Challenging Dogma - Spring 2008

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

Monday, April 21, 2008

HealthierUS Campaign Offers a Tradeoff of Education for the Choice to Live Better Lives - Meghan Schneider

Although the HealthierUS government initiative has the intention to promote healthy lifestyles through education on daily exercise to ultimately reduce and prevent disease, the flaws that make up the foundation of this strategy contribute the program’s demise. The purpose of this paper is to formulate evidenced-based criticism as to why this public health campaign has failed to produce positive health outcomes and to offer comparisons to other qualitatively different, more successful initiatives of which the US could potentially take advantage.

The HealthierUS government initiative is a national public health effort that began in 2002 designed to promote community health and wellness through education[1]. The four key elements to the initiative instruct individuals to “be physically active everyday,” “eat a nutritious diet,” “get preventative screenings” and to “make healthy choices.” Those four goals are conveyed via the website where credible, accurate information is offered in order to help individuals “choose to live a healthier life.” Additional media pathways used to disseminate information to the U.S. regarding the overarching agenda of reducing costs of disease include presidential news releases, community-based programs, volunteer committees, government councils, and school based interventions.

Due to recent disturbing trends of the increased incidence and prevalence rates of potentially preventable diseases like obesity and diabetes (especially among children) and the subsequent costs of those diseases, the government has attempted to implement change by addressing individual behaviors. Two recent demonstrations of the program include the “President’s Challenge” where individuals can log on to a website and track their individual physical fitness progress, and “Steps to a HealthierUS” where funding is allocated to communities, cities and states to address risky behaviors like physical inactivity, poor nutrition and tobacco use. Despite these well warranted efforts to influence an individual’s choice to change their current lifestyle, the trajectory of obesity trends in the U.S. remain on the rise. This begs the question then, are children choosing to be obese or inactive? Are adults choosing to contract deathly diseases like coronary heart disease and diabetes? This paper argues against such a fallacy by illustrating the major flaws of the initiative that depend on this type of logic.

Argument 1: Limited Use of Behavior Change Models Yield Limited Results

Similar to many other public health interventions, HealthierUS relies on models like the Health Belief Model (HBM) and Social Learning Theory (SLT) devised by psychologists in order to predict individual behavior[2]. The basic premise behind the HBM assumes that a person’s engagement in a specific behavior is contingent upon a ‘perceived susceptibility’ to a particular health outcome, a ‘perceived severity’ of its significance and a weighted analysis of the potential costs and benefits that the action may incur. SLT provides a ‘self-efficacy’ component that incorporates the element of confidence that each individual has in themselves to take action[3]. This logical analysis has a direct correlation to the intent of the individual which theoretically predicts behavior. For example, HealthierUS campaign is laden with statistics about obesity, chronic heart disease and cancer aimed at influencing the perceived severity of inactivity. Additional ‘easy’ tips that advise on the type of activity implemented into a daily routine like walking the dog, gardening or riding a bike focus on the self-efficacy component. Individual confidence is built upon messages like “you can do it!” and “you’ve already made a good start.” Even the benefits are explicitly written in terms of reducing the risk for cancer, diabetes, high blood pressure and osteoporosis. Since the HealthierUS initiative is a prime amalgam of both the HBM and SLT, why have the rates of obesity increased from 25% among adults in 2002[4] to 34% in 2006[5]?

Unfortunately, the HBM fails to address major social, economic, and psychological experiences across different environments that are pertinent to predicting behavior. For example, suggesting specific activities like walking the dog make assumptions that everyone has safe places or sidewalks available. Moreover, how many individuals own gardens in New York City, and how many of those people live in low-income housing[6]? Addressing some of the barriers to achieving daily exercise like lack of accessibility, time or social networks help to delve into the contextual predictors of behavior change[7]. In doing so, this initiative could begin to tap into greater sub populations that have been largely ignored up to this point as illustrated in the previous 5-a-day campaign failure.

The “5-a-day for Better Health” campaign, which began in 2000 and then evaluated in 2004, is a prime learning source for illustrating the fate of a program that ignores basic individual social and economic differences. The basic goal behind the promotion was to influence the American people to increase their consumption of fruits and vegetables to five per day. Yet after evaluation, it was determined that there was little or no change in the amount of fruits and vegetables that people reported eating[8]. Access to fresh fruits and vegetables from specialty stores, farmer’s markets, and supermarkets like ‘Whole Foods’ is quite disparate for those living in low-income neighborhoods[9]. Similar to this correlation between the availability of supermarkets and healthier diets[10], a correlation also exists between accessibility to gyms, gardens, parks, or sidewalks and increased physical activity[11].

