced convenience stores in their designated neighborhood, which usually contained a very small selection of fruits and vegetables which did not look appetizing, especially relative to the produce from the South End grocery stores. Therefore, the residents of Roxbury and other similar neighborhoods had to put in a larger time and effort to get the same quality of food which residents of the South End and other comparable neighborhoods can get quickly and easily.
Aside from availability of produce in their neighborhoods, students in the seminar groups also pointed out the safety of the two different neighborhoods. Roxbury has a much higher crime rate than the South End, adding an element of danger to getting groceries at night after people get out of work, which is when most people have time to do so. Since produce spoils faster than less nutritious, packaged snacks, such as cookies or crackers, it requires more frequent trips to the store. The lack of safety of a neighborhood makes keeping fresh produce available in the house even more difficult than it would be if the grocery store were closer or the trip there less risky.
Finally, amongst a variety of other environmental factors that should have been taken into account by the 5 A Day campaign, financial cost was not considered. As is easily observed in any grocery store, the fresh produce that the 5 A Day campaign strongly encourages is much more expensive than other foods that are perhaps less nutritious but would fill stomachs when parents’ main concern is making sure their children are all able to have dinner. The campaign did not enlist the government to subsidize the cost of produce in any way or perhaps try to organize farmers to sell their produce directly to the customer at farmer’s markets, which would be beneficial to both the farmer and the customer in terms of cost.
In short, the 5 A Day campaign was set up as if people made their decisions in a vacuum, but they do not. They have to think about availability of produce, their own safety when they are en route to buy food for the family and how they will bear the financial costs, among many other environmental factors which are likely too numerous to list here.
Poor advertising methods and media.
Lastly, the methods of advertising employed by the 5 A Day campaign were another shortcoming of the national nutrition intervention. They did not utilize basic principles of communications theory or the idea of agenda setting within the theory. Agenda setting within Communications Theory notes that the target audience, in this case people who are buying food for their families or deciding what to eat when faced with different options, must view the information as important enough to really hear the message and act on it (1). Being bombarded on a daily basis with countless messages about what is best for a healthy lifestyle, it is difficult to distinguish the useful information from the useless. If people do not care, they will not spend the extra money on fresh produce or decide to eat that instead of tastier, less nutritious foods. Creating a message the person in the situation can relate to is the primary focus of agenda setting because the goal is to dramatize the issue and get the audience to care about the issue enough to act, since they view it as important (1). Advertising created with this in mind, and using basic principles of agenda-setting theory, such as dramatizing an issue to make it important to people, would be most effective.
However, the main method of advertising used by the 5 A Day campaign was to put a logo on the sides of packaging which contained acceptable servings of fruits and vegetables and to distribute informative pamphlets in the offices of primary care physicians. Not only is this foolish since most people already know what counts as a fruit or vegetable, but this medium, which the 5 A Day campaign chose to use, does not reach the target audience. People who are purchasing products with this logo on them are already attempting to reach their five servings, or at least already have enough information to know that fruits and vegetables are worth their money. The target audience for this message should include the large portion of the population who drastically fall short of the five servings per day mark, which tends to be adults with less education, lower income and uncertainty about whether or not they will consistently have food in the near future (6). This part of the population is either not at the grocery store for reasons mentioned before, or they are not in that aisle, examining the produce closely enough to see the small 5 A Day logo encouraging them to buy that product. They are likely deciding which foods to buy based on the amount of money they have and possibly also what will keep their family feeling satisfied longest. A second reason that this medium is ineffective is that it in no way dramatizes the issue, which would increase the likelihood that people would care enough to pay attention and change their behavior, which showed by a self-reported survey that most people do not get five servings of fruits and vegetables daily (5). It simply provides guidance to the products condoned by 5 A Day, should the person already have established that habit. There was a small improvement with the information in the doctor’s offices, since they actually provided reasons why the reader should try to incorporate more produce instead of simply putting a logo on a package and expecting a drastic improvement. The pamphlets and the information about this program on the Center for Disease Control and Prevention website provide information from studies that found five servings to be where they saw lowered rates of many chronic illnesses such as cancer and obesity, which is where this campaign incorporates tenants of the Health Belief Model, as outlined above.
In conclusion, the 5 A Day campaign tried to change the nutrition of a nation by raising awareness, but awareness does not change behavior. The first flaw of the 5 A Day campaign is assuming that people plan their behavior, which is always rational, and do what they intend to do. As extensively studied, behavior is oftentimes irrational, a fact disregarded by the 5 A Day for Better Health Program. Secondly, the 5 A Day campaign assumes that behavior takes place in a vacuum, and it does not consider various environmental factors that impact people’s food choices, such as the high relative cost of fresh fruits and vegetables, the lack of access people in neighborhoods with a low average socioeconomic status have to grocery stores, and the safety of these neighborhoods for them to get to the grocery store in the first place. Lastly, a lack of consideration for how to deliver the message, by picking ineffective media to deliver the message through, and a lack of dramatizing the issue of incorporating enough produce into a healthy diet have both lead the general public to be largely uninformed or unengaged – as uninformed or unengaged in 1997 after the intervention as they were in 1991.

Since the vast majority of the population falls short of the goal of five servings of fruits and vegetables every day, other groups had to develop ways, separate from the government’s 5 A Day for Better Health program, that those most in need could have access to produce. Four factors have been found to increase fruit and vegetable consumption, including point-of-purchase (POP) information; reduced prices and coupons; increased availability, variety, and convenience; and promotion and advertising (11). Instead of asking the government to subsidize the cost of fresh produce they were encouraging the citizens to eat, in turn further increasing many of the deficits at the state and federal level, Community Supported Agriculture was developed. Little known to many people, Community Supported Agriculture is a grassroots movement that puts produce within reach of people of all socioeconomic backgrounds. Community Supported Agriculture is an intervention that addresses the 5 A Day campaign’s poor advertising, lack of consideration for environmental factors and assumption that people hold their health as one of their core values. In addition, Community Supported Agriculture offers both a wide variety of produce and lower costs, two factors shown to directly increase fruit and vegetable consumption.
