Analysis and Critique of BPHC Helmet Safety Campaign – Yara Tayeh

        Nationally, bicycle safety is a big concern and may be an even larger concern in the Commonwealth of Massachusetts.  According to the Center for Disease control, the annual rate of bicycle-related emergency visits is over 500,000 people in the US, and more than 700 people die as a result of bicycle-related injuries (1).  In Boston in particular, Commonwealth Avenue and Massachusetts Avenue have the highest rate of bicycle accidents, according to three surveys published by Boston Bikes in 2010 (2). Boston Bikes, a bicycle safety campaign and movement sponsored by Mayor Menino since 2007, reported in its key findings of a survey that citywide helmet usage was up to 72%.  This may seem like a high rate, but the survey also reported that helmet use among EMS calls was only 45% (3). 

Despite these overwhelming statistics, it is evident that cyclists make up a large portion of the population. According to the 2002 National Survey of Pedestrian and Bicyclist Attitudes and Behaviors survey, approximately 57 million people, 27.3 percent of the population age 16 or older, rode a bicycle at least once during the summer of 2002 (4). So how can we protect this large group of cyclists and not only encourage helmet wearing but bicycle safety as a whole?

Mayor Menino has actively been promoting bicycle safety in Boston since 2007 but The Boston Public Health Commission very recently launched a new campaign to promote bicycle safety in the city of Boston in October of this year. The campaign introduces various advertisements across high bicycle-traffic areas in Boston as well as stencils featured on bicycle lanes on major streets in the city.  The advertisements scattered around Boston feature three images of bikers.  In two out of the three advertisements, cyclists without helmets are depicted sustaining serious injuries. In the third advertisement, a helmet-wearing female cyclist is portrayed as dirtied up but virtually injury-free. The posters and stencils on city bike lanes share the same or nearly identical messages stating that there are “No Excuses. Wear a Helmet.” The goal of the bicycle safety campaign is to promote and increase helmet use in the city of Boston, with the central message that it is always safer to ride a bike with a helmet than without a helmet (5)

While the Boston Public Health Commission has just recently released this campaign for helmet safety—thus an insufficient amount of time has passed and proper steps have not been taken in order to evaluate the program—there is evidence to believe that the campaign will not be successful in increasing helmet use in the greater Boston area.  Several problems emerge when analyzing this public health approach to helmet safety and promotion.  This paper will discuss three central flaws in the helmet campaign’s design and will then proceed to explore specific recommendations aimed at improving the approach to helmet safety. 

First Critique of Intervention: Health Belief Model is not appropriate for Helmet Safety Campaign

            The Boston Public Health Commission’s campaign for bicycle and helmet safety follows the well-established and one of the most widely used public health models, the Health Belief Model (HBM), but even the most widely used model can be inappropriate when looking at the context of the issue being addressed.  The Health Belief Model asserts that health behavior is motivated by the following six factors: 1) perceived susceptibility to an issue, 2) perceived severity of an issue, 3) perceived benefits of an action, 4) perceived barriers to taking that action, 5) the presence and experience of a cue to action, and 6) the belief in one’s own self-efficacy related to the behavior in question (6).  Essentially, the HBM suggests that people behave in a rational, predictable manner and that they carefully and thoughtfully weigh susceptibility to, severity of, and barriers to an action against the perceived benefits in order to logically make a decision.  The HBM is a value expectancy model, which refers to the assumption that people will behave in a certain way if they value the outcome and if they believe that this particular behavior is likely to results in that outcome (6).

            Despite these logical assumptions, it is clear that people do not behave as rationally and thoughtfully as expected. According to several studies including a study conducted by Clayton, Cantorrelo, and Johnstone, the Drug Abuse Resistance Education program, which was largely modeled with an HBM approach, was ineffective in reducing the rate of drug use and abuse in elementary and middle school populations (7).  Among other theories, D.A.R.E. program’s entire basis revolved around student education about the severity and susceptibility of drug use and abuse and the benefits of abstaining from this unhealthy behavior, but the program was largely ineffective.  Some studies have even observed an unintended reverse effect; the establishment of the D.A.R.E program may actually have increased the rate of drug use and abuse in evaluated populations and thus the U.S. Department of Education has halted all federal sponsorships for D.A.R.E. programs (8).

            This failure in the HBM has been observed in previous helmet safety campaigns, and the Boston Public Health Commission’s recent campaign has failed to learn from previous shortfalls. Surveys conducted by the Boston Bikes have determined that the target population—mostly consisting of students at universities throughout the Boston area—simply do not wear bicycle helmets because they are uncomfortable, too hot, or result in “helmet hair” (3).  With this invaluable data, the Boston Public Health Commission should not then turn around and attempt to educate the public about bicycle safety and the importance of helmets.  Educating the public about the perceived benefits of helmet use will certainly prove to be ineffective.  Bicycle and helmet safety has been a core element in early health education in Massachusetts, but still students choose not to wear helmets (9).   It is not a matter of self-efficacy—a person’s belief in his/her ability to wear a helmet is not of concern here—but the perceived susceptibility of the individual is simply too low.  Young adult populations have been educated about the dangers of cycling without proper protective headgear, but the perceived costs of wearing the helmet seem to outweigh the benefits through the eyes of the trendy, young college student.  In human development, teenagehood and young adulthood are marked by what is called the “Invincibility theory”, which is the belief that despite perceived dangers, a life-threatening event simply will not occur to the student as they perceive themselves to be invincible (10).  Consequently, it is essential that the Commission step outside of the limiting and inapplicable spectrum of the HBM, dismiss the idea of bicycle education, and instead focus on the idea of immediately changing the behavior, which may potentially instill a change of attitude later on. 

