Challenging Dogma - Spring 2008

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

Thursday, May 7, 2009

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.
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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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