First, an explanation of Community Supported Agriculture is necessary, because despite them being quite widespread, not everyone has heard of, or is knowledgeable about, such programs. These farms can come about in a number of ways. Farmers sign up their farms with organizations, or they simply designate their farm as Community Supported Agriculture land without the organization (8). Another way is for a city or town to own land and a group of committed individuals take responsibility for the land each season. Either way, they sell shares, also known as subscriptions or memberships, to people who do not own a farm, known as the consumers. In exchange for a flat rate that consumers pay to cover the costs of growing materials and supplies on a per season basis, they receive a box of fresh, locally grown produce, usually vegetables. They can pay more or less depending on the size box and variety of produce within the box. Additionally, most Community Supported Agriculture farmers will accept food stamps if that is how the family would normally pay for produce, were they to purchase the food in a grocery store. Families may also choose to trade labor for food if they do not have food stamps or the money to pay up front, which is a problem for many families (9). Especially if they have been unemployed or are consistently living beyond their means even as they subsist in unpleasant living conditions, the “labor for food” option offers membership to those who are struggling most. Finally, these memberships are not for sale to those strictly adjacent to the farm. On the contrary, the farmers usually have several drop off locations to reach a wider customer base (8).
More effective advertising.
Community Supported Agriculture does not advertise or communicate with the public as a typical public health campaign is expected to. They do not have commercials on television or the radio, but they use what has been the most effective method of advertising for years: word of mouth. Before the growing season begins, farmers typically try to sign people up for memberships in order to get their cash flow jumpstarted, as they usually have been without a reliable income during the winter. Satisfied consumers will likely spread the word about where they got their produce, and encouragement from a trusted friend or family member is usually most successful in convincing someone that buying something, in this case a membership, or spending their time doing something, such as helping on the farm in exchange for produce, is worthwhile. Additionally, people in the Community Supported Agriculture would be looking for people to share the costs, monetary or labor, which would lead to them recruiting people they trust to follow through on either or both accounts.
The whole premise of Community Supported Agriculture is to keep costs down to everyone, so a mainstream, widespread advertising campaign would, in itself, be contradictory to the message of the Community Supported Agriculture. Instead of spending their time trying to convince people that they should be eating more fresh vegetables, they provide it for those that want it and are willing to buy or work for it. Also, due to hearing about the Community Supported Agriculture through friends, it makes sense that skepticism would be reduced, which is oftentimes high when people are asked to change something about their lifestyle by the government.
Availability of nutritious foods has been shown to have a positive association with their consumption, therefore Community Supported Agriculture makes this food truly available to consumers, unlike the small corner stores typical in supermarket desserts which contain a very small, very expensive produce selection (7).
If Community Supported Agriculture were to improve or expand upon this method of advertising, they should put their information where the largest amount of their target audience will be reached. Needless to say, this is not on the label of a package of produce, as the 5 A Day campaign is currently advertising. The point of such a campaign is to get the potential consumer to walk over to that section of the store and pick up the produce in the first place. Perhaps in community health clinics, which are the main, or only, source of medical care for those without health insurance, informational brochures could explain what Community Supported Agriculture is and the benefits it offers as well as and provide a phone number to call or person to contact if they were interested in getting a membership to that particular farm. Also, in community centers, such as the Boys and Girls Club, a large percentage of the attendees there would benefit from knowing of a Community Supported Agriculture farm, so more information could be distributed at similar places.
Consideration for peoples’ varying environments.
Community Supported Agriculture not only takes environmental factors into consideration, on the contrary it was seemingly founded on the principle of providing produce for those who have difficulty accessing it. Given the way environments are currently, with supermarket desserts, as witnessed in Roxbury, Massachusetts in the seminar exercise, not only is fresh produce expensive once people get to the grocery store, but for residents of neighborhoods similar to Roxbury, it is a huge time investment to take a trip to the grocery store. The drop off locations that many Community Supported Agriculture farms have organized still require the consumers to pick up the produce as they would in a grocery store, but the drastically reduced cost alleviates one of the major stressors people encounter when buying fresh produce. Of course, there are limitations to this idea, especially if the potential consumer is not located near the farm itself or near to a drop off location and does not have a car to get there. However, on the whole, the two major environmental factors which the 5 A Day campaign ignored were the monetary access and geographic proximity to a store with a decent selection of fresh produce. Additionally, the logistical limitations will always be difficult to get around, and the farmers and consumers must work together to set up the most convenient place for as many people as they are able.
As previously mentioned, for people who cannot pay for the vegetables up front, they can work in exchange for a membership to the Community Supported Agriculture. This is another level of alleviating the financial burden and offering inclusiveness, since it provides a way for people who are unemployed and underemployed to also have a membership and access to healthy food. For many, being unemployed usually means an absence of all nutritious or extra food except the bare minimum, in quantity and quality, families can afford.
Not based on Health Belief Model assumptions.
Unlike the 5 A Day for Better Health campaign, community supported agriculture is not based on the major assumption that people behave rationally. This idea does not try to convince people, as 5 A Day does, to eat five servings of fruits and vegetables because it is good for them and then they will be healthier and possibly have reduced cancer risk years from now. It simply offers the option of eating healthier at a lower cost.
Additionally, much like the website discussed in lecture, it does involve an initial monetary payment to the farm, which people do not get back if they do not pick up their food every week. When people put their money on the line, they are more likely to follow through on their actions, and certainly they would be more motivated to go get food they have already paid for.
However, there would most likely be some people who are not paying for the produce, but rather working in exchange for the box of fruits and vegetables. These individuals are driven to stick with eating the produce because they have invested time into the health and growth of the vegetables. Often, they have worked very hard every week and feel bonded to their produce or they know how much work went into producing the vegetables so they are less likely to waste them by letting them go bad or not retrieving them from the drop off stations.
Additionally, children and young people can, and should, perhaps, get involved in the Community Supported Agriculture. Studies have shown that in regards to young people, they are most likely to consume healthier foods when they choose the foods instead of being told what to eat by their parents or guardians (10). If the children had been in charge of watering the same tomato plant or corn stalk each time the family went to the farm, they would obviously have a sense of pride when the vegetable was ripe and ready to eat. This finding is not surprising, given that one of the main core values children and adolescents hold in high regard, indeed much higher regard than their own health, is their independence, separation and growth from their parents, as seen in the Truth anti-smoking campaign.
In conclusion, Community Supported Agriculture did not begin initially as a cheaper option, but it has grown into a major alternative for those of lower socioeconomic status as it provides produce at lower costs and often closer to their homes. Geography and monetary cost often prohibit their access to the government-recommended five servings of fruits and vegetables every day, but when the 5 A Day for Better Health campaign made that recommendation, they should have researched what actually gets people to eat more fruits and vegetables. Unlike that campaign, Community Supported Agriculture is based on assumptions shown to hold true about people’s behavior, that they do not care about their health but other things such as money and independence, addresses environmental factors such as making produce geographically and cost available, and advertising itself through word of mouth of previous satisfied consumers. In all these ways, Community Supported Agriculture is a better intervention than the 5 A Day for Better Health campaign.