The Diffusion of Innovations theory and the idea of a “tipping point” suggests that past a certain rate of adoption of a particular behavior, the rate of adoption will escalate dramatically (11).  The premises and assertions of this theory may be more useful for the helmet safety campaign.  It is important to convince the population of interest to change the behavior first—in this case the behavior being helmet use—and with that behavior change the adoption of a health-oriented mentality will come.  This new theory will be discussed further on.

Second Critique of Intervention: Forceful messages have reverse effects, especially on youth

An important psychological theory that must be considered when developing public health intervention is the Theory of Psychological Reactance.  According to this theory developed by Jack Brehm, when behavioral freedoms are taken away, people will respond in the opposite manner. Brehm writes:

“…people become motivationally aroused by a threat to or elimination of a behavioral freedom. This motivational state is what is called psychological reactance. It impels the individual to restore the particular freedom that was threatened or taken away. It does not impel the individual to acquire just any freedom--only the one threatened or taken away will do” (12).

When a public health campaign begins telling people what to do in a forcible manner, it is likely that the public will respond to this threat to freedom with the opposite behavior.  An example of this dilemma arises in the abstinence-only campaign implemented in several cities and states across the United States.  According to a report published by the Legal Momentum advocacy group and sponsored by Harvard School of Public Health, not only are abstinence-only campaigns wrongly created under the pretext of conservative ideologies and political motivations, they have been proven to be rather ineffective in preventing sexually transmitted diseases and pregnancies (13).  The report states that

“[w]hen youth schooled by abstinence-only programs do become sexually active, the programs’ anti-condom messages may actually discourage them from practicing safe sex, making the negative information the programs offer about contraception and disease prevention particularly dangerous. Such messages deny young people the opportunity to receive vital education to protect their health and well-being and, in particular, impede girls’ ability to avoid unwanted pregnancy and STIs to which they are more biologically susceptible” (13).  

Furthermore, the American Public Health association cites that Longitudinal studies find that although abstinence pledgers, when compared to non-pledgers, were more likely to delay initiation of intercourse, they were less likely to use condoms and other contraception after initiation; at six-year follow-up, pledgers experienced similar rates of STIs when compared to non-pledgers (14).

In addition, the efficacy of mandatory helmet laws is under speculation because what may have been perceived as increased helmet use among the population may actually have been due to the fact that a large group of cyclists simply stopped biking altogether as a result of the law.

Like many of these aforementioned interventions, the Boston Public Health Commission’s helmet safety campaign fails to take into account the Theory of Psychological Reactance.  Instead, it relies on strong, forceful language like the slogan “No excuses. Wear a helmet” to promote healthy behavior.  This is likely to be a significant shortcoming of the campaign in the future.  Rather than taking away freedom from the group, the intervention should focus on giving the population something that they desire.  Shifting directions and thinking less about campaigning and more about advertising may be just what this campaign needs (and this will be discussed further along in the paper).

Final Critique of Intervention: Inappropriate use of marketing images

The helmet safety campaign puts too grand of an emphasis on fear.  Catch phrases like “No excuses” and displaying images of bloodied and severely injured peers only strives to scare the population. Instilling fear in this target population does not seem like it will be a very effective mechanism for promoting a healthy behavior.  A study was published in the Journal of Psychology and Health that explored the use of fear arousal in health education.  It found no solid evidence that fear as a central message in campaigns and health education is an effective means to promote behavior change (15).  The study states that “fear control processes may interfere with precautionary motivation, recommends cautious and limited use of fear appeals in health promotion. It seems likely that fear arousal is less important in motivating precautionary action than perceptions of action effectiveness and self-efficacy” (15).  The authors of the study recommend cautious use of fear appeals for health educational campaigns, suggesting that campaigns may profit more from highlighting the personal relevance of threats to health and the feasibility of preventative action rather than “frightening people about the severity of outcomes following risk behavior by showing images of death and injury” (15).

By contrast, a meta-analysis performed by the Department of Communication at Michigan State University that reviewed the use of fear appeals in public health campaigns found intriguing results (16).  The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, which confirms the efficacy of the Health Belief Model for certain public health campaigns. It appears that strong fear appeals followed by high-efficacy messages are most successful in producing behavior change, whereas strong fear appeals with low-efficacy messages are met with higher levels of defensive responses (16).  In what realm does the Boston Public Health Commission’s helmet safety campaign lay?  While wearing a helmet requires little effort, perhaps this meta-analysis did not take into account the age group and the behavior in question.  It is likely that the target population is immune to strong appeals to fear because of the aforementioned Invincibility theory.  Because the population of interest has such little perception of susceptibility, then a strong fear appeal will only lead to defensive reactions and overcompensated behaviors.

Rather than relying on fear appeals, the Boston Public Health Commission should focus on marketing and appealing to the aspirations of youth. Marketing theory has been very effective in all different fields, including business, product promotion, and public health, which will be further discussed below.

A New Proposal: Redefining helmet safety in Massachusetts

Although the helmet safety campaign sponsored by the Boston Public Health Commission uses traditional designs to promote healthy behavior, there is evidence to suggest that this campaign will not be entirely successful in increasing helmet use in Boston, Massachusetts.  The following sections will propose an alternative approach to this helmet campaign, building off of and improving upon the design of the current campaign.

I propose three modifications to the campaign: 1) focus on immediate behavior change rather than trying to educate the public by providing discounted helmets to the public, 2) instead of taking the freedom away from cyclists by forcing them to obey the law with “No excuses”, promise freedom to the cyclists and give them something instead, and lastly 3) employ marketing techniques to inspire helmet use and change the face of the posters scattered around Boston.  Let us begin by individually examining each of these modifications and try to understand the social and behavioral theories that support these changes to the campaign.

