Wednesday, December 19, 2012

Why Do Public Health Communicational Campaigns Fighting Obesity Fail? A Critique of The “Strong 4 Life” Movement- Ivi Papaioannou

          According to a 2012 report by the Institute of Medicine (IOM) (1), one third of the children in the United States are overweight or obese, and two thirds of the adults fall under the same categories. The implications of these high levels of obesity are multiple. The health consequences are well established, including cardiovascular disease, type 2 diabetes, hypertension, sleep apnea and depression. Additionally, health care costs associated with obesity- related illness are rising reaching 21% of the total annual medical spending (1). Taken into account the health, social and economic burden posed by the obesity epidemic the need for interventions is becoming of paramount importance.
          The most effective way to communicate health and nutritional information to the public is still under investigation. The goal of the policy makers is to create interventions which will be based on well established scientific data and at the same time take into account factors which might influence social behaviors (2). Moreover, mass media are dominating our lives, and thus public health campaigns communicated through the TV, radio, press, internet etc. are important components of public health interventions. Successfully, conveying a health recommendation to a well received message, is a complex procedure including different parameters like: sufficient exposure to the message, creation of a supporting environment, use of social marketing tools, assessment of exposure and at last, deep understanding of social behavior theories (3). Besides the theoretical background providing adequate knowledge for a successive intervention, the effectiveness of mass media campaigns is often questioned.
          An example of a controversial campaign is the “Strong 4 Life” (S4L) intervention (4). The campaign is an initiative of the “Children’s Healthcare of Atlanta”, to fight obesity in children. As mentioned in the website of the campaign, Georgia has the second highest rates of childhood obesity in the country and 75% of the parents seem still unable to recognize the problem. In order to address the importance of the epidemic, the movement S4L was initiated and includes several “aggressive” catch phrases in its campaign in order to awake the members of the society and motivate them to take action. Some of the messages communicated to the public are: “Fat kids become fat adults”, “Chubby kids may not outlive their parents”, “Big bones don’t make me this way. Big meals did”, “He has his father’s eyes, hid laugh and maybe his diabetes”, “Being fat takes then fun out of being a kid”, “Fat may be fun to you, but its killing me” and other. All these very direct phrases are posted under the pictures of overweight children at bus stations, billboards and many other public spaces in the state of Georgia generating a great controversy around the appropriateness of tools used for this initiative. Creators of the movement argue that the situation shouldn’t be sugarcoated and underscore that straight talk is the only solution (5). But on the other side , health experts are concerned that this type of campaign is not only ineffective but it is also damaging for the obese kids (5).
          In 2012 a one of its kind study by Puhl et al. (6) was published. The authors examined how the public perceived the messages of different mass media campaigns fighting obesity. Among the interventions included in the analysis was the S4L. The results demonstrate that among the 29 messages evaluated, those of S4L (“Fat kids become fat adults”, “Chubby kids may not outlive their parents”, “Being fat takes then fun out of being a kid”) were the less motivating and the most stigmatizing. This finding suggests that when issues of personal responsibility and blaming are implied there is less intention to comply with the intervention. S4L is an excellent example to demonstrate that even though behavioral theories should be a fundamental component of the mass media campaigns they are often ignored (3).

Critique #1: S4L stigmatizes children and fails to take into account the importance of self- esteem

There are not a few public health actors who believe that by stigmatizing bad behavior, in this case excess weight, individuals would be motivated and take action. This opinion is fully endorsed by the policy makers of S4L, as words like fat, chubby and big are the cornerstone of the “movement”. It may be a paradox, but it is believed that stigmatization may be the only solution. However, blaming individuals fighting on a daily basis with social isolation because of their weight contradicts basic assumptions of behavior theories. After all we live in a society bombarded by weight stereotypes, and if stigmatization was the gold solution the obesity rates wouldn’t keep rising. Stigma was first defined by Goffman in 1963 (7). According to Goffman stigma is a “deeply discrediting attribute” resulting in a “discounted person”. In our society the “thin norm” is promoted as it is synonymous to health, beauty and responsibility, whereas obese individuals are stigmatized by their appearance, and the visibility of fat. As a result, overweigh people are considered unhealthy, irresponsible, weak and ugly (8). In addition, it is suggested that overweight individuals tend to accept their role in the society and they function as expected by a “fat” person. They internalize the characteristics following the stigma of obesity, and they rarely challenge any negative perceptions (9). They learn to live with the stigma. By characterizing a child as “chubby” in the S4L campaign, there is a great risk that the kid will have extremely low self esteem and passively accept how the society thinks about him, as being fat and weak.