1. Edberg, M. (pp. 35-47) In: Edberg, M., ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
2. Heimendinger J, VanDuyn MA, Chapelsky D, Foerster S, Stables G. The National 5 A Day for Better Health Program: A Large-Scale Nutrition Intervention. Journal of Public Health Management and Practice 1996; 2 (2).
3. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
4. Stables G, Subar A, Patterson B, Dodd K, Heimendinger J, VanDuyn MA, Nebeling L. Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association 2002; 102 (6): 809-816.
5. Thompson B, Demark-Wahnefried W, Taylor G, McClelland J, Stables G, Havas S, Feng, Z, Topor M, Heimendinger J, Reynolds K, Cohen N. Baseline fruit and vegetable intake among adults in seven 5 A Day study centers located in diverse geographic areas. Journal of the American Dietetic Association 1999; 99 (10): 1241-1248.
6. Quan T, Salomon J, Nitzke S, Reicks M. Behaviors of low-income mothers related to fruit and vegetable consumption. Journal of the American Dietetic Association 2000; 100 (5): 567-569.
7. Williams DR. Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports 2001; 116:404-416.
8. United States Department of Agriculture. Defining Community Supported Agriculture. Supported Agriculture/Community Supported Agriculturedef.shtml
9. National Sustainable Agriculture Information Service. Community Supported Agriculture.
10. Consumer Health Interactive : The Edible Schoolyard.
11. Glanz K. Yaroch A. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Preventive Medicine 2004; 39 (2): 75-80.

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Exercise is Medicine: A Poor Prescription for Physical Activity Promotion – Maureen Harris

Regular physical activity is a critical component of a healthy lifestyle and has a strong role in health maintenance and promotion. Exercise has been shown to reduce the risk of chronic diseases such as cardiovascular disease, diabetes, and cancer; promote quality of life; aid in maintenance of a healthy weight; reduce symptoms of depression; and enhance functional health (1-2).
Despite the manifold benefits of being physically active and risks of being inactive, adherence to the recommended guidelines for activity is remarkably low. The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) recommend 30 minutes of moderate-intensity daily physical activity five days per week (3), and the 2008 Physical Activity Guidelines for Americans released by the Department of Health and Human Services (DHHS) calls for a minimum total accumulation of 150 minutes of moderate physical activity per week (4). Nearly two-thirds of adults in the United States do not meet these recommendations, and a quarter do not exercise at all (5). This has clear and severe public health implications.
The “Exercise is Medicine” Initiative
To address this burning issue, hundreds of small- and large-scale interventions have been developed, yet the problem persists. Many of these programs are based on faulty or tenuous theories or, worse yet, are not based on any framework at all. The Exercise is Medicine (EiM) initiative (6), sponsored by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA) seeks to improve rates of physical activity through encouraging a dialogue about exercise between patients and health care providers. Despite the best intentions, this program, like the others, is fatally weakened by multiple flaws.
The program’s goal is to make physical activity a standard “vital sign.” EiM calls upon health care providers to assess patients’ activity levels at every office visit and to counsel patients on how to become more active. Providers are encouraged to “prescribe” exercise for disease treatment and prevention just as they would prescribe a pharmaceutical as well as to refer patients to fitness professionals just as they would refer to a medical specialist. Additionally, EiM instructs patients to ask their doctors about exercise. The program’s website provides reference materials for providers to facilitate dialogue with patients, and it offers “tool kits” and educational videos for patients to help them initiate an exercise routine. The initiative aims to link exercise with medical treatment and equate exercise with more traditional and familiar modes of treatment, such as pills. It promotes the long term physical health benefits of exercise while presenting limited information on other, more immediate benefits of exercise.
EiM appears to be based on the Health Belief Model (HBM; 7-8), which presents four factors central to an individual’s health behavior motivation: perceived susceptibility (assessment of the likelihood of acquiring disease/condition), perceived severity (assessment of the physical and emotional hardship that may be experienced if the disease/condition is acquired), perceived barriers (assessment of obstacles to perform health behavior, such as cost, access, embarrassment), and perceived benefits (belief that a given action will be efficacious in preventing a negative outcome or minimizing its severity). Each of these factors is considered during decision making and, if the pros of the behavior exceed the cons, the individual will form an intention to engage in the behavior. Intention is assumed to result in behavior. EiM, following the logic of the HBM, emphasizes the risks (i.e., severity) of not exercising, assuming that if people know that they should exercise then they will exercise. Despite its good intentions, EiM’s design is fraught with lack of foresight and faulty logic that severely hinders its potential to improve adherence with national physical activity guidelines. Three fundamental issues with EiM will be discussed: the definition of exercise as a medical treatment, the choice of doctor-patient interactions as the mode of message delivery, and the failure to anticipate barriers.
Definition of Exercise as a Medical Treatment
Defining exercise as medicine is potentially damaging and counterproductive. While the definition is intended to convey the importance of exercise and stress its role in health maintenance, it is more likely to reduce intrinsic motivation to engage in physical activities. Intrinsic motivation is considered to be a desire to participate in an activity for the inherent satisfaction of the activity whereas extrinsic motivation is desire to participate in an activity for a reward distinct from the activity (9). Cognitive evaluation theory (CET; 10-11) proposes that intrinsic motivation relies on social-contextual factors such as perceived choice, autonomy, and enjoyment. Supporting this concept, self-efficacy and perceived satisfaction were shown to predict maintenance of physical activity (13). Presenting exercise as a treatment and as a "doctor's order" implies a lack of choice on the part of the patient. Moreover, by suggesting that exercise is something the patient must do, rather than something the patient wants to do, it undermines inherent enjoyment of, and desire to participate in, the activity (12). Deci and Ryan propose a hierarchy of motivation, including amotivation (no motivation), extrinsic motivation, and intrinsic motivation (11, 14). Extrinsic motivation is broken into four categories which are differentiated by the ratio of external to internal locus of causality. The most external category, external regulation, is associated with compliance and external rewards, whereas the most internal, integrated regulation, is associated with overlap between personal values and the activity. An individual has greater enjoyment of, and greater likelihood of maintaining, an activity when the locus of causality is most internal (9). Thus, intrinsic motivation, or deeply internalized extrinsic motivation, is critical for maintaining a physically active lifestyle. Through its disregard for the components necessary for intrinsic motivation, EiM substantially weakens its ability to promote physical activity. Worse yet, it may even have the unintended effect of decreasing physical activity by reducing inherent enjoyment of active hobbies (e.g., dancing, playing soccer) by suggesting that the reason for engaging in the activity is because it is necessary or "the right thing to do," rather than simply an enjoyable activity.