First Defense of New Intervention: Change behavior, change a mind

The helmet safety campaign is largely based off of the Health Belief Model, where educating the public about the severity and susceptibility of bicycle accidents in order to promote helmet use is significantly stressed.  But we have seen how in more than one case, the Health Belief Model just does not seem to work out as well as expected, especially when dealing with youth who do not feel especially susceptible to the dangers of the road.  The Diffusion of Innovations Theory explains the pattern and rate of behavior adoption in society, which is usually portrayed by a sigmoidal curve (17).  Along the curve range people we call Innovators, then Early Adopters, then the Early Majority, the Late Majority, and finally at the very end of the curve are the Laggards (in order of early to late adopters of the behavior of interest).  In a study conducted by James Dearing, Edward Maibach, and David Buller, the Diffusion of Innovations theoretical approach was explored in promoting physical activity (18).  Among other results, the study found that in order to be effective, interventions should focus on tailoring messages according to each individual’s degree of readiness (where he/she is on the sigmoidal curve) and employ change agents to interact with potential adopters (18).  

In his book, The Tipping Point, Malcolm Gladwell writes about the phenomenon called the “tipping point”, which is the idea that explains change as not a gradual occurrence but something that happens at one dramatic moment of time; little changes can have big effects (11).  So how can we combine both the Diffusion of Innovations Theory and this “tipping point” concept to promote helmet use?

The Boston Public Health Commission should focus on providing discounted helmets to the target population, and past a certain point of behavior adoption, the use of helmets should escalate dramatically. When just a small subset of people potentially adopts helmet safety, they, in turn, will influence the vast majority of other potential adopters to use a helmet while cycling.

            The Boston Public Health Commission’s agenda has included providing $5 bicycle helmets to cyclists in the past, but students do not want cheap and unstylish headgear (5).  These helmets should be stylish and have a slightly aerodynamic shape so as to be more aesthetically appealing.  It is important that the helmets are fun and sleek, but still of the highest and safest quality. The helmets can even be designed to have built in compartments made of breathable material—perhaps built in headphones—that does not jeopardize the safety of the rider.  If the Boston Public Health Commission focuses on making the helmets more fashionable and appealing, then perhaps more people will begin wearing the helmets.  Another strategy could be to pay public health professionals to cycle around Boston while sporting these fashionable helmets.  The more these helmets are sighted, the more likely observers will be to begin wearing helmets until the number of peoples wearing the helmets will pass the “tipping point” and escalate dramatically.

Second Defense of New Intervention: Advertising for freedom

The Advertising Theory can take the idea of providing discounted helmets one step further.  Not only should these helmets be stylish, they should display one single word on them—a word that the bicyclists themselves can choose.  For example, a bicyclist can either custom-make the helmet by selecting a word that holds great meaning for him/her (such as “hope” or “freedom” or “courage” or the name of a significant other or perhaps a loved one who has passed) or he/she can choose from a range of helmets with a range of statements.  Imagine how these helmets can immediately transform from unstylish and annoying to equipment that symbolizes the ideals and system of beliefs of the wearer.  The helmets can become symbols of youth, independence, originality, and most of all freedom.  Students will want to wear their helmets in order to proclaim to the world what they stand for and compare their symbols with others.  Imagine if one cyclist reads the word on another’s helmet and this ends up striking up a wonderful conversation between two strangers.  The helmets can come to symbolize and expand the social lives of those who wear them.

Advertising Theory focuses on meeting the needs and desires of the intended audience, promising the audience that they will be or feel a certain way if they adopt this particular product or behavior (19).  These helmets potentially make promises of freedom, uniqueness, and expression to consumers.  Relying more on Advertising Theory quickly bypasses any sort of psychological reactance that may occur as a result of strong, forceful messages (“No excuses. Wear a Helmet”) and instead empowers bicyclists to take control of their own lives.  This change in campaign design may significantly improve rates of helmet usage in Boston.

Final Defense of New Intervention:  Appealing to aspirations

Lastly, let us take a look at Social Marketing Theory and see how it can apply to and support the modified helmet safety campaign.  Social Marketing Theory is based on the idea that the behavioral and social change of interest should be reframed and repackaged in such a way so as to make it more appealing and more tailored to the target beneficiaries (20).  Public health professionals must focus on tailoring the message according to the needs and values of the audience, as well as appealing to the population’s preferred channels of communication (20). 

Social Marketing Theory has been found to be the most effective model used to influence behavior change, specifically in regards to sexual health (21).  The Hombres Sanos, a social marketing campaign aimed at the promotion of condom use and HIV testing for Latino men and women, was well-received and showed promising results.  This campaign employed social marketing techniques—which involved consumer-centered, culturally sensitive communication, branding and catchy slogans, as well as visual media such as appealing and humorous posters—in order to promote condom use and HIV testing (20).  The campaign really focused on the population’s interests and aspirations, molding its message and tone to fit the needs and values of Latino men and women.

So how can we employ social marketing techniques in order to increase helmet safety in Boston? The helmet safety campaign should appeal to the aspirations of the youth that are not wearing helmets via various media used by youth.  What do young, college-level adults aspire for?  What do cyclists aspire for?  Let us return to the idea of freedom and fun introduced earlier in this paper.  College students usually strive for independence, fashion, and a good time, and we know that helmets do not necessarily evoke any of these values.  How can we transform perceptions of bicycle helmets?  Building upon the proposals mentioned earlier, public health professionals should focus on advertising for the new, trendy bicycle helmets using empowering and stylish posters scattered around Boston as well as utilize social media as a means of communication.  These posters and advertisements should be catchy and appeal to the motivations of freedom and independence, branding these helmets as tools for expression. All materials for the campaign should be consistently branded under the concepts of independence, strength, and empowerment.  The helmet brand could be called ‘Xpression’, which emphasizes that these helmets are not just for safety but mainly for the freedom of expression.  Envision an electric poster that shows the silhouette of a man or woman on a bike with the words “strength” or “fierce” or the catch phrases “I am my own person” or “keep smiling” imprinted on his/her helmet.  The poster will display a single phrase on it “Xpression: what defines you?”  This poster would strike the average college student more than an image of a young adult male covered in blood after a bicycle accident.

