Saturday, December 15, 2012

A Critique of New York’s “Cut the Junk” Healthy Eating Campaign: Suggestions for Improvement using Social and Behavioral Theories – Lisa Martin

While obesity affects all socioeconomic groups, approximately 20% of obese Americans have incomes below 130% of the poverty level (1). Americans with an income at this level are eligible to receive federal food assistance through the Supplemental Nutrition Assistance Program (SNAP) (2). SNAP, formerly known as the Food Stamp Program (FSP), was designed to alleviate hunger by providing additional food-specific income to low-income families. Drewnowski suggests that the highest rates of obesity occur among population groups with the highest poverty rates (3). It has thus been proposed that participation in food assistance programs has contributed to the high rates of obesity among low-income Americans.
According to the Yale Rudd Center for Food Policy and Obesity, people receiving food stamps score lower on an index of healthy eating than do wealthier Americans, and also lower than people of similar income who do not receive food stamps (4). Federally funded SNAP nutrition education programs are implemented in many states to address this problem. This paper aims to critique the flaws of New York City’s “Cut the Junk” healthy eating campaign, aimed specifically at New Yorkers participating in SNAP. Furthermore, an intervention in the form of a revised campaign that addresses these flaws using social and behavioral theories is proposed for encouraging healthy eating in this population.

What is “Cut the Junk”?
Cut the Junk is a campaign developed by the New York City Human Resources Administration and Cornell University Cooperative Extension of New York City to promote healthy eating on a budget. Launched in September of 2012, the campaign included month-long ads on buses and subways, a healthy eating guide, and educational sessions at SNAP centers. The campaign attempts to teach people that it can be more affordable to eat healthy foods than it is to eat “junk” foods, and emphasizes fruits, vegetables, whole grains, and lean meats. In addition it attempts to educate individuals how to read and understand food labels and how to utilize portion control to improve their diets (5,6). While the “Cut the Junk” campaign is factually informative and visually catches the eye, there are several issues with the campaign that will potentially cause the campaign to fail. The implementation of Cut the Junk ignores several social and behavioral theories that are often critical to the success of a public health campaign.

Critique Argument One – Invoking Psychological Reactance
            The “Cut the Junk” campaign utilizes a brochure that offers healthy alternatives to popular junk foods, such as French fries, cheeseburgers, and burritos. In doing so, the brochure specifically tells readers what they shouldn’t eat and what they should. Not only that, but the title of the campaign itself orders the individual to cut something out of their lives. Restriction of something increases the desire for what is restricted. People have a strong need to be in control of their lives, and when that control is threatened or taken away by the imposition of a restriction, psychological reactance is invoked and people attempt to regain control by doing the opposite of what they are told. This behavioral theory was first evidenced by psychologist Sharon Brehm in a 1977 study that demonstrated children as young as two years of age exhibited psychological reactance in showing a preference for the toys they were told they could not have (7). This campaign is likely to have an opposite effect of the one that was intended, and result in people craving unhealthy foods even more. Freedom and control should not be threatened or taken away in any way when attempting to entice someone to engage in a certain behavior. As will be discussed in the next section, it is important for public health campaigns to capitalize on the core values that people hold in high regard, and freedom is one of the most powerful core values.  By providing images of junk foods and instructing readers not to eat those junk foods, the want for them is greatly increased.
In addition to threatening the individual’s control over which foods they can eat, the campaign also threatens control over how much is to be eaten. The phrasing of Cut the Junk’s “Portion Control” section of the brochure uses orders readers to “save part of your meal to take home” and “put some of the food away for a later meal.” While these may be useful pieces of advice, when individuals are told to do something or to not do something, their desire to do the opposite of what they are told increases in attempt to regain control.