          Several studies prove the above theories in practice. It has been suggested that overweight individuals who feel bad and ashamed engage in unhealthy behaviors.  In a study by Vartanian et al. (10) in 100 female college students, participants which suffered from weight stigma had lower levels of body image satisfaction and, most importantly, were more likely to avoid exercise compared to non- stigmatized students. According to research, weight teasing among adolescents could be a risk factor for engaging in eating- disordered behaviors such as binge eating and use of laxatives (11). As an innate response to the social expectation for dieting, obese individuals may also overeat (12). It is probable that stigmatized children in Georgia  will not benefit from physical activity and will also not experience the benefits of weight loss. Even though obesity is a complex phenomenon with metabolic, genetic and social causes, nowadays mass media tend to award complete responsibility to the individual. It is highly probable that the S4L campaign in Georgia will deteriorate the physical and psychological health of overweight children. Moreover, it is expected that stigmatization will reinforce disparities. This would be of particular importance as the majority of obese kids already belong in low income or minority groups. The S4L may also mask the need for another more intuitive, efficient and effective anti- obesity intervention as other causes of obesity are overlooked. Stigmatization is a concept which needs to be addressed in public health campaigns, as it threatens both the individual and the social values (13).
Critique #2: S4L overlooks the importance of self- efficacy
          The anti- obesity messages, which are part of the S4L campaign, are certainly direct, strong and shocking. However, they lack a fundamental component of the social behavior theories, and especially of the Social Cognitive Theory (14). This component is called “self- efficacy”. Self- efficacy is defined as the “belief that one has the power to produce that effect by completing a given task or activity related to that competency”. In other words, it reflects how empowered and capable someone feels in order to reach a goal. It is hypothesized that a positive results is produced if the situation is mastered. At this point it is important to distinguish between self- efficacy and self- esteem described above. Self-esteem is associated to self- worth, whereas self- efficacy is the perception of the ability to achieve a goal (14). Moreover, according to the theory of self- efficacy, the more someone believes he can achieve a goal, the more likely he will put much effort and will persist in achieving it. In the case of the present S4L obesity campaign, children are poorly empowered to engage in a persistent behavior to fight obesity. Again, the focus of the S4L is to present raw facts and it doesn’t allow for motivation and goal setting. Given these characteristics of the S4L, children are less likely to set any proximal or distal goals, and thus reduction in calorie intake and weight loss will not be achieved (15). A common feeling of obese children, exposed to messages for “fat kids”, could be the creation of failure scenarios, resulting from doubting their capability to achieve weight control. Procrastination and avoidance are other characteristics (16).
          Several studies have been performed in the domain of self- efficacy as an important contributor in weight loss. Original research was performed by Bandura and Simmon (15). In order for Bandura, the father of the Social Cognitve Theory, to test his hypothesis, he recruited a population of obese participants which were randomized in different groups of: 1) goal setting or 2) no treatment in order to achieve weight reduction. The results of this early trail contribute significant findings in the theory of self- directed change. Specifically, a motivational and self- regulatory environment was a positive risk factor against obesity. Thus, we understand that obesity was the perfect example for Bandura to evaluate his theory. Since then a number of scientific data have been published and are in accordance with these findings. A characteristic example would be the prospective study of 2006 by Linde et al (17), in which overweight and obese participants followed treatment including cognitive interventions for weight reduction. The findings suggest that during the treatment period high self- efficacy was predictive of successful weight management. However, this association was not observed during the follow-up period, after completion of the treatment. This unique finding suggests that self- efficacy is a strong predictor for the initiation of a new behavior, but if the individual will adhere to the change depends on how satisfied they may or may not be. This is an important concept to keep in mind when designing an intervention.