            Overall, the Boston Public Health Commission’s helmet safety campaign can be improved by using and modeling after theories such as the Diffusion of Innovations Theory, Advertising Theory, and Social Marketing Theory.  “No Excuses. Wear a helmet” just does not sit well on the tongue, but a campaign that revolves around empowering youth while still remaining fashionable and easily adoptable may just be what Boston has been waiting for all this time.

REFERENCES

(1) Center for Disease Control and Prevention. Bicycle Related Injuries. Atlanta, GA: Home and Recreational Safety, 2009. http://www.cdc.gov/homeandrecreationalsafety/bikeinjuries.html
            (2) The Daily Free Press. Bike initiatives aim to increase cyclist’s safety. Boston, September 2012. http://dailyfreepress.com/2012/09/20/bike-initiatives-aim-to-increase-cyclists-safety/
            (3) City of Boston. Bike Statistics. Boston, MA: Parks and Recreation Department, 2010. http://www.cityofboston.gov/bikes/statistics.asp
            (4) Pedestrian and Bicycle Information Center. General Bicycling Statistics. North Carolina: University of North Carolina Highway Safety Research Center. http://www.bicyclinginfo.org/facts/statistics.cfm
            (5) Boston Public Health Commision. Helmet Safety Campaign. Boston, MA: Injury Prevention, 2012. http://www.bphc.org/programs/cib/healthyhomescommunitysupports/injuryprevention/Pages/HelmetSafety.aspx
            (6) Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
            (7) Clayton RR, Cattarello AM, Johnstone BM. The effectiveness of Drug Abuse Resistance Education (project DARE): 5-year follow-up results. Preventative Medicine, 1996; 3: 307-318.
            (8) Hanson, D.J. Alcohol Abuse Prevention. Drug Abuse Resistance Education: The Effectiveness of DARE. Potsdam, NY, 2007.  http://www.alcoholfacts.org/DARE.html
            (9). Mass Ride. Safe Routes to School Funding in Massachusetts. Massachusetts: Safe Routes to School National Partnership, 2012. http://www.saferoutespartnership.org/state/srts-in-your-state/massachusetts.
            (10) Jack, M.S. Personal fable: a potential explanation for risk-taking behavior in adolescents. Journal of Pediatric Nursing, 1989; 5:334-338.
            (11) Introduction. In: Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown and Company, 2000, pp.3-14.
            (12) Brehm, J.W. Psychological Reactance: Theory and Applications. Advances in Consumer Research, 1989; 16, 72-75.
            (13) Legal Momentum: Advancing Women’s Rights. Sex, Lies, & Stereotypes: How Abstinence-Only Programs Harm Women and Girls. New York: Committee on Oversight and Government Reform, 2008.
            (14) American Public Health Association. Abstinence and U.S. Abstinence-Only Education Policies: Ethical and Human Rights Concerns. Washington, DC: Advocacy and Policy, 2006.
            (15) Ruiter, R., Abraham, C., Kok, G. Scary warnings and rational precautions: A review of the psychology of fear appeals. Psychology and Health, 2001; 16:6.
            (16) Witte, K. and Allen, M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education and Behavior, 2000; 27:591.
            (17) Dearing, J. Applying Diffusion of Innovation Theory to Intervention Development. Research on Social Work Practice, 2009: 19:503.
            (18) Dearing, J., Maibach, E. and Buller, D. A Convergent Diffusion and Social Marketing Approach for Disseminating Proven Approaches to Physical Activity Promotion. American Journal of Preventative Medicine, 2006; 31:4.
            (19) Grier, S. and Bryant, C. Social marketing in public health. Annual Review of Public Health, 2005; 26:319-339.
            (20) Andreasen, A. Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. Jossey-Bass, 1995.
            (21) Cardeno, A. et al. Marketing HIV Prevention for Heterosexually Identified Latino Men Who Have Sex with Men and Women: The Hombres Sanos Campaign. Journal of Health Communication: Health Perspectives, 2012; 17:6.

Distracted Driving: The Plight of Teenagers and Texting

Distracted driving has become a serious issue in this country; vehicular accidents can easily occur when drivers are doing something other than focusing on driving. With the rapidly rising popularity of cellular phones, their use in the car has increased as well. Talking on the phone while driving is problematic, however, texting while driving is even more problematic as that requires the driver to use his or her fingers while driving, as opposed to simply holding the phone to his or her ear. In 2010, 2.052 trillion text messages were sent and received by cellular phone users (1). Texting has been the cause of many injuries and fatalities due to vehicular accidents.

            Teenagers communicate on their smart phones mostly by texting, and the rate of texting is highest amongst teenagers. Further, the rate of texting while in a vehicle is also highest amongst teenagers. Drivers aged 16 to 24 were most likely to use a handheld electronic device as was reported in a 2008 National Highway Traffic Safety Administration report (2). In a study using college students, 91% of participants reported texting while driving (3). Young drivers are new drivers and accordingly inexperienced and more likely to cause vehicular accidents, especially if they are distracted while driving. Motor vehicle accidents are the leading cause of death among adolescents and young adults (4). Thus the risk of vehicular accidents caused by distraction is greatest amongst teenagers. A Florida study on 16 – 24 year old drivers found that 87.2% stated that they use cellular phones while driving and 70.4% use hand-held phones (5). The largest proportion of distracted drivers is under the age of 20; 11% of fatal crashes involving drivers in this age group were distracted (6). Action should be taken to curb distracted driving as a whole, with a special focus on texting and driving, especially among teenagers.

Distracted.gov

            There are several existing public and private campaigns that aim not only to educate drivers about distracted driving but also to decrease its pervasiveness. Chief among these campaigns is Distracted.gov, the Federal government’s official website for distracted driving. The website includes educational information, ways to become involved, and things to do to help keep American roads safe. The website seems to do a good job of compiling and showcasing information about distracted driving, however, there are changes that could be made to improve certain aspects of the website geared towards teenagers to help them comply with the laws that govern cellular phone use while driving.

