Wednesday, December 19, 2012

It’s Time to Stop the Childhood Obesity Epidemic: Flaws of the UK’s Change4Life Campaign Overcome by the Activ8 Campaign – Molly Vaughan

Across the world, there has been an explosive increase in lifestyle-related diseases resulting in premature mortality and chronic morbidity.  In the U.S., three of the top ten killers are cardiovascular disease, diabetes, and stroke(1); while there is a genetic component to these diseases, lifestyle and obesity play a major role as well.  Diet, smoking, sedentary lifestyles, and increased alcohol consumption are the most common behaviors that lead to chronic disease and poor health(2).
            Despite public health initiatives to decrease these unhealthy behaviors, people continue to be unhealthy(3).  In the UK, 23% of adults consume more alcohol than is recommended and 60% do not reach the recommended physical activity guidelines(2).  Adults’ unhealthy behaviors are affecting our country’s children as well.  Childhood obesity has become an epidemic, due to its presence in wide age ranges, socioeconomic groups, and various ethnic groups.  In the U.S., the overweight and obesity rates have increased from 2.3 to 3.3 times over the last 25 years; in England, the rates have climbed from 2.0 to 2.8 in only a decade(4).  These children are unfairly being set up for a lifetime of chronic illness, stigma, and even pain, as with increased obesity comes a number of co-morbities, such as diabetes, high blood pressure, chronic pain, to name a few.
            The issue of childhood obesity has been far from ignored by Public Health advocates.  A number of campaigns have been enacted over the past 10-15 years, with varying levels of success.  These range from changes at smaller scales, such as decreasing soda machines in schools (5), to larger multi-component programs that address nutrition, physical activity and other factors, such as First Lady, Michelle Obama’s “Let’s Move!” campaign (6).
                With the UK being fourth in the world in terms of obesity and with 61% of adults and 28% of children aged 2-10 overweight or obese, the British government launched the Change4Life Campaign in 2009 as the social marketing companion to the larger Healthy Lives, Healthy People campaign.  The Change4Life campaign was initially created to target parents and children ages 5-11 who were at high risk of obesity.  With a budget of 14 million pounds for the 2011/2012 year alone, it is a multi-component marketing campaign intended to, by 2020, create a sustained decrease in excess weight amongst children and adults(2). 
            The Change4Life: Eat Well. Move More. Live Longer campaign not only has a multitude of information on their website regarding physical activity recommendations, health recipes, and information for parents and families, but also has formed partnerships with businesses and neighborhood communities(2).   There have been a large number of commercials created by the brand, discussing how unhealthy behaviors (inactivity, poor nutrition, or alcohol overconsumption) can lead to poor health(7).  It has branches that have been formed by other groups, such as Cook4Life, Walk4Life, and Start4Life that are associated with the campaign.  Additionally, it has hundreds of thousands of members and has spread to other countries, such as Ireland(2).   Studies on Change4Life have shown that it has good brand recognition and has a positive message without stigmatizing overweight or obese individuals(2,8).
Critique Argument I

While there are some good initiatives within the Change4Life campaign, it is flawed in the use of an individual-based behavior change model, the Transtheoretical model.  In the most recent Change4Life marketing strategy document, the authors discuss how the campaign is loosely based on the Transtheoretical model of behavior change(2).  This model encompasses the idea that individuals move through six different stages (pre-contemplation, contemplation, preparation, action, and maintenance) to overcome a behavior, with each stage requiring different interventions in order to move the person to the next consecutive stage(9).  As individuals move toward the later stages of Action and Maintenance, they develop self-efficacy in overcoming a behavior(10).  Individuals may regress from one stage to the previous or become “stuck” at any phase along the way.  The Transtheoretical model was developed and is used often to treat addiction, such as smoking or alcoholism. 
One of the Change4Life campaign’s goals is to move people from either pre-contemplation or contemplation through the phases until they reach the maintenance phase, for both behaviors of health eating and physical activity.  They created 4 stages (Motivate, Activate, Monitor, and Recognize) based on the original six Transtheoretical model’s stages(2,10), however they do not provide specific interventions for people in the different stages of the model or enable people to figure out in what stage they are currently(2).
The flaw with using a social cognition model, like the Transtheoretical model, for reducing obesity is that these models are focused on the individual and do not always consider the social context or environmental barriers to behavior change.  Obesity is a challenging construct, influenced not only by individual behaviors, but also social stigma, socioeconomic status, geographic location, school programs, and much more.  Additionally, studies have shown that social cognition models are not as effective as theories of group behavior change, however the public health world continues to use them in ineffective campaigns(11).  The Change4Life campaign tries to influence individuals or individual families, assuming (like social cognition models) that if they are given the correct information they will be able to move through the stages of behavior change.  The Change4Life Marketing Strategy states that it “will provide information, products and tools for individuals and families who are seeking to improve their lifestyles(2).”  However, a person’s beliefs/education about a subject do not necessarily dictate their behavior.   Newer models of behavior change focus on changing the behavior first (such as unhealthy eating) and then a change in beliefs will follow(12,13).
Critique Argument II