Other morbid statistics concerning widespread patterns of inconsistent safe sex practice among the gay men community also help to exploit the need for the recognition of contextual social factors within public health programs[12]. HIV and other deadly sexually transmitted disease prevention efforts have been primarily based on the assumption that raising levels of education surrounding safe sex practices will help to initiate change. Data does not support this assumption; rather, Ron Stall suggests that interventions must address the actual context with which risky sex behaviors occur. Similarly, educating the American public about healthy eating habits or physical exercise does not address the circumstances, like type of neighborhood or family structure that may influence actual food consumption and exercise practices.

Moreover, some argue that the amount of acknowledgement and understanding that policies lack is a motivating factor to having unprotected sex for gay males[13]. In a sense, the potential health outcome of unprotected sex is seemingly less destructive that the guilty, shameful, anxious or depressed feelings that are felt by some throughout their daily lives. So the actual messages that are being portrayed are in direct conflict to the core values of the target audience! In parallel, the method with which African Americans internalize racism and discrimination throughout their daily experiences could be influencing overeating and underactive behaviors. Or as some literature suggests, being large in the African American female community is a value that signifies empowerment or attractiveness to black men; education that focuses on being fit and thin also acts in contention with their own embedded beliefs[14]. Prevention programs like these that are formulated from the HBM or SLT are dangerously lacking the attention to major psycho-social variables essential for successful results.

Argument 2: Generational Gaps Expose Gaps in Results

Another argument as to why the HealthierUS campaign has failed to show significant results is in part due to the method of how the message is conveyed. To the website’s advantage, it incorporates attractive sites and links that are geared towards distinct age sub groups like children, pre-teens, adolescents and adults. Children can view a 30 second TV ad of their favorite Shrek characters who talk to them about exercise, healthy facts are integrated into contests and online games for pre-teens to enter, and famous NFL players like Reggie Bush speak directly to teens about the importance of sport and play as images of football, four-square, and freeze-tag are demonstrated throughout the video. This purposeful design illustrates both the Theory of Reasoned Action and SLT where changes in attitudes about exercise are influenced from external socially acceptable ‘characters’ who are held in such high esteem; the expectation is that these behaviors are then modeled. But there is a profound flaw with enticing very developmentally different age groups using the same tactic.

The success of the TRUTH campaign in Florida speaks volumes about how teenagers mentally synthesize the external world, which is qualitatively different from how kids or adults process their surroundings. In order to ‘sell’ the smoking prevention or cessation idea to teenagers, Florida’s Department of Health incorporated several new techniques which had previously been untapped resources in Public Health. This two-year program was funded from a $200 million dollar settlement allocated by the tobacco companies which helped create an unconventional branding method[15]. TRUTH began with actual youth pilot data that was translated into a marketing strategy that still maintained a humorous tone without manipulation. From 1998 to 2000, an evaluative study found that the percentage of youths using tobacco within the previous 30 days had declined by 7.4% in middle schools and 4.8% in high schools[16]. Again, the success among teens was related to unexpected images where they didn’t feel “they were being told what to do.”

Unfortunately, HealthierUS has not adopted any of the useful methods that are correlated to the TRUTH’s triumph over the tobacco industry. Instead, messages overtly implore teens in an officious manner to “be active everyday” and “eat better.” Given the extensive and well-documented data that mark the adolescent years as a time of rebelliousness and asserting independence, it would be counteractive to demand teens to change specific behaviors and expect results. Arguably, in doing just that could instigate even less participation by this sub-group.

One final salient point is that adolescence is also a primary time where individuals take on different identities and formulate tight cliques with those exhibiting similar interests. How teenagers act within these cliques directly relates to the Social Network Theory (SNT) which supposes that people behave differently as a group than they would as individuals. For example, the President’s Challenge campaign within HealthierUS is designed to set school standards that relate to five main assessments including a one mile run (endurance), sit-ups and pull-ups (strength), ‘sit and reach’ stretch (flexibility) and a shuttle run (agility). The program is designed to offer individuals the opportunity to compete against all others in their age group where they are measured against a percentile. The focus of this program offers the majority of the rewards to those that are already athletic, or the ‘jocks’ in the school, and does not attempt to interest those that are not currently active. A study exemplifying this phenomenon showed increased exercise involvement within a community based intervention only among those of whom reported engaging in at least some exercise prior to the intervention[17]. Perhaps if the President’s Challenge were ‘branded’ to cut across these social cliques, participation and success might mirror that of the TRUTH campaign.

Argument 3: Selling the Right ‘Products’ Sells Successful Results

The final contention with the HealthierUS initiative is its failure to use well-known marketing strategies that actually empower the U.S. audience. As previously mentioned, the tone of the four goals represented throughout the website and its implemented programs across the states implore individuals to outright change their behavior. And although the underlying message is a positive one with a motivational intent, previously cited rates of obesity from 2002 to present are a much greater indicator of a foundational error that precedes the actual type of conveyed message.