The website is designed to serve parents, teens, educators, and employers, and it is thus heavy with statistics and scientific information. On its main menu, it offers options to peruse categories such as statistics, research, and state laws. Teenagers have become accustomed to receiving information in short (and often entertaining) bursts and at a fast pace. Those teenagers who find their way to Distracted.gov would likely become bored with the presented material, losing focus, and consequently disengaging. The website does have a section with videos, something younger individuals are more likely to view. There is also a section titled “Glee Campaign” (7) which describes a partnership with the television show Glee. Glee is very popular with teenaged viewers. Aside from a distracted driving PSA video, this section of the website contains mostly additional statistics. There are web banners and infographics, but they are comprised of quotes such as “A texting driver is 23 times more likely to get into a crash than a non-texting driver” (7). The message -- which signifies someone yelling as it is all capitalized -- is very direct, but it borders on abrasive and may only incite fear in its readers. There is nothing in the Glee section showing cast members of the program. This is a missed opportunity to use celebrities as spokespeople to convey messages about distracted driving. It has been demonstrated that the success of changing the behavior of groups is tied to the behavioral model used, and that adding or changing the use of a model can improve outcomes. 

Critique 1: Eliciting Psychological Reactance

            The Psychological Reactance Theory, developed by Sharon Brehm, explains what happens when there is a perceived loss of control due to being told what one can or cannot do. As a rule, people like to feel in control and perceived loss of control can create serious effects. Control is a drive like hunger and thirst, and being in control lights up the pleasure centers in the brain. These same pleasure centers also light up when people feed their addictions. Humans are thus biologically programmed to do the opposite of what they were told not to do in order to regain control.

Many public health and safety campaigns make the mistake of triggering reactance by telling the population what they should be doing. In general, teenagers do not like being told what to do, and greatly desire their freedom. The teenage years are spent working on gaining independence from parents and other authority figures. Distracted.gov uses slogans such as “Stop the Texts, Stop the Wrecks” (8) in an attempt to reduce teens’ combining texting with driving. Therefore, telling teenagers to stop texting (because it is unsafe) creates a greater desire for them to do so, over and above their simple desire to communicate.

Further, in a posted message, Secretary of Transportation Ray LaHood states that, “There's one message we hope everyone receives loud and clear: the safest way to get from one place to another is to hang up and drive. Powering down your cell phone when you're behind the wheel can save lives - maybe even your own” (9). These messages, while certainly valid, incite reactance because they do nothing other than tell young people to stop texting and driving. Additionally, studies have shown that the more explicit the message, the more reactance it will evoke (10). The Transportation Department’s messages are extremely explicit; consequently, the level of reactance in teens is high. Ultimately, the messaging backfires on its goal and may actually encourage texting. The key to reducing reactance is the frame used to convey the message; the frame should appeal to and include the audiences’ core values. A negative frame, often used in public health, is not as successful as positive frames used in marketing and advertising.  

Critique 2: The Weakness of the Use of the Health Belief Model

            The Health Belief Model, a traditional theory developed to predict health-related behaviors (11), states that behavioral decisions are made at the individual level, weighing perceived costs and benefits. The individual incorporates perceived susceptibility and severity into the perceived benefits. While the Health Belief Model is often used in public health, it does not do a good job of addressing the necessity to change behavior prevalent in epidemics (and distracted driving is becoming epidemic) because of its underlying assumption that people behave rationally. The model also assumes that once people make a decision to change their behavior, that change will take place, making no distinction between theory and practice. This is not the case because human decision-making typically involves irrational behavior (12). Traditional behavioral models were developed in the 1960s, and were effective for one-time health-related decisions such as immunization, but have been ineffective regarding addiction and long-term changes (13). Texting has become an addiction, especially for young adults.

Teenagers may be concerned about vehicular accidents and fatalities but simply inundating them with statistics and the consequences of texting and driving does not necessarily mean they will act differently the next time they receive a text message while operating a vehicle. Assuming teenagers will change their distracted driving behavior because they have the knowledge of its dangers is similar to assuming teens will stop or (better yet) never start smoking. Adolescents’ decision-making regarding smoking is based on emotions not rational thinking (14). Teens have always participated in risky behavior and simply providing them with a plethora of information regarding the risks will, unfortunately, be ineffective in accomplishing the goal of behavioral change.

            The Health Belief Model uses the assumption that behavior is changed on an individual level. However, many teenagers are socially oriented, wanting to spend all of their time with their friends. Teenagers adopt ways of dressing, speaking, and behaving by copying each other, especially if a behavior is perceived as cool. Distracted.gov does make the attempt to address teens on a group level (rather than simply as individuals) by offering information for organizing school presentations and hosting other distracted driving events. However, downloadable information and posters to be used during these events include negative and scary messages, and more statistics.  

            Another assumption that is made by using the Health Behavior Model is that teenagers will weigh the costs and benefits of abstaining from texting and driving. Again, this is a flawed approach; if teenagers weighed the benefits of discontinuing risky behavior we would no longer have adolescent smoking, drinking, engaging in sexual activity, and the ensuing unplanned pregnancies. Unfortunately, using the Health Belief Model does not address the need to account for teenagers’ persistent irrational and group-influenced decision making.   

Critique 3: Lack of Celebrity Peers and Role Models

            Distracted.gov includes, among many other things, videos, which have become very popular especially with younger viewers. As the cliché states, “a picture is worth a thousand words” (15). Videos are far more user-friendly and easier to grasp than reading text. The majority of these videos are tragic and heart-breaking stories about lives lost to distracted drivers. Family members and friends describe the victims and also talk about how their lives were sadly taken. The videos include victims of all ages, races, and geographical locations. There is also a range of ages among the friends and family members speaking in the videos. There are many parents speaking about the loss of a son or daughter. Teenagers do speak about the loss of a friend or family member, however while they may be similar to the target audience in age, they are not familiar to their audience.  