            Whereas the developers of the Change4Life marketing campaign sought to utilize current social marketing theories, they failed to incorporate a core value other than health(2).  The backbone of a strong advertising campaign is to 1)provide a promise (Change4Life’s promise can be summed up in their subtitle: Eat well. Move more. Live longer)(2), and 2)support the promise with stories, images, and music, and 3) utilize strong core values(14,15).  The support for the Change4Life’s advertisements is adequate, as they use characters (created by the claymakers of the popular British Wallace & Gromit series) that are familiar to British audiences, but the information conveyed in the stories are not memorable for their target audience as they are based on health.  For example, one of their television ads bombards consumers with information about inactivity leading to clogged arteries(7).
Advertising and Marketing theories insist that what audiences want to see in a brand or campaign are strong core values with which they identify.  These might be freedom, control, or family, unlike Change4Life’s core value of health, which is less important to most people.  The core value of health has been used in previous public health campaigns and has failed miserably; one example is the ineffective Surgeon General’s warning on cigarette boxes that “Smoking kills(16).”   Another example is the $1 billion National Youth Anti-Drug Media Campaign, which was paired with organizations and equally widespread, similar to the Change4Life campaign.  The National Youth Anti-Drug Media campaign used similar marketing strategies of health, in this case discussing the negative side effects of drug use.  Both Change4Life and the National Youth Anti-Drug Media campaigns were able to have high exposure levels  (due to high levels of funding), but because of their use of health as their core value, they have not been able to elicit behavior change in their target audiences(17,18)  It is clear that powerful campaigns, such as Make Your Move: Nakanjani!(19), Live Up campaign(20), or Kind bars(21), have utilized more powerful promises, support, and core messages than health, which have enabled their success.
Not only does Change4Life use a flawed social marketing strategy through the use of health as a core value, but also by having an unclear target audience.  Looking at other successful youth campaigns, such as the anti-tobacco Truth campaign, it is clear that a media campaign is strongest when they have a specific audience they want to impact(14).  This allows for detailed research as to what core value will be most memorable and the most effective methods to affect change in the population(16).  Change4Life targets both young children, their parents, and middle-aged adults in their advertisements.  In a 6-month, cluster-randomized trial of 1,419 families with children ages 5-11 recruited from across England, Croker et al. found that parents in the intervention group that received the Change4Life’s Family Information packet (marketing materials) were not engaged in the program and felt that it was for their children.  Croker et al. stated, “Given that ultimately parents are being asked to implement change, being more explicit about this in the campaign messages, and measuring proximal targets of parental behaviour change, may increase the likelihood of success(17).” 
Change4Life’s lack of a clear target audience may have led to the conclusions by parents with higher socioeconomic status that the information packs were “patronizing,” with lower SES families giving higher ratings overall for the packets.   Surprisingly, the intervention group rated the importance of physical activity significantly lower at six months, as compared to the control group; there was no significant difference between control and intervention groups regarding levels of TV watching or diet at 6 months(17).  The intervention group might have been undergoing psychological reactance, which commonly occurs if a campaign tells its audience what they should do (as in eat 5 fruits and vegetables per day, which is one behavior Change4Life promotes)(2).  People inherently like control, and once they feel that it is taken away, they might do the exact opposite behavior that is wanted, as in not eat healthy foods or avoid physical activity(22).  Parents were not convinced they needed to change their child’s diet by the information presented in the Family Packet, illustrating that the individual-level targeting information by the Family Information Packet, one component of the Change4Life’s Marketing campaign, was unsuccessful in promoting behavior change(17).
Critique Argument III
Another flaw of the Change4Life Marketing strategy is that it assumes that people act rationally.  This is illustrated through their use of health as a core value and the use of an individual behavior model (Transtheoretical Model) that assumes that people act logically and rationally.  These models assume that once a person is educated on risky health behaviors, and creates an intention, the corresponding health behavior will follow.  However, past public health campaigns that have used this approach have had poor results.  For example, the National Youth Anti-Drug Media campaign uses health as their core value and bombards its target audience with health information; however, it failed to decreased marijuana usage among teens(18).  It is ineffective for people to have the health information (consider the large amount of education smokers receive about tobacco’s negative health effects and yet still do not quit); as Menashe et al. concluded, “Political battles are seldom won only on the elegance of logic, or by those who can best assemble rational arguments(16).”
There is mounting evidence that people do not act rationally and instead are swayed by social influence.  An individual’s behavior can be completely unpredictable, depending on the circumstances or their mood.  Alternative theories of behavior change pose that change more often happens at the group vs. the individual level.  In other words, take groups of people and you may be able to elicit behavior change, due to the power of social influence.  Edward Bernays, the father of the Theory of Mass Persuasion, said it best: “It’s easier to change the minds of millions than the mind of an individual.”  He believed that people are often affected by those before them and the theory of group behavioral change can be more powerful than individual behavioral change models(12). 
The power of those around us can be huge in changing our behaviors(13).  In fact, friends of children who are overweight or obese tend to gain weight themselves.  Childhood obesity is quickly becoming a social norm in our society.  Despite the fact that Change4Life’s Marketing strategy discusses alternative theories of behavioral change, it does not seem to be utilizing these principles in the campaign effectively and is wary of fully adopting alternative social marketing strategies(2).  However, it is imperative for it to embrace group behavioral change if it wishes to make a difference in childhood obesity.  As dictated by the Diffusion of Innovations Theory, small changes or small social nudges from early adopters of physical activity and health eating to another, can lead to a tipping point, at which point the targeted behavior (in this case, healthy weight in children) may become a social norm(12,13). 

