Sunday, December 16, 2012

Diabetes Risk Awareness Campaign CheckUp America May Cause Americans to “Check Out” of Behavior Change: A Closer Look at Relevant Social Science Theories to Improve Campaign Strategy - Laura Parker

Diabetes: an increasingly common word in many American households continues to burden lives with increasing severity. With twenty six million Americans diagnosed with the disease, communities face increased health care costs, further health complications, and chronic self-care practices  (1). Not only are a greater number of Americans suffering from diabetes and other negative health outcomes, but fewer Americans are exercising regularly or eating adequate number of nutritious food. Regular physical activity has decreased from 53% to 43% in the past 18 years, and eating 5 or more fruits and vegetables has decreased from 42% to 26% (2). For the at-risk population or individuals facing pre-diabetes, public health interventions are taking shape to staunch the development of the disease.    
            The American Diabetes Association (ADA), sponsored by Janssen Pharmaceuticals, rose to action to combat the intervention challenge by developing the CheckUp America nationwide campaign.  Through various media outlets (radio, TV, internet etc.), the campaign targets at-risk populations for diabetes by illuminating contributing risk factors and seeking to encourage and empower individuals to know if they are at risk and to adopt behavioral and life style changes to lower their risk.
To communicate the campaign, the CheckUp America homepage features the PSA “One Step at a Time (3).” The commercial features a slightly overweight African American man running through pastoral America. He communicates, “Gaining weight was easy, all I had to do was sit down and eat. Losing weight’s a lot harder. I have to work at it every day. But with every step, I lower my risk for type II diabetes and heart disease, and that makes every step, every choice, every day (3)…” There’s dramatic pause as the runner stops by a graveyard and the camera zooms in with intense musical accents on gravestones. He concludes with relief, “very much worth the effort (3).” From there, as the carefree man runs off into the distance, a woman explains the risks for diabetes, how to lower risks and where to go to find more information at This prevention campaign is well intentioned, but by choosing to employ traditional public health intervention theories such as the Health Belief model aimed at individuals, excluding inhibiting social determinants, and poor implementations of marketing and advertising theory the campaign may miss the mark on effectively engaging communities at the core value level and thus could see little improvement in behavior change.

Use of the Health Belief Model to Decrease Diabetes Risk Places a Heavy Burden on the Individual
            CheckUp America seeks to empower Americans who are at risk for developing Type II diabetes by encouraging all Americans to know their risk status, to understand the scope and burden of each risk factor, and upon receiving information to take incremental steps to change lifestyle patterns which in turn could help lower the risk for diabetes. This approach to behavior change follows the health belief model. Traditionally, public health practice follows the methodology of the Health Belief Model in behavior change. Through a rational cost benefit analysis the model proposes that an individual will weigh perceived susceptibility, perceived risk, and perceived benefits in decision making  (4). Once a decision has been made, there is a direct assumption that the individual will change or not change behavior based on the decision and the weighed support.
With this is mind, CheckUp America has poured heavily into the perceived risk and perceived susceptibility components of the health belief model. Once an individual learns of his or her risk status (susceptibility), the life-threatening consequences of negative behavior (perceived risk), and the benefits of changing behavior (perceived benefit) logically the individual should make the decision to take steps towards changing behavior. The PSA advertisement “One Step at A Time,” follows this logic seamlessly. Essentially the advertisement explicitly emphasizes that even though the cost to physical comfort is high and the road to behavior change is admittedly difficult, if you know the risks you will take action (increased physical exercise) to prevent the negative health outcome and death.
Unfortunately, the health belief model is flawed in its approach to truly affect change in this particular at-risk population, largely because research has shown the assumption that individuals make rational decisions does not always hold to be true (5). In a study from the American Association of Diabetes Educators, researchers found that three months after an “intensive exercise education program and behavior modification program” there was a 50% dropout rate and a 90% dropout rate after one year (6). Because well informed individuals do not always make rational decisions (5), it can be assumed that after viewing this campaign, thoroughly reading through the website so an individual would have a comprehensive understanding of risk status and would know how to lower risk through preventative behavior changes, sustained change could likely remain elusive.
Additionally, the Health Belief Model places the burden of behavior change on the individual. Research has shown that sustained change in diabetes prevention is most effective at the community or neighborhood level with multiple parties engaged (7, 8, 9). In a study analyzing various trials around diabetes prevention programs, individuals were enrolled in community weight loss programs with health care facilitators or community lay workers. Researchers found that greater weight loss was achieved within community lay-workers programs and the influence of a trusted person (1).  The burden in diabetes prevention cannot rest as heavily on an individual’s choice to change their behavior as implied in the CheckUp America campaign. Whole communities and trusted networks should come together to create encouraging environments to overcome difficult behavior change. Perhaps the road to becoming physically active and adopting other sustained behavior changes to reduce diabetes risk becomes substantially more difficult when tackled alone, so public health advocates promoting the CheckUp America campaign need to take into consideration another tactic to change behavior.