            There are few other images of people on the website. Of these, approximately 75% are of government or law enforcement personnel. For example, there is a large image of the Secretary of Transportation on his message page. There is also an image of the Secretary shaking the hands of law enforcement agents at an event. A third image shows the Secretary speaking from a podium with officials standing behind him on the stage. It is clear that these images are present to not only identify the Secretary, but also show the department’s activities, however additional opportunistic images have been omitted. An image showing the Secretary at an anti-distracted driving event for teens, interacting with them, would have been a great choice to add to the image library.

            In addition to the lack of celebrities and role models on the website, the images of other teens involved in activities they enjoy are also lacking. The main menu of the website includes a section specifically for teens, but there are no fun group images showing teens at an event in this section. It is clear that the topic of distracted driving accidents and fatalities is heavy, serious, and no laughing matter, but inundating teenagers with that kind of atmosphere will not be effective. Websites such as the84.org and thetruth.com, both anti-youth smoking movements, have images and videos throughout the website showcasing smiling and engaged teens at events. These menu categories on the websites include games, sports, music, merchandise, and art. These are concepts that interest teens, unlike facts and statistics, although those are also included on these websites. One image on the thetruth.com’s sports section shows teens on the beach at a surfing event in Hawaii. The caption reads “(T)ruth ripping it up. We’re hanging loose and taking in the Vans Triple Crown event in Hawaii” (16). By incorporating videos of things teenagers love on their website, sporting activities for example, the campaign is able to find a way to get teens to come back to the website. Adolescent viewers will return to the site to see if videos and images of additional sporting events are posted. 

            As previously mentioned, the Department of Transportation has partnered with Glee and lists information regarding this collaboration on Distracted.gov. This is another missed opportunity as there are no images or videos of the cast members. The PSA in this section calls itself the “Glee Distracted Driving PSA” (7) but other than the Glee logo in the bottom right-hand corner of the video, there is only one other mention of Glee on the webpage. A brief paragraph describing the campaign states “Thanks to the cast of Glee for their continued efforts to raise awareness about this issue” (7). Based on what is listed on the website, the particulars of the affiliation with the television program feel sparse. 

Additional Features on Distracted.Gov Could Increase Teen Compliance

            The website Distacted.gov is put together well and offers an abundance of information geared toward distracted driving education and ways to reduce its prevalence and consequences. However, additions or improvements can be made to the website so that it may work better in interesting teenagers. Appealing to teenagers’ core beliefs of freedom and independence, affecting their predictably irrational behaviors, and attracting them with their idols are all ways that the campaign can improve its efficacy. Capturing teenagers’ interest and engaging them in the discussion of the dangers of texting and driving is an important step in increasing teens’ use of Distracted.gov and their connection to distracted driving prevention.  

            The website should revise its teen-oriented section by framing it to appeal to their core beliefs of freedom and independence. Videos, games, and images attractive to teenagers should be used, similar to the design of the website of the84.org (17). The84.org is a Massachusetts based movement working to decrease youth smoking. The website is fun, playful, and captivating to young adults. There are contests, challenges, and fun activities for teens to become involved.   

Modification 1: Freedom and Independence, Not Safety and Health

            Appealing to teenagers’ core beliefs will reduce the risk that psychological reactance is in part a cause of their continued texting while driving (18). Freedom and independence, not safety and health, are core beliefs of teenagers. The site should explain to teenagers that technology has taken away their freedom. All of the messages they send electronically and post online can be tracked. Nothing is ever deleted when one presses the delete button. Overuse of technology also takes away from face to face time that could be spent with friends and participating in fun activities. If the question is posed to teens, it is likely they would prefer to be at the mall with their friends rather than sitting alone in a room texting. We are also losing the freedom to not be inundated with messages, advertisements, and electronic jargon. Teens have so many connections on Facebook, Twitter, and YouTube, which cause them to be constantly overwhelmed by unnecessary notifications and communications. By producing messages that convey the potential loss of freedom caused by technology, youths may view texting and driving as the nemesis not the desire. Non-reactance messages need to be implicit as opposed to explicit. Conveying the ideas in a way that is subtle will be more effective than bombarding them with direct messages.

            The key to avoiding reactance is in how the issue is framed. Frames that work well appeal to the core values and beliefs of its audience (19). The truth campaign, which aims to stop youth smoking, changed its frame by replacing health with freedom and rebelling against tobacco companies. On the main page of its website, it states, “Heck, we love everybody. Our philosophy isn't antismoker or pro-smoker. It's not even about smoking. It's about the tobacco industry manipulating their products…” (16). This message is not a direct fear-inciting one that attempts to scare people into changing behaviors. It redirects blame from being placed on the smoker to the tobacco companies. Distracted driving campaigns should change the theme of their messages; blame should not be placed on young drivers texting, but on technology for taking control of our lives. Teenagers will respond to a theme of regaining control of their lives, as it stands for the freedom and independence they crave.

Modification 2: Decisions Are Not Made Rationally or Independently

            Alternative behavioral theories, unlike traditional theories, address the fact that people behave irrationally in their decision-making regarding health issues. Fundamentally, alternative models address groups rather than individuals. Two of the underlying premises of alternative models are: that a group dynamic exists and thus behavior should be predicted at the group level; and, behavior is dynamic and unplanned. Further, traditional models focus on changing attitudes first and behavior second. Alternative models have been more successful by focusing on changing behavior first and assuming that a change in attitude will follow. Based on these fundamental themes, alternative theories could be more effective in capturing the attention of teenagers and subsequently, reducing their distracted driving.