Critique Argument Two – Framing and Rational Decision Making
            Campaigns are most effective when they frame issues in such a way that they appeal to the core values that people consider most important. As summarized by Menache and Siegel, “Message framing has been shown to influence not only public opinion, but individual behavior as well” (8). Cut the Junk fails to do this in an effective way. It exclusively appeals to the core values of Health and Economics, which are very weak core values. Some of the stronger core values that should be emphasized are Freedom, Autonomy, Equality, Security, and Hope, among others. While Health and Economics are important when we think logically, most individuals do not make decisions in a rational way, and thus campaigns must tap into their emotions. In fact, it has been shown that there is a neurological basis for presenting things in a way that appeals to emotions and core values. In a study entitled “Frames, Biases, and Rational Decision-Making in the Human Brain,” DeMartino et. al showed that “human choices are remarkably susceptible to the manner in which options are presented,” and that “the framing effect was specifically associated with amygdala activity, suggesting a key role for an emotional system in mediating decision biases” (9). This shows that decisions are often made based on one’s feelings and not on their thoughts.
            The Cut the Junk campaign focuses on logic and knowledge alone, and does very little to appeal to emotions or core values. It is even described by HRA Commissioner Robert Doar as “common-sense guidance” that sends the message that “good nutrition can both save lives and taxpayer dollars” (5).  The campaign appears to be based on the Health Belief model, which is an individualist behavioral theory assuming individuals will weigh the perceived costs and benefits of an action, and will use reason to decide whether or not to take that action (10). However, this model has strong limitations in that it does not address the fact that human decisions are influenced by many different social and environmental factors that often result in irrational behavior. It is also limited in that it puts everyone on an equal playing field in terms of having access to adequate information to make reasoned decisions (10). Although this model can be very effective for short-term decisions, it is typically ineffective for inducing behaviors and actions that are long-term, such as maintaining a healthy diet. As previously stated, people make decisions in an irrational way, often based on the emotions and the core values that are invoked by what they are exposed to. The only emotion that Cut the Junk remotely attempts to appeal to is fear, by making a few statements such as “your health may suffer,” “eating too much fried, fatty and fast food can bring on obesity, diabetes and heart disease,” and by including a cartoon silhouette of a very obese individual dumping a bag of chips into his mouth on the back cover of the brochure. The degree of fear invoked by these aspects of the campaign is very low, and it is thought that when fear appeals are too low (or too high), they do not invoke persuasion (11, 12). While there are a few hints in the brochure indicating that healthy food should be enjoyable, such “satisfying your sweet tooth” and eating slowly to savor your food and “pay attention to how you feel,” there are very few emotional aspects to the campaign, which is likely to render it ineffective.

Critique Argument Three – A Failure to Communicate
            Cut the Junk fails to utilize the psychology of communications theory effectively in its presentation. For example, individuals are more likely to be persuaded to do something if the message they are receiving is associated with positive images, and if they are in a positive state of mind when the message is delivered (13). Cut the Junk instead focuses on negative images, specifically the health risks and economic costs associated with eating unhealthy foods. The ads for the campaign are vivid images of greasy, fattening junk foods, and the brochure contains a cartoon image of an obese man pouring chips into his mouth. As discussed in the previous section, attempting to invoke fear through the use of negative images is not always effective, especially when the level of fear invoked is minimal, as in this scenario (11, 12). While there are some positive images in the brochure, they are contradicted by the negative connotations implied by the unhealthy images provided.
Another important aspect of communications theory concerning what makes messages effective is the concept of similarity. In other words, the more similar the messenger is to the audience, the more persuasive the message being delivered will be. Hovland expresses that people are likely to adhere to the shared beliefs of their “in-group,” indicating that if a message is delivered by someone from that in-group, it is more likely to be complied with by individuals who associate themselves with that group (14). Cut the Junk makes no attempt to establish similarity between the messenger and the audience. It is a message delivered by a governmental agency, and does not establish any type of connection or relationship with its audience. Because the message is clearly being delivered from an authority figure, it may potentially be viewed as condescending and invoke feelings of rebellion. There is also little likeability of the messenger when the messenger is the government or an authority figure instructing restrictions on individual behaviors. This greatly affects the effectiveness of the campaign and makes individuals less likely to adhere to the proposed behaviors.

Proposed Intervention Summary
            The intention of the Cut the Junk campaign is positive, and it utilizes visually stimulating images. However, because of the flaws discussed above, the campaign is likely to have little effect on changing the behaviors of low-income New Yorkers. Instead a revamped version of this campaign can be developed to address these problems. This new intervention will include brochures, advertisements, and educational sessions just as Cut the Junk has, but will utilize social and behavioral theories to promote greater change. The brochures and ads will be more positive in nature, and will appeal more to emotions than to logic. The way in which the messages of the campaign will be delivered will invoke less psychological reactance and will implicitly encourage people to comply. Educational programming should be available not only at SNAP-centers, but also at local community centers such as churches, schools, and parks. The details of how this campaign should be carried out are discussed in the following sections, each addressing the three specific flaws discussed above.