An additional issue with defining exercise as medicine is that adherence to medically prescribed regimes is often low (15-21), especially for difficult, complicated, or long term treatments. Poor adherence to medical regimes is even present when the consequences of non-adherence are severe, such as in the case of medication for coronary heart disease (21). Committing to an exercise routine requires significant effort and dedication, putting exercise adherence at great risk for low adherence. Although adherence is a difficult construct to assess, a review of the literature (22) found estimates of adherence between 4% and 93%, with most rates falling between 29% and 59%. A second review (23) found estimates of poor compliance in 30-50% of all patients, regardless of diagnosis or setting. These discouraging rates of adherence, especially considering the time consuming and long term nature of exercise that increase likelihood of low adherence, suggests that EiM's strategy of defining exercise as a medical treatment is misplaced. Lack of trust in physicians (24) or perceived discrimination (25) can cause patients to disregard their provider’s exercise “prescription,” further damaging the chance that patients will adhere to providers’ EiM recommendations.
Choice of Doctor-Patient Interactions as the Mode of Message Delivery
EiM aims to relay messages about the importance of exercise through doctor-patient interactions, but this limited strategy is a poor choice. First, many people do not have access to, or choose not to seek, healthcare services. People do not access health services for a wide range of reasons, including lack of insurance (26), lack of time (27), lack of nearby health facilities (28), and lack of trust in healthcare professionals or medicine (24). Rates of healthcare utilization are also low among minority groups (5, 29) and non-English speakers (30). Low income families may not have access to healthcare even if they have insurance due to barriers such as distance from healthcare providers and high financial costs beyond what is covered by insurance (31). The low rates of healthcare access and utilization among the uninsured and the consequent low rates of doctor-patient interaction in this population represents a significant weakness of EiM, particularly because members of low SES groups (1, 5, 32-33) and low education (1) have higher rates of inactivity and, therefore, are at greater need for exercise interventions than member of high SES groups. Among the general population, a 2007 study (34) reported that 21 percent of Americans has an annual preventive physical exam. This indicates that a large percentage of the population will not see a doctor unless they perceive a health problem requiring treatment, suggesting that many sedentary, but otherwise healthy people will not receive EiM's message. A recent review of health insurance and access (26) reported that 67% of adults, including both insured and uninsured individuals, had no contact with a health professional in the past year, similarly indicating EiM’s lack of reach.
Assuming patients have access to and seek healthcare services regularly, a provider’s advice may not result in increased exercise behavior. As previously mentioned, distrust (24) and perceived discrimination (25) in healthcare settings can cause patients to disregard doctors’ recommendations. Additionally, even if patients have a good trust relationship with their doctor and accept the message that exercise is medicine, intentions to exercise may improve without a corresponding increase in rates of exercise. The doctor-issued recommendation puts the responsibility to be physically active in the hands of the patient without addressing larger scale and upstream factors. Moreover, EiM’s success lies on the Health Belief Model-based premise that increasing salience of health risks associated with inactivity will increase intention to exercise. However, this logic is flawed and, even if intentions to exercise improve, behavior will not necessarily follow. The Health Belief Model assumes rational behavior, but it is clear that people often act irrationally. Moreover, the relationship between intention and behavior cannot be assumed. Research has shown that many who intend to engage in a behavior fail to do so (35) and that habits may inhibit the influence of intention on behavior (36). In order to improve behavior, EiM must do more than improve intentions to exercise through doctor-issued guidance.
Failure to Anticipate Barriers
A major flaw of EiM is its failure to anticipate barriers to exercise and its subsequent failure to address these barriers. The physical, “built” environment plays a substantial role in one’s choice to be physically active or inactive. Subjective assessment of physical activity in adolescents (37) and adults (38) as well as objective (39) measurement of physical activity in adults using accelerometers has shown that proximity to physical activity-related facilities (e.g., schools, parks, dance studios, YMCAs, swimming pools, bicycle rentals) increase engagement in physical activity. Similarly, the more convenient it is to exercise and the less convenient it is to be sedentary, the more likely an individual is to choose active over sedentary activities (40). Thus, the lack of areas and facilities suitable for exercise make it inconvenient and less likely that individuals will exercise, even if they know they should. Physical activity-related facilities tend to be less common in low SES and minority areas (37, 41). This barrier for low SES areas is particularly concerning because, as mentioned previously, rates of physical activity are lower in these population (1, 5, 32-33). An environment characterized by barriers to exercise will likely counteract the effect of increases in exercise intention motivated by EiM.
An additional, but related, barrier is the easy availability and convenience of alternative sedentary behaviors. According to behavioral economics, individuals weigh alternative choices based on costs and benefits as well as the proximity and tangibility of the costs and benefits (42). Behaviors with high immediate benefits and low immediate costs are preferred, even if high costs will be experienced later (43). The immediate costs of exercise (e.g., inconvenience, hard work, time, physical discomfort) are high and salient whereas the benefits promoted by EiM are distal and uncertain. Though exercise may reduce the risk of chronic disease, it is not a guarantee. Subsequently, from a behavioral economics perspective, a sedentary lifestyle may be perceived as more rewarding and higher value than an active lifestyle. While EiM aims to inform patients of exercise’s future health benefits, it focuses little attention on exercise’s more immediate benefits and does little to anticipate and downplay immediate costs of exercising. Evidence has shown that, given the choice between sedentary activity and exercise, most will choose sedentary activities (44). If access to sedentary behavior is restricted such that exercise is more convenient, however, exercise behavior increases (40, 45) demonstrating the utility of behavioral economics in exercise promotion programs. EiM’s failure to incorporate the ideas of behavioral economics inhibits its efficacy. Its chance of success would be far greater if it anticipated the barrier of readily available and tempting sedentary activities and encouraged perceptions of exercise as being more accessible and rewarding than sedentary behavior.