          The procedure of evaluating our self begins in childhood and it is an ongoing procedure. The environment created by the S4L adds has a significant effect in damaging the ego of overweight and obese children. The theory of self- efficacy fully explains why children in Georgia will eventually become obese adults who put the needs of the society above their needs.
Critique #3: S4L fails to take into account the interaction between an individual, the environment and behavior

          Social Cognitive Theory (SCT) is a useful tool for explaining the etiology of different behaviors and for designing activities that will result in attitude changes. The SCT was used in several health promotion interventions to manipulate factors influencing individual behavior (18). The SCT (19) is a multi- factorial model which takes into account self- efficacy, described above, alongside with “cognized goals, outcome expectations, and perceived environmental impediments and facilitators in the regulation of human motivation, action, and well-being”. In other words, SCT takes into account both personal and socio- environmental determinants of health, and looks at how these reflect back to the self- efficacy of the individual.
          The S4L campaign fails to take into account the conditions which contribute, or not, in the initiation of a change. By reviewing the catch phrases of the messages (ex. “won’t outlive their parents”, “take the fun out of being a kid”) one could easily conclude that no action is proposed. After been exposed to such a slogan a child, or a family, are left with no advice. Underlying the problem will not necessarily lead into action, especially in absence of solutions. Health policy recommendations should be applicable and well endorsed by the society. Recent research (6) has shown that   individuals have a positive perception about nutrition campaign messages, if they are focusing on specific changes in dietary patterns, for example “eat more fruits and vegetables”. Other slogans receiving high intent to comply were those including multiple health and lifestyle advices, like “Eat well. Move more. Live longer.” It is well accepted that the prevalence of obesity is higher in lower socio- economic classes. It is of great importance to understand that in many cases unprivileged populations acknowledge the problem but they don’t have the education to treat it.
          Moreover, S4L could be characterized as ignorant, because it fails to take into account the environment and the social milieu where these kids grow up. Emerging literature suggests that when planning a dietary intervention, policy makers should shift their attention from the level of the individual to the environment (20). Obesogenic environments are suggested to impact both food choices and physical activity levels resulting in positive energy balance and subsequent weight gain. In a 2011 review (20) by Giskes et al., living in a neighborhood with greater access to supermarkets and lower accessibility to takeaway outlets, was a protective risk factor against obesity. On the contrary limited access to supermarkets and increased access to fast- food was correlated with higher levels of obesity. Moreover, another predictor of obesity is living in a socioeconomically deprived area which will increase the chance of reliance to convenience stores for food supply. These data add another reason to why S4L may fail.
          With 23% of Georgia’s population living in poverty, with the median annual household income being lower than the national average ($45,642 vs. $50,443) and with minority levels being higher than in other states (21), we understand that Georgia is a state that needs particular attention when it comes to designing an intervention for obesity. There are more factors than overeating and lack of physical activity which might influence the epidemic. A shocking campaign is not the solution. Based on the social theories and scientific data presented above, it seems like S4L is predetermined to fail. A multi- disciplinary approach, tailored on the specific high risk population is considered necessary.
The Intervention: Changes proposed in the mass media campaign of S4L
          According to a 2007 review on policy making (22) for obesity there is a “cacophony” dominating the field. In other words, policy makers have not yet identified what the target of the intervention should be and as a result complex schemes of intervention are proposed. This is highly attributed to the multiple causes of the disease. In anti- tobacco campaigns the solution would be to stop smoking, but when it comes to losing weight more than one advices can be given. Furthermore, and as already mentioned in the present paper, obesity is not a problem of the individual anymore, it is the problem of our society and that is the reason why policy makers are asked to contribute in the efforts to halt the epidemic.