The Health Belief Model Fails to Take Into Consideration Important Social Determinants

The PSA, “One Step at A Time” assumes that sedentary Americans are gaining weight through a combination of eating and laziness; it is the choice of the individual and as such once the individual understands the risks of this behavior, they have the ability to take steps to change. By using the health belief model, The PSA through the CheckUp America campaign unfortunately ignores important environmental factors or social determinants in various American communities that prevent high risk individuals from being able to make life-altering decisions. For example, not all Americans find themselves in picturesque, safe environments in which they are able to be physically active as portrayed in the PSA advertisement. The reality is that many Americans who are faced with risk factors leading to diabetes live in urban environments with limited resources. In Boston, Massachusetts for example, there is an unequal distribution of diabetes rates dependent upon the neighborhood (10) Lower income neighborhoods have significantly higher rates of diabetes (10). Within these urban spaces, research has shown that there are associations that neighborhood appearance and safety concerns have  negative consequences on residents and have been shown to be associated with preventing individuals from being physically active outside (11). The CheckUp America campaign perhaps unintentionally ignores large portions of America’s population who do not have access to traffic-free country roads, but this does not mean they idly spend their days sitting down and eating, but engaging in physical activity is still hard. 
Furthermore the scarcity of green space in urban environments negatively contributes to physical activity. A study conducted in England showed that there is a positive association with green space and physical activity (12, 13). The environment or neighborhood can drastically limit an individual’s choice in healthy outdoor physical activity behavior as is implied in the PSA advertisement in the CheckUp America campaign. Within the health belief model, the environmental factors do not necessarily contribute to the decision made and thus behavior change. Even with a comprehensive understanding of the risks of diabetes, change may not take place if access to physical activity is limited in urban environments.
            Once an individual knows their risk status, they are advised to visit their doctor. However, not all Americans have access to health insurance or healthcare. In a study looking at health insurance coverage among three ethnic groups of diabetic adults, researchers found that while diabetes had increased among Non-Hispanic Whites, Non-Hispanic Blacks and Hispanics, a great proportion of diabetic adults lacked health insurance (14). Additionally only 30% of diabetic Non-Hispanic blacks were likely to be covered by private insurance as compared with 70% of Non-Hispanic Whites (14).  Perhaps at risk individuals do not have the same access to health insurance, or the same available capital to health care that would significantly contribute to their success in taking small steps towards decreasing risks. As the campaign suggests, it is important to know the risks that lead to diabetes, and to know one’s risk status, however once that objective is achieved not every individual will be able to effectively change their environment or access to health insurance and health care. By placing the burden of behavior on the individual through the health belief model, advocates have limited responsibility at the community and neighborhood level.