While the Exercise is Medicine program is intended to increase exercise behavior, its design has fundamental flaws that reduce its efficacy and may even be counterproductive. It oversimplifies the problem and the solution, creates potentially damaging associations between exercise and medical treatment, makes faulty assumptions, is too limited in scope, puts too much responsibility on the shoulders of individuals, and ignores substantial barriers. A novel intervention that capitalizes on social and behavior sciences theory and research would have higher chance of success in increasing exercise behavior and helping Americans reach national physical activity guidelines.

Active Communities Today: A Social Science-based Physical Activity Intervention – Maureen Harris
The Exercise is Medicine (EiM) initiative aims to battle the alarming prevalence of sedentary lifestyle and encourage adults to meet the national recommended guidelines for physical activity. Despite its good intentions, the program’s ignorance of social and behavioral principles greatly inhibits its efficacy. A previous critique of this program highlighted several crippling flaws. Here, an alternative program is proposed.
The Active Communities Today (ACT) initiative is based heavily on social science research. As its names suggests, it has three primary objectives. First, to get people active and moving, without necessarily framing exercise in a health context. Second, to engage communities, foster social support, avoid blaming individuals, promote policy changes to encourage activity, and to campaign for improvements in the built environment that facilitate physical activity. Third, to emphasize that the time for change is now; exercise behavior, not exercise intentions, will lead to public health improvements. These objectives are targeted by three key strategies that specifically address EiM’s fundamental weaknesses.
Strategy 1: Foster Intrinsic Motivation and Adherence
The EiM program defines exercise as “medicine” and employs medical terminology (e.g., “prescription”) throughout its materials. This definition is not only ineffective, but potentially counterproductive. By limiting the factors known to support intrinsic and internalized motivation, EiM reduces the likelihood that people will voluntarily choose to be active. The importance of protecting intrinsic motivation is more than theoretical. Applied research has shown that promotion of the factors that enhance internalization of motivation is positively related to exercise behavior (13, 46-49). ACT, guided by cognitive evaluation theory (CET; 10-11) and motivation research (e.g., 9-11, 14), promotes perceived choice, autonomy, self-efficacy, and the inherent enjoyment of physical activity to foster intrinsic/internalized motivation.
The program empowers people to make their own decisions and avoids directives and orders, with its primary goal being to allow exercise to become a naturally reinforcing activity. Through program materials and outreach events, ACT proposes a wide variety of activities, including competitive (e.g., road races and sports leagues), cooperative (e.g., recreational sports leagues and walking groups), and individual (e.g., health club workouts and swimming sessions) options from which people can choose, allowing people with all personality types to select an activity that is most appealing to them. The program recommends experimenting with nontraditional exercises (e.g., boxing or dance classes) to maximize interest and maintain satisfaction. Importantly, though abundant choices are offered, guidelines are provided. To make a noticeable public health impact, people must achieve a certain volume and intensity of physical activity. ACT advises participation in at least one activity for at least 30 minutes most days of the week in order to see short term benefits, such as increased energy and improved mood. As Whitehead notes (12), freedom of choice can be maintained within guidelines.
To enhance exercise self-efficacy, ACT encourages simple activities (e.g., brisk walking) as well as offering community classes and online tools to provide tips and skills on more complicated activities. At outreach events, fitness experts offer free consultations to help people design appropriate workout routines. While educational, the primary emphasis will be to encourage confidence. This aspect of the program is critical as self-efficacy has been shown to predict exercise behavior (46, 48-49) and adherence (13, 47).
ACT markets exercise as fun, with the goal of helping adults reconnect with the enjoyment of playful activity of childhood and to incorporate daily activity into their lifestyle. Defining exercise as a positive and pleasurable activity portrays physical activity as a satisfying choice. Furthermore, the expectation that exercise will be enjoyable increases the likelihood that an individual will perceive exercise as enjoyable. Cognitive biases often cause us to see what we want to see or experience what we predict we will experience (50). Positive exercise expectancies have been associated with exercise behavior (51).
By facilitating the factors necessary for intrinsic/internalized motivation, ACT simultaneously addresses EiM’s likely problem with poor adherence. A smoking cessation intervention that supported autonomy and perceived competence increased long term adherence to tobacco abstinence (52). Similarly, it has been demonstrated that those who adopt exercise as a personal value are more likely to adhere to regular physical activity (9).
Strategy 2: Employ Widespread, Effective Communication
As noted, many people do not see their doctor for various reasons. Even among those that do see a healthcare provider, many lack trust in him or her, meaning that directives from a provider may be disregarded. In order to communicate the core program messages effectively, ACT employs a multifaceted communication strategy.
To maximize distribution, print, radio, and television ads are used to broadcast ACT’s key messages widely. Posters are placed in public buses and trains as well as high traffic centers such as libraries, schools, and outside of grocery stores and banks. Radio and television ads are aired several times a week. Local outreach events featuring ACT representatives bring key concepts directly to community members. A website offers confidential guidance, encouragement, and tools to get started. Visitors to the site will be encouraged to offer suggestions for site improvements to maximize its utility (53). A network of message boards hosted on the site will offer a forum for social support and exchange of questions and answers. Importantly, medical experts will moderate the boards to ensure the accuracy of answers provided by community members. The site will also feature a space for individuals to get involved in policy change by reporting concerns (e.g., crime levels render neighborhood unsafe for outdoor exercise) and requesting changes (e.g., construction of bike lanes on city streets). This space is intended to open a dialogue between community members and policy makers.
In addition to being well-distributed, it is equally important that ACT’s communications are interpreted positively. This involves appealing to values of the intended audience (54), as assessed by pilot focus groups and survey samples, rather than the values of ACT staff. As an example, the program promotes commuting by bike rather than car to be “green” and doing house/yard work on your own rather than hiring landscapers to be thrifty. ACT’s materials and events feature a wide range of regular people with whom the target population can relate, including members of various racial and cultural groups, young and old, male and female. Beyond facilitating social learning (55), this shows that exercise is truly for everyone and helps develop imagery of people having fun being active. The aim is for members of the target population to begin to imagine themselves in an active lifestyle and consider adoption of an active lifestyle as an achievable goal.
Strategy 3: Reduce Barriers and Market Immediate Benefits
ACT is firmly based on behavioral economic principles and recognizes that there are infinite sedentary activities competing with exercise to fill the limited number of hours in a day. To portray exercise as a valuable choice, the short term benefits must be emphasized while short term costs are minimized (42). The program’s goal is to sell the idea that exercise is a small investment with a large immediate reward.