          The present intervention will focus on changes which can be made in the S4L to address the critical points mentioned earlier in the present paper. The main focus will be on messages included in the campaign, and how these could become effective, while in accordance with the social theories for behavior. Before describing the main points of the campaign, it is important to identify our goal and our population. The ultimate goal is to lower the prevalence of childhood obesity in Georgia, the state with the second highest levels of childhood obesity in the US. Our main target population is children from families with a low socio- economic status (21). However, because it is difficult to create a different campaign for each target group (18), we assume that our intervention will have as recipients all groups involved in the obesity epidemic, from obese children and their families, to political actors, producers and food industries.
          The most important component of the proposed campaign are the messages adopted. The “slogans” should: have an explicit point in relation to why people may- or may not- engage in certain behaviors, be specific and give advice for actions instead of including general guidelines, provide easy to follow “how” and “when” information, encourage positive behaviors instead of discouraging bad ones and appear to the irrational part of the brain rather than the rational (18). How to frame the issue is critical. It is suggested that focusing on the benefits to gain, as well as recommending a specific solution are positive elements of such a frame (18). Moreover, research (6) has shown that people are positively predisposed to messages which do not emphasize on the word “obesity”. Again, focusing on the overall health of the body rather than the weight seems to be more effective. Taking into account these guidelines, some of the messages which could be incorporated in S4L are: “You have the power to do it, walk to school and change your life”, “Eat health, walk more, live better”, “Want to help your kids? You can! Cook more at home, exercise all together, enjoy family time more!”, “Take action! Make half of your plate fruits and vegetables”, “Want to eat healthier and cheaper? Make a small step and start using frozen vegetables”, “Add a fruit in every meal! Make a small change in your plate, make a big change in your life”, “Eat cheap, cook at home! Join the cooking classes at S4L”, “Give your child a better life! Learn what healthy eating involves S4L community cooking classes”, “Take action! You talk to your parents about 10 teaspoons of sugar in you soda can! Learn more at”, “You chose what to eat for dinner! Visit and help your parents make a healthier visit at the supermarket” and “Help your child have a healthier life. Join the S4L movement” (6). In order to take into account any rational disparities, and acknowledging that obesity levels among Latinos are skyrocketing, it would be a good idea to have some of the slogans in Spanish.
          Another component of the campaign is where are these messages going to be included? Young kids and more affluent and educated individuals tend to spend more time on the internet, while adults and poorer people respond better in printed material. Television is uniformly effective for all groups (18). In the present campaign exposure theory will be considered. According to this theory, “variation in exposure of a message, is more important than variation in the quality of a message” (23). Moreover, the more a person is exposed to a message the more likely it will take action, frequent exposure to a slogan increases the chances of reaching the individual in a state ready to receive it and finally, a message repeated multiple time and by various sources appears important. The intention of the present campaign would be to maximize exposure of the messages through: billboards, bus stations, public transportation, schools, playgrounds, tv adds, movie theaters, magazines, web, even public restrooms!
          In the next three sections the present analysis will go into the specifics of the intervention in order to address the issues which came up during critiques 1, 2 and 3 according to the principles of social behavior theories.
Defense #1: Combat the stigma
          “Fat” kids are definitely stigmatized for their whole life by reading with big bolded letters that they are at risk to die. Specific steps and ideas should be implemented to combat the formation of stereotypes. Firstly, as already mentioned, emphasis should be given in the overall health of the individuals. A recent study (24) suggests that obese individuals, who were metabolically healthy, had a better prognosis for mortality and morbidity compared to the metabolically unhealthy subjects. Thus the slogans of the intervention do not set as a goal losing weight but improving health and enjoying a better quality of life. After all, healthy dietary practices are beneficial for the population as a whole and not only for obese individuals.
          Secondly, in the S4L campaign pictures and testimonies of existing children are included. This could be the ultimate form of stigmatization, as you can watch the 10 year old school- kids calling themselves fat. It seems that these children have learned to live with this stereotype, and they have passively assumed the role our society has chosen for them. As an effort to change the components of the original S4L initiative, I would substitute the pictures of overweight kids, with drawings- sketches of normal weight children and adults promoting healthy attitudes.