PSA One Step at a Time Inadequately Utilizes Advertising Theory

CheckUp America ineffectively delivers the campaign message through the PSA “One Step at a Time.” The campaign is framed through the lens that increased physical activity reduces the risk for diabetes and ultimately death. Framing through “positioning an issue to convey a certain meaning (15)” has incredibly important implications when delivering a powerful message through media. The core value suggested by CheckUp America is health, through the message: run or die. Death may not be the best motivator to change behavior. Research has been conducted around the anti-smoking advertising campaign in which consumers purchase cigarette packages containing graphic images of damaged lungs. The studies found that contrary to intuition, smokers in fact were not discouraged by the negative images on the packaging (16), but rather may have been compelled to increase smoking (16). The core value of health which was being promoted through the cigarette packaging with negative imagery was a poor use of advertising theory. If research was conducted around the CheckUp America campaign, potentially similar results could be found that with negative threats, people may be compelled to “tune out” the benefits of reducing the risk which could lead to further resistance of the intended healthy behavior. In research conducted on similarity, researchers found that a negative message from the speaker resulted in lower adherence to the suggested behavior (17)
From this perspective at the heart of advertising theory is aligning the product with the core value of the audience (15). CheckUp America fails to communicate viable core values in American society by choosing to promote a health frame. Having a weaker frame with a value of health could fall on deaf ears when the products and behaviors offered through other advertising agencies contribute stronger values that resonate with Americans.
Another important factor in effective advertising theory is the ability for the audience to connect with the speaker or similarity (17). While the main actor is an African American man, the person to actually communicate the risks contributing to diabetes is a woman speaking with the knowledge and sage of a health professional. In general men are less likely to respond to health professional’s advice or counsel (2). While the main actor could speak to the targeted audience, neither his motivation nor method of physical activity (jogging) resonates with a larger group of people. He frames that exercise is hard, but worth it because health and life are more valuable. This frame is ineffective for thousands of people who think that exercise is hard but do not value health. The advertisement is limited in the type of “acceptable” physical activity.
            Additionally, the campaign could be unintentionally creating an atmosphere for psychological reactance. The theory of psychological reactance is the perception of limited freedom and the response to regain that freedom (18). In a study on the effects of the National Youth Anti-Drug Media Campaign, researchers found that there was little to no effect on decrease in drug use in response to this campaign (19). More striking evidence was seen in that researchers found there was possibly an “unfavorable influence” with increased exposure to the campaign (19). It was speculated in the discussion that youth internalized that their freedom was limited, thus creating psychological reactance (19). While the intention for promoting good health is important, the communication provided by CheckUp America is similar to the sentiment in the anti-drug campaign targeted at youth. There is an explicit message that limits the freedom of a “typical” American to choose how to exercise, moreover the burden of blame falls exclusively on the individual and their poor eating choose and sedentary behavior. As was seen in the campaign targeted at decreasing drug use, public health professionals could be unintentionally limiting freedom by misguided use death as a threat for increase physical activity through advertising and marketing theories which in turn could have the unintended result of increased negative behavior.

Big Blue Test Model: A Replicable Intervention to Increase Healthy Behavior among Individuals at Risk for Diabetes

            CheckUp America is in need of a new campaign that will shift the focus away from the individual and towards a movement.  The organization should adopt a collaborative, group initiative that will captivate the values of Americans as well as allow them to take back their freedom: a life risk free of diabetes. To implement this, CheckUp America should model an initiative developed by the organization Diabetes Hands called “Big blue test (20).” The campaign was launched in 2010. While the test is aimed at individuals currently living with diabetes, the fundamental of the campaign is to increase physical exercise which will decrease blood glucose levels and prevent further health complications from diabetes. While the goal is similar to the CheckUp America campaign, the approach is innovative and effective.
In 2012 the aim of the campaign was to have 20,000 people take the “test.” The goal was reached by early November and thousands of people continue to engage in this movement. The rules are simple 1. Test your blood glucose 2. Get Active 3. Test again and then share (20). Why is this campaign so effective? There are no public health medical professionals sharing the advantages of physical activity, there are no explicit messages about the risks of inactivity for those living with diabetes, and yet thousands of people are choosing to get active. If CheckUp America collaborated with this intervention, and was able to restructure the initiative to engage the large group of Americans who are pre-diabetic or at high-risk for diabetes, in the next two years and beyond thousands of people could start engaging in physical activity far beyond the current limitations of the CheckUp America campaign.

Big Blue Test Model Focused on Group Decision Making Versus Individual Decision Making