Defense One – Reducing Psychological Reactance
            In order to decrease psychological reactance, the language and presentation of educational materials should differ from the brochure Cut the Junk has produced. The title of the campaign should be changed so that it does not instruct people to remove something from their lives. Instead of “Cut the Junk,” a title along the lines of “Embrace Good Food” should be adopted.  Healthy eating advice should be phrased as suggestions rather than as orders to avoid psychological reactance. For example, instead of Healthy Tip #2 in the brochure saying “Choose protein foods, such as lean beef and pork, or chicken, turkey, beans, or tofu,” the tip can be re-phrased to say something like “Lean cuts of meat, as well as beans and tofu can be healthy and delicious alternatives to fattier protein sources.” Wording information in such a way eliminates restrictions and orders, and leaves the individual informed and in control. It has been suggested that using a “gain” frame and emphasizing benefits rather than costs may be more effective than “loss” frames in promoting health behaviors (15). The image comparisons featured in the Cut the Junk brochure should be eliminated, and only the healthy alternative option should be shown in the new campaign. This will reduce the reactance of people wanting something they can’t or shouldn’t have (7). While this approach is utilized in the “Snack Attack” section of the Cut the Junk brochure, it should be utilized in the other sections of the brochure as well by depicting visually appealing images of healthy foods.

Defense Two – Reframing the Issue
            The new campaign should emphasize core values that are held in higher than Health and Economics, and should not be based on logic about healthy behaviors.  One of the reasons the tobacco industry has been largely successful in promoting tobacco use is because it has associated smoking with values like freedom and autonomy, whereas anti-smoking advocates tend to emphasize science and health (16). This principle was first discovered in a study by Meyerowtiz and colleagues examining the effect of message framing on attitudes and behaviors concerning mammography (17). This same principle that the tobacco industry uses should be applied to public health campaigns such as this one in order to invoke the audience to want to engage in healthy behaviors. For example, in this newly proposed campaign, the core value of Hope could be depicted through the use of children or families looking towards a healthy and happy future, juxtaposed with healthy food. The core value of Family could be emphasized here as well. The values of Freedom and Autonomy could be utilized in such a way that individuals are depicted as free to enjoy certain activities due to their fitness and good health that result from eating healthy. Associating values such as these with healthy eating are more likely to change behaviors than bombarding audiences with facts and rational thinking about healthy eating.

Defense Three – Utilizing Communications Theory
            Communications Theory can be used in several ways to make the messages of the campaign resonate strongly with the audience. One way to do this is to feature individuals who are similar to the SNAP participant-demographics in the ads, as it is known that people are more likely to comply with suggestions from someone they find relatable (14). For example, there might be a variety of ads that have senior citizens, single moms, young adults, and working-class families, all of whom may be likely to be on food stamps, delivering the message of “Embrace Good Food” (or another positive slogan) throughout the campaign. The ads should also be place in positive environments, as communications theory indicates that individuals are more likely to be persuaded if they are in a positive state of mind when the message is delivered. It has been shown that if someone is in a state of sadness, they view themselves as less capable of performing a health-promoting behavior (13).  . In addition to the ads being placed on in public transportation, they should also be places in locations where good moods are common, including movie theaters, parks, schools and daycares, farmers markets, bowling alleys, and salons and barbershops. By doing so, the chances that individuals are exposed to healthy eating messages while they are in a positive state of mind are increased.  Additionally, persuasion is more likely if the specific images associated with the campaign are positive. The ads of the new campaign will utilize people that appear happy, healthy, and confident, featured with images of healthy and appetizing foods, rather than cheeseburgers and donuts.

            New York’s Cut the Junk campaign has the basis for a good public health campaign, but its approach needs to be re-evaluated. By emphasizing the “cutting out” of certain foods from one’s diet, the campaign is likely to invoke psychological reactance and result in a negative attitude towards the desired behavior of healthy eating. Additionally, by focusing on issues of health and economics, the campaign fails to appeal to the emotional part of the brain that is associated with changes in attitudes and behaviors. The messages of the campaign aren’t communicated to audiences in a way that is relatable or enjoyable, and thus are unlikely to have a strong impact. These flaws can be overcome by creating a new campaign with similar messages presented in a different manner. Psychological reactance can be reduced by promoting positive behaviors through suggestions and choices, rather than through demands and restrictions. The campaign can emphasize how healthy eating can be associated with strong and important core values such freedom, hope, and autonomy, rather than with health, economics, science and logic. Lastly, these messages can be conveyed in a way that is relatable and inspiring to the audience, such that being exposed to the implicit and explicit messages of the campaign will make individuals develop the desire to change their own behavior. Reworking this public health campaign could result in reaching out to more people and having a greater impact on improving the health of New Yorkers.

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