            Advertising Theory takes these themes into account and understands that change takes place on a group level and also that behavior is dynamic. The original Florida truth campaign (different from the website thetruth.com), an anti-smoking campaign geared toward teens, used these concepts to produce successful outcomes (20). Advertising Theory promises to fulfill the viewer’s deepest aspirations and supports this promise with emotionally provoking images, stories, and music.  The promise and its supporting themes are tied together by the core values of the target audience. Tobacco control advertisements have used Advertising Theory; one ad shows tobacco executives around a table laughing and makes no mention of health. The message is that smokers are being manipulated by the industry and will regain their control (an aspiration of teens) if they stop smoking.

Distracted.gov should use Advertising Theory as a basis for its website or at the very least, for the teen-oriented pages. For example, videos, posters, and brochures should be designed to appeal to teens’ desire for freedom and independence and their desire to be with their friends. The promise of the message is that teens will feel like a part of the movement to stop distracted driving; they will feel like they belong to the group. The website’s features should be branded in a way that engages the teens and provides uniformity throughout all of the material. As a group, teens will feel empowered to make the decision to stop texting and driving.

Modification 3: Familiar Messengers

            According to the principles of Communications Theory, in order for a message to be persuasive, the person chosen to deliver the message should be likable, familiar, and similar (21). For this reason, familiar speakers such as teen celebrities and iconic role models such as famous athletes should be used in videos to speak to the American teenagers. Advertising Theory uses this tactic. Many successful companies use icons as spokespeople in their advertisements; Gatorade is using Peyton Manning to endorse their products, while CoverGirl uses Taylor Swift. Teenagers look up to the iconic celebrities they follow, trying to emulate them. These famous personalities are revered by many in our society, especially impressionable adolescents.

Teenagers look up to and listen to similarly-aged celebrities and iconic role models such as famous athletes (22). Distracted.gov should add video advertisements with these icons as spokespeople. In these ads, celebrities will explain how they do not use their cellular phones while driving. The celebrities will also explain how they tell distracted drivers to stop using their phones, when they are the passengers. Teenagers viewing these commercials will more highly value the messages when they are delivered by similar and familiar individuals. For example, a compilation commercial modeled on Rock the Vote could be used (23). Rock the Vote is a movement that aims to engage youth in political awareness and build involvement. It has registered more than 5 million young people to vote (24). Rock the Vote produced ad spots that showcased approximately 15 celebrities per advertisement, such as Miley Cyrus, Miranda Cosgrove, and cast members from Modern Family to encourage political engagement.

In the proposed distracted driving prevention advertisements, celebrities such as Justin Bieber, Taylor Swift, and members of the band One Direction would speak directly into the camera, each for a few seconds. They would all deliver similar messages, such as “ I always leave my phone on the back seat and wait until I get home to text my BFF back”. Additionally, the partnership with Glee should be expanded. The cast of Glee should also have a video with short spots of each of them explaining to camera that they do not drive distracted. Images of the cast members should be posted on the webpage promoting non-distracted driving in the aforementioned ways of gaining control and freedom by putting aside their smart phones.   

Conclusion

            Usage of cellular phones will likely only increase as technology becomes an even greater part of our lives, and it becomes even more of a social norm to use electronic gadgets throughout all activities and at all times of day (25). With our increasingly busy lives, the use of a phone in a vehicle may always be an enticing prospect. Many individuals attempt to multi-task by returning texts and phone calls while commuting to work or for errands. Teenagers, used to using their phones incessantly, will likely be among the drivers that reach for their phones out of instinct. It may take many years for a significant decrease in distracted driving to be visible. For this reason, it is imperative to ensure that all audiences are targeted appropriately and effectively in order to eliminate the ubiquity of distracted driving.

REFERENCES

1.       Farris A. LOL? Texting while driving is no laughing matter: proposing a coordinated response to curb this dangerous activity. Journal of Law and Policy 2011; 36:233-259.
2.      Khan CA. Commentary: Youth risk for deadly driving. Annals of Emergency Medicine 2010; 56:186-187.
3.      Harrison M. College students’ prevalence and perceptions of text messaging while driving. Accident Analysis and Prevention 2011; 43:1516–1520.
4.      Halpern-Felsher B. Adolescents and driving: a position paper of the society for adolescent health and medicine. Journal of Adolescent Health 2010; 47:212–214.
5.      Hassan H and Abdel-Aty M. Exploring the safety implications of young drivers’ behaviors, attitudes and perceptions. Accident Analysis and Prevention 2013; 50:361– 370.
6.      U.S. Department of Transportation/Distraction.gov. Facts and Statistics. Washington D.C. http://www.distraction.gov/content/get-the-facts/facts-and-statistics.html.
7.      U.S. Department of Transportation/Distraction.gov. Glee Campaign. Washington D.C.http://www.distraction.gov/content/get-involved/glee-campaign.html.
8.     U.S. Department of Transportation. The Official Blog of the U.S. Secretary of Transportation. New PSAs Against Texting While Driving. Washington D.C. http://fastlane.dot.gov/2011/10/3-new-psas-against-texting-while-driving.html.
9.      U.S. Department of Transportation/Distraction.gov. Message from Secretary LaHood. Washington D.C. http://www.distraction.gov/content/about-us/message-from-secretary-LaHood.html.
10.  Silvia, Paul. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3):277–284.
11.   Thomas L. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.
12.  Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: Harper Perennial, 2010.
13.  Siegel M. SB721 Lecture October 4, 2012. Boston University. Boston, MA.
14.  Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
15.   Barnard F.R. Advertisement. Printers' Ink. 1921.
16.  The truth. Main page. Washington D.C. http://www.thetruth.com/
17.   The 84. Main page. Boston, MA http://the84.org/
18.  Lee G et al. The roles of self-concept clarity and psychological reactance in compliance with product and service recommendations. Computers in Human Behavior 2010; 26: 1481–1487.
19.  Torelli C and Kaikati AM. Values as predictors of judgments and behaviors: the role of abstract and concrete mindsets. Journal of Personality and Social Psychology 2009; 96(1):231-247.
20. Davis KC et al. Association between national smoking prevention campaigns and perceived smoking prevalence among youth in the United States. Journal of Adolescent Health 2007; 41: 430–436.
21.  Roskos-Ewoldsen DR et al. The influence of accessibility of source likability on persuasion. Journal of Experimental Social Psychology 2002; 38:137–143.
22. Keel A and Nataraajan R. Celebrity endorsements and beyond: new venues for celebrity branding. Psychology and Marketing 2012; 29(9): 690–703.
23. Rock the Vote. YouTube videos. Washington D.C. http://www.youtube.com/rockthevote
24. Rock the Vote. About. Washington D.C. http://www.rockthevote.com/about/
25.  Atchley P et al. Stuck in the 70s: The role of social norms in distracted driving. Accident Analysis and Prevention 2012; 48: 279– 284. 