Unlike CheckUp America which used the Health Belief Model to encourage individuals to weigh the perceived risks, benefits and susceptibility in a diabetes outcome, the Big Blue test adopts a group behavior change model. Group models overcome the limitations of individual irrationality by focusing on appealing to the masses and recognizing that individuals will follow the trend. The Big Blue test is a media campaign which appeals to a larger audience and focuses on core values of control and freedom. This method is similar to the Truth media campaign launched in Florida which saw drastic reductions in youth smoking (21).  In the Truth media campaign, researchers saw 40% reduction in smoking among middle school students and 18% reduction among high school students in two years (21). The campaign featured “youth leadership” which appeals to the ownership aspect of the psychology of persuasion and theory of cognitive dissonance. Youth took control against the tobacco industry. In a similar way people involved with the Big Blue Test media campaign who are living with diabetes are taking control and leading their cohort to be active not because they have been told to do so, but because their freedom is at stake and being physically active is the proposed solution to effectively regain control.
By using this type of media campaign, individual irrationality is reduced significantly. People are choosing to be a part of the movement, and as a result they are choosing to become active. The method of the Big Blue test also eliminates the direct line from decision to behavior. Instead those who join the movement must change their behavior first. Once the behavior is changed, ideally individuals will continue to change their attitudes regarding the benefits of being active. There is an immediate result in seeing lowered blood sugar, unlike the CheckUp America campaign which frames exercise as hard and difficult.
The Big blue test like the Truth campaign appeals to stronger core values that resonate with Americans: control and freedom. Physical activity is the road to receiving these goals. In joining a movement individuals are entering into a group mentality which empowers and supports them and removes them from isolation.
Broad and Inclusive Approach to Engage in Physical Activity Regardless of Environment

The Big Blue test employs various methods of psychological persuasion including positive associations, the theory of cognitive dissonance, and similarity which overcomes environmental barriers. The advertisement features a broad spectrum of people who are engaging in a variety of physical activities which do not necessarily have to take place outside. People are shown doing yoga, playing instruments, basketball, cheerleading, and a variety of other activities. All people are represented in this short advertisement, communicating that everyone is affected by diabetes, and everyone has the ability to engage in physical activity no matter their level or experience. All of a sudden physical activity is no longer too hard and little steps are not emphasized. The limitations to the environment are not as glaring.
In spite of not having pastoral America as the setting for the advertisement, people are engaging in physical activity. The environment featured in the advertisement is a white background so that the viewer is focused exclusively on the people and their behavior. In this way cognitive dissonance and ownership in behavior change are fostered, because viewers can take responsibility for their physical activity by becoming part of a greater movement of people who stand in solidarity regardless of environment or circumstance. Most people have the psychological perception of control or ownership (22). As such, it is important in a campaign to empower this need for control. Ownership was seen to be effective in the Truth media campaign launched in Florida (21). The similarity of circumstance is an important component of the Big blue test campaign, with a wider group of people represented in the advertisement; a wider audience is able to connect with message. Similarity is significant because in general using this approach in conveying a message will “decrease the negative force toward resistance (17).” If environmental or social factors create perceptions of resistance, having a broad group of people to convey the message in the campaign could increase adherence.

Big Blue Test Effectively Uses Advertising theory

By being a part of the greater social fabric of those at risk of suffering from diabetes, communities could be radically changed if whole groups of people decided to take advantage of the resources and protective factors to lower risk. In advertising theory, the chief aim is to sell a product which appeals to the strongest core value within the community. For the Big Blue test, the core values are control and freedom. As mentioned before, the Truth campaign had a similar appeal and saw substantial reduction in smoking rates among youth (21). Additionally, the message is not a threat to freedom as was the perhaps unintentional tactic in the CheckUp America advertisement. In a study evaluating similarity, researchers found that “persuaders are more effective when they avoid threatening persuasion (17).” The Big Blue Test stays away from the negative frame which explicitly states that the lack of healthy behavior leads to death and regret. Instead the campaign has a positive frame that shows people who are living with diabetes to be truly alive, free and able to enjoy being active. The campaign gives room for freedom of choice and control which is lacking in the current CheckUp America campaign.
The advertisement has strong support, another important component of advertising theory. Elliot Yamin, a popular musician who has diabetes is featured, and there is empowering, relevant song called Let’s Go Home by Carousel with lyrics that say, “We can take this road, let’s go home. All those dreams we know. We could take this road on our own. All those dreams we know. All those dreams won’t go. I won’t let it go. I’m taking control. I want you to know, you’re already home (23).” The music as well as the popular musician featured resonate with the viewer as well as lend implicit support to the core values of control and similarity. Those a part of the movement are not on their last legs at death’s door even though they have diabetes- this is a completely contrary message that is communicated in the CheckUp America media campaign. A group of at-risk people in some ways are united by diabetes are taking a stand against their limited freedom by being physically active. The CheckUp America campaign should be advised to adopt a similar approach to truly meet the audience whom they are currently, perhaps unsuccessfully, hoping to empower.


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