          Another approach to stigmatization, moves responsibility from the individual to the “social justice” (25). According to this hypothesis a conductive social environment should be created, and this should eliminate disparities. All the individuals in the society should have equal access to resources to fight the obesity epidemic (ex. education, supermarkets, fresh produce). In terms of the present intervention, this could be part of a multidisciplinary approach of a general anti- obesity policy, accompanying the S4L slogans. It is only after the reallocation of resources is achieved that an individual can assume any responsibility about being overweight. Moreover, again in a more general spectrum, stigma could be combated through legislation against weigh discrimination, at school, work environment or health care (13).
Defense #2: Promote self- efficacy
            Depending of the feelings of the individual, responsible/ irresponsible, attractive/ unattractive etc, one is going to act accordingly. Thus, the messages of the intervention should focus on how the individuals can take action. Such empowering messages include phrases like:  you have the power to do it, you can!, take action! , make a small change, give your child a better life! etc. By creating an image of responsibility and capability about one’s self this will be turned into reality, and overweight children and their families will find the emotional strength to make a small change for themselves or for their loved ones (26).
            A characteristic example of how mass media campaign may result in significant weight loss of obese participants is the BBC’s “Fighting Fat, Fighting Fit” (FFFF) campaign(27). In this large scale intervention (N= 2,112 at follow up), participants were exposed to the main message of the campaign (“fight obesity with small and permanent changes to diet and exercise”) for 7 weeks through the BBC network. One of the cornerstones of the campaign was promoting self- efficacy, self- monitoring of behavior change and encouraging participants to take action, join groups, and make life- style changes by using the resources available in the community. According to the findings, 75% of the individuals experienced some weight loss and increase in their physical activity. The take home message of this study, which could apply to the present S4L campaign, is that repeated exposure to an empowering message can actually be beneficial for weight management.
            VERB was another successful intervention, managed by the Department of Human and Health Services and the Centers of Disease Control and Prevention (28). This mass media campaign was designed to empower twins and engage them in physical activity. The VERB initiative contributed significant results and provided guided for future research. One of the implications of VERB is that “persuasion should be used beyond education”. This is a component also adopted in the proposed catch phrases of the modified S4L , as many among them aim for the irrational part of the human brain (ex. Want to help your kids, change your life, live better, make a big change in your life).
            It has also been suggested (17), that high self- efficacy itself is not an adequate predictor for weight loss. Self- efficacy may promote weight control behaviors, which effectiveness is not guaranteed. As a result, the messages used to empower receptors of a campaign should be carefully chosen, and should have high specificity (ex “make half of your plate fruits and vegetable”, “exercise for 30 minutes on a daily basis”, “visit our website etc.”). In other words our modified intervention will focus not only in motivating our target groups, but will also provide guidance to engage themselves in effective practices.
Defence #3: Take into account the social milieu, and adopt a multidisciplinary approach

          Shifting our attention from the individual to the environment begins with framing the issue differently in a mass media campaign. It is the society’s role to create an environment in which it will be easier for the obese individual to make a healthy choice. This would include not only motivation to consume more fruits and vegetables, but also making them more accessible as a part of a multidisciplinary policy (29). Part of this notion could be the solutions provided to low income families (ex. “Want to eat healthier and cheaper? Make a small step and start using frozen vegetables”), and the translation of the messages in Spanish.
          Moreover, policy campaign terminology should evolve. Excess weight should be associated with the context in which the behavior occurs, in other words with the environment and the circumstances. In the specific milieu the individual should become aware of which are the healthier choices (ex. fruits and veges, cook at home), what does more active mean, etc. Additionally, using descriptive phrases such as healthful eating are considered effective (29).
          The obesity campaigns are at the point where tobacco campaigns were 30 years ago. After many years tobacco policy makers learned how to distribute the responsibility between the individual and the society. By now, it is clear that smokers should make a great effort to quit smoking, but at the same time social actors should provide a smoking-free environment (29).
          Mass media campaigns are only one tool used in public health policy. In order to reverse the obesity trends a multidisciplinary approach is necessary, which will be based on a holistic approach of the system. Moving from increasing physical activity time and modifying dietary factors to concomitant changes in agriculture, food industry, taxation and education, is considered critical (22).


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