Overview of Proposed Intervention: The Activ8 Campaign

            The Activ8 campaign will be a multi-faceted campaign that will strive to decrease childhood obesity by motivating the teenage population (ages 12-20) to take action against unhealthy food companies and to make a change in their daily lives.  The “8” portion of the Activ8 campaign title is due to the fact that there will be 8 teenagers from different backgrounds and ethnicities who will generate ideas for the campaign to target healthier eating and increasing physical activity.  These 8 teens will work with their communities and their teen peers to help determine the backbone of the campaign(14). They will also serve as the spokespeople for the campaign, so that the target audience feels a sense of familiarity with Activ8, and to minimize psychological reactance(22).  The Activ8 logo will feature the core 8 jumping into the air against a brick backdrop; the logo will emphasize the core 8’s energy, enthusiasm, and unity.
            The Activ8 campaign will incorporate effective ideas from other obesity campaigns, such as Move It! by First Lady, Michelle Obama, EmpowerME, and the Change4Life campaigns(6,2,23).  Due to the teenage target population, the core values behind the campaign will be control and independence.   Led by the 8 core teenagers and members, the campaign will promote youth activism in their communities and empowerment. 
Defense of Intervention, Section I

            Unlike the Change4Life campaign, the Activ8 campaign will incorporate theories of mass persuasion, and will not be based on individual behavior change.  Group behavior change has been shown in the literature to be more effective than individual behavior change(11).  Instead of attempting to change each individual person’s beliefs, the Theory of Mass Persuasion asserts that large groups of people can be influenced at once.  Starting with the core 8 teenagers, the Activ8 campaign will grow by each of the original members reaching out to groups in their community and “nudging” them to join the movement, in addition to advertising techniques(12). 
Advertising and marketing theory will be strong components of Activ8, the theories of which will be discussed in more detail in the next section.   There will be a strong social media component, such as Facebook and Twitter, which will aid in reaching large members of the teenage community.  Facebook and other social networking sites will allow followers of the Activ8 campaign to provide feedback and have an ongoing dialogue with the core 8.  It will also promote friendships to be made amongst members, as seen in the Change4Life campaign(2).
Additionally, community events will be planned that are focused around physical activity or healthy eating (although they will not be advertised that way); these may include planning a school or community garden or an Activ8 walkathon (with live performances every mile by popular singers in the teen world).  The website, in addition to information about the movement, will also have an “I’m Bored” tab, under which will be posted different physical activities for teens to do with their friends, such as planning a flashmob (instructions by Beyonce, or another known celebrity), an Activ8 wheel (based off of the Change4Life’s “Fun Generator”) with ideas such as hula hooping contests or relay races(2).  Teens will be able to post pictures of themselves participating in any of the events and “tag” photos of their friends, like on Facebook, in order to “nudge” others to get involved(12).  There will be an Activ8! tab on the website that will have local deals for joining sports classes, such as boxing or cycling, or workout tips from Olympic athletes or celebrities.  Another tab will have downloadable discounts on healthy foods that teens like and healthy recipes.
In order to make change on a larger scale, the Activ8 campaign will partner with schools and local businesses to help make activities and healthier foods affordable, much like Change4Life and Let’s Move!(2,6)  School food constitutes 51% of daily energy intake for low-income students, so this is an important area where Activ8 can have an impact on teen nutrition.  Schools can also work to incorporate more physical activity into the school day, through walking group competitions among grade levels or more physical activity-based learning(24).
            The initiatives set forth by the Activ8 campaign will help to change teen’s physical activity levels and eating practices through group and community activities that are engaging for the teenage population.  As they start to feel more healthy and energized, their beliefs about healthy eating and physical activity will start to change.  This is much more effective than the reverse, or trying to force facts on teens about healthy eating/physical activity to try to change their behaviors(12,13).
Defense of Intervention, Section II