ACT works to reduce immediate costs by making physical activity accessible and convenient. A major obstacle in the widespread adoption of active lifestyles is the lack of exercise-friendly environments. With unsafe streets, car-dependent communities, and neighborhoods lacking recreational centers, finding opportunities to be active can be difficult, even if an individual has an intention to be active. In order to make improvements in physical environments, ACT works closely with government officials, community developers, and business leaders. The program sponsors grassroots organizations to campaign for change at the town and city level while opening a parallel dialogue with state and federal leaders. As mentioned in the second section, ACT involves the community members in this dialogue. Short term projects include establishment of bike share programs in urban centers. The long term vision is for development of high-density, “walkable” communities with low crime rates, low pollution, and abundant physical activity-associated facilities (e.g., recreational centers, swimming pools, tennis courts). These attributes are associated with higher rates of physical activity (e.g., 56-58), and a recent case study reported that increased access to recreational resources raised physical activity levels (59).
In addition to reducing structural barriers, ACT reduces perceived immediate costs by showing that exercise can be just as easy and uncomplicated as sedentary behaviors. The program website and print materials offer suggestions on how to incorporate simple exercise and non-exercise physical activity (e.g., walking for transportation, vigorous housework) into a daily routine. Moreover, it suggests inexpensive activities that can be done without leaving the house (e.g., exercise videos, jumping rope, dancing), and reminds people that if they cannot tolerate high intensity exercise, they can still reap benefits from higher frequency, lower intensity workouts.
Keeping in line with behavioral economic principles, the immediate benefits of physical activity are advertised much more heavily than long term health benefits. Program materials highlight increased energy and vitality, improved mood, higher quality sleep, improved mental functioning, reduction in mild depression, increased self-esteem, and even higher sex satisfaction. Fun activities that are considered pleasurable rather than painful (playing tag with the kids, playing tennis with a friend or spouse) are highlighted. To help physical activity gain an extra edge over sedentary activities, behaviors such as television viewing and video game playing are marketed as having few benefits. Time spent TV viewing has been shown to be inversely related to leisure time physical activity in women (60), girls (61), and adolescent boys and girls (62), suggesting that reducing TV viewing may encourage activity.
ACT is a broad, multifaceted program. It works primarily above the individual level to create large scale changes in the culture, physical environment, and social environment. In parallel, it targets individual level behavior by reframing exercise with positive terms and promoting exercise’s inherently reinforcing properties.

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England’s Maternal Prenatal Smoking Cessation-Robbie Frank

There are a number of successful smoking cessation interventions based on behavioral theories. Even though many smoking cessation interventions are deemed successful, none of the interventions are without flaws (12). In England, there is a smoking cessation intervention targeting pregnant women. This intervention is based on the theory of planned behavior (TPB). An intervention based on the TPB model is a fundamentally flawed approach to maternal prenatal smoking cessation because it is an individual level based intervention, it asserts that perceived behavioral control is a predictor of actual behavioral control, and assumes that human behavior is the output of rational, linear decision making process.
The England Department of Health launched a smoking cessation ad campaign based on the TPB model targeting pregnant women (20). The ad shows an obviously pregnant woman smoking a cigarette. The campaign then goes on to provide information on how cigarette smoke “restricts the essential oxygen supply to an unborn baby, so that their tiny heart has to beat harder every time a pregnant woman smokes.” The campaign reinforces the message that cigarette smoking harms unborn babies, and that stopping smoking is the right thing to do (social norms say smoking when pregnant is bad). The ad also goes on to inform the reader that smoking cessation –no matter how far long the pregnancy is−will immediately benefit the woman and her baby (control belief—the belief in the ability to control the improvement of the health of mother and child will make it easier for the mother to participate in smoking cessation). It then offers information on how pregnant women can take the situation into their own hands and receive professional support to assist them in smoking cessation (perceived power). The offer of assistance in smoking cessation is meant to turn intentions into the desired behavior. This ad presents smoking cessation as a positive, desirable behavior that one can control.
Theoretical Framework of Intervention
To contextualize the flaws of the England smoking cessation intervention, it is important to understand the health behavior model upon which the intervention is fashioned. The TPB model was proposed by Icek Ajzen in 1985 as an extension of the theory of reasoned action (TRA). TRA is an individual level theory based on the concept that individuals go through complex cognitive assessments before making decisions on behavioral intentions. This is then followed by the rational movement from assessment to behavior (15). A person’s intent to perform (or to not perform) a behavior is viewed as the instant determinant of the action (13). TRA includes two determinants to intention: personal (attitude) and social (subjective norm). An attitude is described as a negative or positive evaluation of performing or not performing a desired behavior. Subjective norm indicates a person’s perception of the social pressure exerted by others who think that a given behavior should or should not be performed. This theory lacked because a person can go through the process of assessment and have a behavioral intention, but still not be able to do the behavior (13). To address this issue, a new element called perceived behavioral control was added to TRA. Perceived behavioral control refers to the degree to which someone believes they have control over whether they can take the action (control belief) and the strength of that belief (perceived power). This new element reformulated TRA to TPB. It attempts to explain the relationship between people’s attitudes and their behaviors, based on people’s perceived behavioral control and perceived power (13).
Flaws of Intervention
Individual Level Intervention

The ultimate goal of the ad intervention is to reach a broad target audience of maternal prenatal smokers and convince them to change to the desired health behavior of smoking cessation. This smoking cessation intervention is based on the TPB model. Due to such, this intervention has inherit flaws of the TPB model, one of which being that this intervention functions on the individual level. The ultimate goal of an individual level intervention is to change the knowledge, awareness, and skills of an individual. These types of campaigns focus on changing a specific aspect of an individual’s attitude, belief, and/ or cognition (27). This is a drawback in an attempting to change the health related behavior of a target audience because the enactment or non-enactment of the target audience’s behavior is likely a result of personal individual-level processes that precede the behavior. Because maternal prenatal smokers are not a homogenous group, different women will have different reasons for participating or not participating in the desired health behavior of smoking cessation. England’s individual level smoking cessation interventions does not take into account that being healthy and giving birth to a healthy baby is not a core value for all women. Due to such, a smoking cessation intervention must be able to find a common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation.