The idea of reducing obesity and disease rates without selling exercise, healthy eating habits, and regular health screenings may seem counterintuitive, but some of the greatest businesses across the globe have encountered enormous successes in not selling their product, but in selling something else. Multi-billion dollar industries like Miller, Volkswagen, Marlborough, and Louis Vuitton are just a few name brands that use this marketing strategy for their own capital advantage. These companies do not sell beer, cars, cigarettes, clothes or handbags; they sell better relationships, higher quality of life, autonomy, independence, strength, beauty, and youth. These are the precise messages that are too often lacking within public health initiatives like HealthierUS.

A few key concepts highlighted in successful marketing strategies of fortune 500 companies involve ‘defining the product’[18]. For example, customers interested in buying software will actually be sold increased productivity, efficiency and savings. In turn, HealthierUS ‘customers’ should not buy vegetables like broccoli, they should purchase sex or happiness. Another tactic cited was to ‘know the competition.’ In stark contrast, public health campaigns actually team up with their competition demonstrated by the sponsorship of initiatives from fast food chains like Burger King and McDonalds. Campaigns like HealthierUS must begin to adopt some more multi-dimensional marketing approaches in order to reap the benefits that so many other prosperous companies have effectively executed.

The marketing tools used throughout some of the most well-known product in the world have adopted the ‘4-Ps’, product, place, promotion, and price which takes into consideration the social perspectives of the audience[19]. How the product is branded, the mediums throughout the environment where the product is advertised, and the tone of the promotion follow mass societal views. Likewise, normative re-educative approaches to changing behavior involve similar non-cognitive and perhaps much less logically rational determinants like values, attitudes, personal emotions, and social norms[20]. Some of the underlying assumptions to this theory is that people live in social environments and generally adhere or ‘go with the flow’ with social standards. Because culture is a defining characteristic to this model, selling physical exercise should take into consideration some of the distinct culturally based American values intertwined with exercise[21].

Provided that there are many models and theories to choose from, selecting the most appropriate intervention is paramount. There is no specific formula for public health scientists, researchers and activists to apply that yield a 100% success rate. Some considerations include recognizing the desired degree of change and the subsequent resistance to change that may exist. Various dependent variables also take into account population size, time frame, available expertise and the stakes of the situation which can call upon very different model applications to obtain optimum results. The VERB campaign is one final example that illustrates the use of an appropriate strategy with victorious results.

Successful strategy

The underlying mission of the VERB campaign was to increase and maintain physical activity among pre-teens, or ‘tweens’ ages 9-12. This national, multicultural initiative which ran from 2001-2006 by the Center of Disease Control and Prevention used commercial marketing strategies to heighten awareness about the various options and opportunities tweens have surrounding physical activity[22]. Additional audiences included parents, teachers, youth leaders, pediatricians and coaches all targeted as a medium to spread the slogan, “it’s what you do.” Over 350 million federally funded dollars allowed for copious quirky ads throughout major television networks like MTV and Nickelodeon encouraging kids to find their own “verb” that reinforced their present core values of spending time with friends, playing, and having fun. Tweens began to gain ownership over general verbs like ‘run’, ‘jump’ and ‘swim’ and integrated them into their own personal actions or games that appealed to them. It did not take long for this innovative program to spread to communities and elementary schools across the nation where research evaluations quickly validated its success.

Just after year one of the program, over 3100 tweens completed a survey which found that 74% were aware of the VERB campaign, and those 9-10 year olds that were aware engaged in 34% more physical activity per week than those who were unaware[23]. These findings were also illustrated in an incremental fashion where the highest awareness correlated with the greatest amount of exercise in comparison to moderate and least aware subgroups. Another study after two years illustrated the same dose- response effect after 2250 parent-child dyads were surveyed[24]. Yet despite such positive results, the end of the VERB mirrored that of the TRUTH initiative when the Bush administration eradicated the federal funding so essential to its success[25].

The uncontested value of the VERB campaign lies within its framework to reach its target audience and illustrate positive behavior change. Using a brand name like VERB, coupled with sophisticated commercial marketing strategy, across every type of communication medium, made possible from great funding, is a prime example of an appropriate model application. The recipe for future public health campaigns directed towards all types of health outcomes can be this successful when the consideration of various ingredients of methods and models and properly executed.

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[8]. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Updated October 2005.
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22. National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health. Youth Media Campaign VERB. Last modified, Aug, 2007.

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25. Krisberg, K. Successful CDC verb campaign in danger of losing funding: budget cuts likely. Nations Health: American Public Health Association 2005; 35(8).

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