The most important component of the Activ8 campaign is that its marketing and advertising techniques will not include the core value of health, or bombard its audience with health facts, like the Change4Life campaign.  Also, Activ8 will have a more defined target audience of teenagers, aged 12-20(2).  It will follow the guidelines of Advertising theory, with a promise of empowerment by rebelling against fast food companies, which are controlling their generation.  This promise will be framed using core values of control and independence, both that are strong for the teenage population.  Support for the promise will come directly from the 8 core teens themselves and the research they have done amongst teens; it will include powerful music, images, and stories(14,26). 
As mentioned earlier, there will be no mention of the word obesity or health(16) in the Activ8 marketing, nor will it preach to teens(14).  Like the Truth campaign, Activ8 will work with teen populations to determine what it is they want, in order to have a more successful advertising and marketing campaign(14).  As Keven Hogan describes in his book, Covert Persuasion, changing beliefs about obesity through framing and by using the core values that resonate with the teen generation will help to reinforce the ideas that eating well and taking part in physical activity aligns with their beliefs(25,16).  Hence, instead of trying to change teens by educating them on healthy habits, the Activ8 campaign will emulate their core values (control and independence) throughout its marketing strategy.
The media will be a powerful modeling tool for the Activ8 campaign and will help to combat obesity amongst teens(26).  It will not only highlight events that are taking place with the campaign, but the core 8 members will stage press releases for events during which they rebel against fast food companies.  This rebellion against sugar and fast food companies will be a major portion of the advertising and marketing for Activ8.  Like the Truth campaign, Activ8 hopes to reveal what the fast food companies aren’t telling us and how they are slowly killing us (such as how their food is processed, inhumane animal practices, and how they get us addicted)(14).   The core 8 Activ8 members and others will film an ad (similar to the Truth campaign) in which they stack body bags in front of major fast food companies; each body bag will have a disease linked to obesity written on it, such as “diabetes,” “heart attack,” or “stroke.”  In the ad, people nearby will start to notice and will be shown putting on an Activ8 shirt and helping move the body bags, with the Activ8 theme song playing in the background. 
Another Activ8 commercial idea would be to compare fast food prices to homemade food prices to show that families can afford to eat healthier food, at lower costs.  This might be done with teens performing a flashmob with a celebrity and chanting their findings in the background.  A final ad idea would be to have the core 8 members of Activ8 stuck between many fast food or dessert restaurants, scrambling to find a way out.  Once they do, they start running as fast as they can, (with their frowns turning into smiles as they feel free) until they reach a community garden with fresh food, or a farm – and help the group to make a wholesome meal together (only teenagers will be in the video).  These are just a few of the ideas that might help to promote physical activity and healthy eating using the core values that are strong for teens: independence & control.
            By working alongside teens in their communities and promoting the idea that the Activ8 campaign is run by teens only, there will be less of a chance for psychological reactance.  The anti-tobacco TRUTH campaign utilized similar strategies and had very good success, along with their effective marketing campaign(14).  The most important component of Activ8 advertising is that teens will not feel bombarded with what they should and should not do – even from other teens themselves.  By having the core 8 teens be visible in the advertising and on the website (with their 8 individual bios posted), as well as opportunities for other teens to post photos from events, there will be a sense of familiarity established, which, as Communications Theory describes, can increase influence and effectiveness of the campaign(26).  Additionally, new advertising ideas brought forward will be pilot-tested on diverse groups of teenagers, asking if it embodies the core values; for example, questions might be: “does this commercial make you feel like you are in control?” or “did this message try to make a decision for you?(27)”  In addition to gaining an understanding for the explicitness and familiarity felt by the target audience, this research will help decrease psychological reactance.  Psychological reactance is a theory that when people are told directly what to do, they tend to do the exact opposite(22).  As a result, it is very important to reduce the potential for psychological reactance in a campaign.
Defense of Intervention, Section III