The individual level approach to maternal prenatal smoking cessation is unable to address the social factors that may influence the behavior of continued smoking. Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics) (22). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy. Some women have cited a socio-economic burden as a barrier to smoking cessation. These women are unable to fund smoking cessation aids such as cigarette modification products, thought changing products, and stop smoking educational products (22). In a study conducted by Greaves, research found that some women use cigarettes to “organize” their social interactions in order to build and bond pleasant social and work relationships (24). In other studies, pregnant women cited smoking as a tool of self definition. Continued smoking projected a personal image perceived by the smoker as cool, tough, defiant, adventurous, sexy, young, and slim. Smoking was also cited as a means through which pregnant women are able to suppress emotions or dissipate feelings of fear or pain in preference to expressing negative emotions openly. The behavior of continued maternal prenatal smoking was also influenced by the smoking habits of husbands, partners, family members, and friends. These factors can contribute to the difficulty of smoking cessation (2). An individual-level model is inappropriate in shaping a smoking cessation intervention for pregnant women because it neglects to acknowledge that the decision of smoking cessation is not necessarily made on and individual level and that there are a number of social factors that impact decisions related to health behaviors.
Perceived Behavioral Control is a predictor of Actual Behavioral Control
A fundamental defect of a maternal prenatal smoking cessation intervention based on the TPB is the assumption that perceived behavioral control is a predictor of actual behavioral control. It is postulated that perceived behavioral control serves as a proxy for actual behavioral control, therefore having a direct influence on both intention and the actual behavior (1). On the contrary, perceived behavioral control is fundamentally different from actual behavioral control. Perceived behavioral control is a strong predictor of the strength of a person’s intention to participate in a certain behavior (25), not a substitute or predictor for the actual behavioral control that a person possesses. Actual behavioral control refers to the extent to which a person has the skills, resources, and other prerequisites needed to perform a given behavior (19). Due to the conceptual difference between perceived behavioral control and actual behavioral control, it is inaccurate to assume that perceived behavioral control can predict or impact a person’s actual behavioral control. Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). The TPB model does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control.
In a study conducted on the influence of perceived behavioral control, research revealed that perceived behavioral control impacts behavior only through the prediction of a person’s behavioral intentions (8). Perceived behavioral control is a strong predictor of the intent to do a behavior, but not a predictor of the actual behavioral control a person possesses (25). The fulfillment of many health behaviors do not coincide with attitudes towards, or intentions regarding a specific behavior. The England’s maternal prenatal smoking cessation intervention possesses the ability to convince a pregnant woman to develop a strong belief that she has control and power over her ability to stop smoking. However, strong perceived power and control beliefs do not lead to actual behavioral control, which is necessary to act on the desired behavior intention. Strong perceived power and control beliefs lead to strong intentions to do the desired behavior. Strong intentions is not sufficient enough to illicit the execution of a desired behavior. Pregnant women must possess actual behavioral control in order to perform the intended behavior (19). The assertion that the belief of perceived behavioral control is linked to pregnant women’s ability to act on the intention to participate in smoking cessation is inaccurate. Actual behavioral control must be present in order for a person to act upon his/her perceived behavioral control. Without actual behavioral control, the pregnant woman does not possess the skills and resources necessary to enable her to exercise the intended behavior of maternal prenatal smoking cessation. It is therefore difficult to assess how the construct of perceived behavioral control impacts behavior modification without first understanding the role that actual behavioral control plays in the human decision making process.
Human Behavior is Rational and Linear
Due to the fact that this intervention is rooted in the TPB model, its design oversight assumes that behavior is the output of rational, linear cognitive decision making processes (15). Many behavioral theorists and social scientists argue that human behavior is complex and irrational, therefore difficult to predict (18). Irrationality is defined as the tendency that humans possess to behave, express emotions, and think in ways that are inflexible, unrealistic, absolutist and self- and social-defeating and destructive (16). In light of the irrational nature of human behavior, it cannot feasibly be asserted that decision making is a linear, planned process. Human behavior is affected by the broad social or cultural environment surrounding the behavior, the immediate social situation or context in which the behavior occurs, the characteristics or disposition of the person performing the behavior, the behavior itself and closely related behaviors, and the interaction of all these conditions (22). There are a number of factors that can cause a person not to carry out their planned behavior. In smoking cessation, the decision to use or not to use tobacco is linked with a range of factors, some of which have little or not relation with actual tobacco usage (22). The human decision making process is the result of a complex interplay between cognitive, emotional, social, personal, and environmental influences (16) that can often time lead to irrational, self defeating unplanned behavior.
Today, most pregnant women seem to be aware of the health risks associated with maternal prenatal smoking, however, awareness alone is not sufficient enough to prompt women to stop smoking (9.). Studies show that maternal prenatal smoking is not solely the result of a lack of knowledge of health risks associated with the behavior. It is instead the result of the human decision making process which is shaped by external factors that can persuade women to deviate from the planned, desired behavior of smoking cessation (7). The assumption that decision making is a linear process neglects to consider the extraneous factors that might influence the target audience’s behavior. In a study of women’s attitudes toward smoking, it was found that although most of the women in a focus group considered themselves addicted and dislike smoking itself, they liked the social, psycho-logic, and physical effects of the cigarettes (23). Some reasons given by women for maternal prenatal smoking included those related to an inability to cope with psychological issues (i.e., depression, anxiety, irritability, etc.) and their physical addiction to nicotine (the appearance of characteristic withdrawal symptoms when the use of nicotine is suddenly discontinued) (3). Other factors associated with smoking cessation for pregnant women are their level of education and their race. Research reveals that smoking cessation among pregnant women increases as their level of education increases (5.). In 1991, 45.4 percent (±10.5) of women with 16 or more years of education quit smoking during pregnancy. This finding is consistent with previously published studies (6, 11.). Studies also showed that the percentage of smokers who reported having quit smoking for at least one week during their pregnancy was higher among American Indian mothers (64 percent) than among white mothers (57 percent) or black mothers (49 percent) (26). The factors that impact the decision to participate in maternal prenatal smoking cessation are not all rational, nor are they part of a linear decision making process. The previously stated research helps to illustrate the fundamental flaw of a maternal prenatal smoking cessation intervention based on the TPB model because it demonstrates that the human decision making process is irrational and unplanned (10), thus completely contradicts the functioning of the TPB model.