            Unlike the Change4Life campaign, the Activ8 campaign embraces the notion that people do not act rationally.   In order to make a difference, particularly among teenagers, social norms about unhealthy eating and physical activity are going to have to change.  This is no small feat.  Social influence can be incredibly powerful, not to mention peer pressure amongst teenagers.  In the book, Nudge, the author discusses how “obesity is contagious.  If your best friends get fat, your risk of gaining weight goes up(12).”  Compared to 20 years ago, being overweight today has become the social norm.
            However, Activ8 aims to take advantage of the power of mass persuasion and social influence by building a group of highly influential teens (beginning with the core 8) backed by a powerful brand & logo, celebrity support, as well as an effective advertising and marketing campaign.  As Activ8 continues to grow through strong initiatives, it will eventually hit a “tipping point” followed by an upward spike in the numbers of teens getting involved, as described in the Diffusion of Innovations theory(13).  Such strong initiatives include powerful advertising revealing the truths about the sugar and fast food industries, ideas on the website for community involvement and physical activity with friends, healthy recipes and downloadable healthy food discounts from businesses, as well as ways for teens to become involved and recognized for their work through social media outlets.  Additionally, teens will feel empowered by starting their own community garden, designing a flashmob with friends, or working to create an Activ8 walkathon(2).  As with the Social Expectations theory, the media’s involvement in portraying what large numbers of teens are doing as part of Activ8 will inspire teen audiences to be more active in their communities and become part of the Activ8 movement.  The Activ8 campaign’s numerous powerful methods will ensure that it is successful in changing social norms and beliefs about obesity and physical activity among teens(26). 

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(2)  Department of Health: Change4Life marketing strategy. London: Crown Copyright; 2009.  Available at:  Accessed December 1, 2012.
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(7)  Change4Life: watch our videos.  Available at:  Accessed December 01, 2012.
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(18)          Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G.  Effects of the national youth anti-drug media campaign on youths.  American Journal of Public Health 2008; 98: 2229-2236.
(19)          LoveLife’s Nakanjani Campaign.  Available at:  Accessed December 6, 2012.
(20)         Live Up: Love. Protect. Respect.  Available at:  Accessed December 8, 2012.
(21)          KIND Bars: Our Story.  Available at:  Accessed December 2, 2012.
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(23)         EmpowerME: alliance for a healthier generation.  Available at:  Accessed November 30, 2012.
(24)         Hollar D, Messiah SE, Lopez-Mitnik G, et al.  Effect of a two-year obesity prevention intervention on percentile changes in body mass index and academic performance in low-income elementary school children.  Am J Pub Health 2010: 100: 646-653.
(25)          Hogan K, Speakman J.  Covert Persuasion: Psychological Tactics and Tricks to Win the Game Hoboken, NJ: John Wiley & Sons, Inc., 2006.
(26)         DeFleur ML, Ball-Rokeach SJ.  Theories of Mass Communications (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227.  White Plains, NY: Longman Inc., 1989.
(27)          Dillard JP, Shen L.  On the nature of reactance and its role in persuasive health communication.  Communication Monographs 2005; 72(2): 144-168.
(28)         Flay BR, Burton D.  Effective mass communication strategies for health campaigns (pp. 129-146).  In: Atkin C, Wallack L (eds), Mass Communication and Public Health: Complexities and Conflicts.  Sage, Newbury Park, CA, 1990.

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