Due to the inherent flaws and shortcomings of all health behavioral theories, there is no one theory able to adequately and accurately predict human behavior. Human behavior is complex and influenced by a number of intrinsic and extrinsic factors (12). When attempting to predict human behavior, it is important to examine behavior decisions in the context of the target audience’s needs, preferences, social and environmental networks, and core values. In regards to such, public health practitioners must design and utilize health behavior modification interventions based on appropriate health behavior models in order to continue to advocate for healthier behavior.
In assignment #3, the fundamental flaws of a maternal prenatal smoking cessation intervention based on the theory of planned behavior (TPB) approach was highlighted. This paper addresses the fundamental flaws highlighted in assignment #3 by offering an alternative approach to the maternal prenatal smoking cessation intervention. To address the fundamental flaws of the TPB approach, the new approach is based on the framing theory. Framing theory asserts that an issue can be viewed from a number of different perspectives . These different vantage points can be interpreted as having implications for multiple deeply ingrained core values of a population. Framing refers to the process by which people develop a particular conceptualization of an issue or organize their opinions about an issue (30). Thus, framing theory redefines, repackages, repositions, and reframes behavior modification interventions in a way that addresses the fundamental core values and needs among the target audience (33). The framing theory approach improves upon the flaws of the TPB approach in assignment #3 because it functions on a community level, takes advantage of the fact that human behavior is irrational and decision making can be non-linear, and it understands that perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact whether or not a person performs a desired behavior.
Functions on Community Level
Unlike the TPB approach, the framing theory functions on a community level by addressing the wide-spread core values of the target audience. This theory does so by speaking to the packaging and positioning of a public health intervention to appeal to deeply ingrained, widely shared core values held by the target audience (33). A community level smoking cessation intervention must be able to address the common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation. Literature shows that health is generally important to individuals because it impacts their core values by garnering the fundamental need and desire to have a certain degree of personal freedom, independence, autonomy, and control over their lives (33). To market changes in health behavior, public health must redefine, repackage, reposition, and reframe the health behavior intervention in a way that satisfies an existing demand among the target audience (33). By redefining the problem, framing also suggest a new solution to the problem (35). Framing theory moves the maternal prenatal smoking cessation intervention from the individual level to the community level because this approach equips the intervention with the capacity to appeal to the core values of the general public (34).
While the underlying model in assignment #3 tries to change current health behaviors to fit with the suggested health behaviors, the framing theory recognizes that the target audience will only take action when they believe that the suggested behavior aligns with the core values of their community. Thus, the framing theory focuses on appealing to its audience’s widely accepted core values and not the health value of the public health practice (33). For example, if public health practitioners were trying to market a framing theory approach of smoking cessation to pregnant teenaged girls, the intervention should address the core values of this target audience. Research shows that continued smoking during pregnancy projects a personal image perceived by the smoker as cool, tough, defiant, adventurous, and sexy (29). The framing theory approach could use these core values to create an intervention that sends the message that not smoking during pregnancy is cool, tough, defiant, adventurous, and sexy. This repackaging and repositioning of teenaged maternal prenatal smoking cessation speaks to the core values of a large community of people, thus having appeal beyond the individual level.
Takes Advantage of Irrational Human Behavior and Non-Linear Decision Making

The framing theory takes advantage of the fact that human behavior is irrational and that decision making can be non-linear. This theory addresses the flaws from assignment #3 by using irrational human behavior and spontaneous decision making as means through which it can change the perception of a suggested behavior while ultimately changing the audience’s perception of self interest. It does so by altering the relationship between the perception of the behavior and the audience’s self interest. Framing theory does not assume the need to change its audience’s health behaviors to conform to the suggest health behavior. This model redefines the suggested behavior so that it is perceived as being in the audience’s self interest and addresses the audience’s core values (33). This will encourage the audience to participate in the suggested behavior. This is achieved by demonstrating that the intervention will help the audiences to fulfill its fundamental needs and desires.
For example, a maternal prenatal smoking cessation campaign based on the framing theory can use a group of core values; such as freedom, independence, and control, to frame an intervention. Instead of defining a smoking cessation intervention as a behavior that will improve a person’s health, it can be redefined to be perceived as a behavior that will offer smokers freedom from the tobacco industry’s manipulation, independence from the addiction of nicotine, and control over the fate of their lives. In this smoking cessation campaign, the solution to the problem of loss of freedom, independence, and personal control is smoking cessation. The irrational behavior and non-linear nature of human decision making enables the relationship between the perception of the audience’s behavior and the perception of the audience’s self interest to be altered by repackaging and repositioning a smoking cessation campaign to be about empowerment within the target community.
Perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact a person’s ability to perform a desired behavior

The framing theory accounts for the fact that perception of control over one’s ability to complete a behavior (perceived behavioral control) does not necessarily lead to actually having the power or control to practice that behavior (actual behavioral control). Perceived behavioral control does not lead to actual behavioral control because there are external factors that can limit a person’s ability to perform a behavior in which he/she might have perceived control over (13). Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy (22).
The TPB approach does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control. It does not consider the impact of external factors in a person’s ability to have actual behavioral control. The framing theory addresses this flaw by redefining, repackaging, repositioning, and reframing the health behavior intervention in a way that satisfies an existing demand or need within the lives of the target audience, thus, addressing the external needs and desires of the audience to enable them to participate in the desired behavior (33). For example, a group of pregnant women have the desire to stop smoking are offered an opportunity to participate in a free program that will assist them with smoking cessation (perceived behavioral control). Unfortunately, many of the women are unable to attend the weekly program due to transportation issues, lack of appropriate child care, work, etc. This means that these women do not possess actual behavior control to carry out their desired behavior of smoking cessation. A framing theory approach would restructure the health behavior intervention in ways that would satisfy the demands and needs within these women’s lives in order to give them actual behavior control to participate in smoking cessation.
Maternal prenatal smoking is a complex behavior that is influenced by a number of factors. The framing theory is able to addresses the different ways in which situational and personal factors influence a woman’s decision to participate in smoking cessation. The framing theory provides public health practitioners with a means through which they can define, position, and package a smoking cessation intervention in ways that address pregnant women’s core values and help to them to quit smoking.

Works Cited

1.) Ajzen, I. The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 1991: 50, 179-211.
2.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal Jan. 15, 1995; 152(2): 163–166.
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Psychology Health & Medicine 2001; 6, 95−99.
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pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
6.) Floyd, R et al. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annual Review of Public Health 1993; 14:379–411.
7.) Gillies, P., Madeley, R., and Power, F. Why do pregnant women smoke? Public
Health Sept. 1989; 103 (5): 337-43.
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