Motivating or Stigmatizing? Addressing the Need for the Public Health Community to Promote Multi-Disciplinary and Motivating Obesity-Related Messages – Katherine Rosa

Introduction

The National Center for Health Statistics reports that 17 percent of youth under age 20 were obese in 2009-2010 (1).  The statistics are staggering, and the prevalence of obesity among youths in the United States has nearly tripled from 1980, when approximately 6% of the youth population was obese (2). Obesity is a major public health problem in the United States and other developed countries. It is associated with serious consequences for individuals in terms of higher mortality and worse health outcomes, including hypertension, elevated cholesterol levels, and Type 2 diabetes (3). Furthermore, obese children are more likely to be obese as adults, which leads to higher risks of poor health outcomes including heart disease and stroke, and diabetes cases in children have increased by one fifth since 2000 (4).  There are clear, evident, and significant consequences to early-onset obesity. The lasting effects of childhood obesity can be highly detrimental to a child’s future. Consequently, obesity-related public health interventions are needed to hinder the growing problem of childhood obesity.   

Various public health approaches to combatting childhood obesity have been implemented in the United States. One recent intervention was developed by Children’s Healthcare of Atlanta in partnership with the Strong4life campaign. A major component of the intervention was a series of black and white billboards and commercials featuring stark and blunt captions on the individual weight problems of the child in each commercial. Captions included ‘Get healthy, get moving, get a life’, ‘Fat kids become fat adults’ and ‘Being fat takes the fun out of being a kid’ (5). Atlanta’s pediatric health care system has defended these advertisements, insisting that a bold message was needed to convey the urgency of the childhood obesity rate in the state of Georgia, whose overall obesity rate is the second highest in the nation (6). Conversely, critics of this approach claim that the advertisements inadvertently stigmatize the individuals they intend to help; by stigmatizing obesity, the campaign could alienate the audience of children and families it intends to motivate and hinder the behavioral changes it means to encourage (5).

Ultimately, the approach that Children’s Healthcare of Atlanta took in its intervention strategy is based too heavily on the Health Belief Model and simultaneously fails to promote self-efficacy (7). The approach also promotes an incredible amount of weight stigma, and it fails to account for the geographic maldistribution of educational and economic resources.

Critique of the Health Belief Model

Children’s Healthcare of Atlanta’s intervention depends too heavily on the Health Belief Model.  This model primarily focuses on individual decisions and reasoning. It neither accounts for disparities in knowledge nor addresses social, economic, or environmental factors (8). The model also assumes there is a solid arrow from intention to behavior and assumes once an individual makes a decision, he or she will act (8). These assumptions are too unrealistic and simplified for a childhood obesity intervention campaign. Factors aside from individual reasoning must be considered in order to effectively intervene against childhood obesity. These factors include cultural, sociopolitical, and economic conditions which set the context for individual health experience and behavior (9). By only focusing on individual children and behavior, and in some instances including a parent, the commercials individualize the problem and inadvertently create negative implications for the way obese individuals are viewed. The Health Belief Model can taint the way individuals are viewed and, as discussed in the following section, create a stigma associated with unhealthy behavior.

Furthermore, the primary resource for change within the Health Belief Model is self-efficacy. People with greater levels of self-efficacy, or confidence, will more likely engage in a specific behavior, persist until they get it right, and maintain the behavior over time (10). Yet the commercial advertisements do not provide children or families with any tools to promote self-efficacy. Rather, they show startling images to increase the perceived severity and susceptibility of childhood obesity. Perceived severity and specificity are two concepts within the Health Belief Model. The campaign commercials specify the consequences of obesity to increase the perceived severity, but they do not recommend any action (11).  These commercials attempt to startle viewers into action, but they neglect to propose alternative, actionable behavior. They do not build any confidence in the viewer that he or she has the ability to perform an alternative behavior to combat obesity (10). In fact, the commercials entirely fail to propose any alternative behavior.

 Research has shown that messages that obese individuals find least motivating are ones that provided no specific actionable behaviors (5). This finding suggests the importance of testing messages in advance among the general public and ensuring that the responses and perceptions of obese individuals are understood and considered (5). Ultimately, this public health campaign fails because it neglects to propose alternative, actionable behavior, it does not consider the reactions or perceptions of the obese individuals whom it intends to help, and because its underlying assumptions based on the Health Belief Model are flawed.

Critique of Weight Stigma and Attribution Theory

The Children’s Healthcare of Atlanta intervention also fails because it promotes weight stigma. As previously mentioned, the Health Belief Model can negatively affect the way individuals are viewed and can create stigmas. In the case of childhood obesity, children may be viewed as inherently flawed or made to feel a great deal of shame and stigmatization. According to the Centers for Disease Control and Prevention, ‘stigma hampers prevention’ (12). A number or research studies show that experiencing weigh stigma increases the likelihood of engaging in higher calorie intake, unhealthy eating habits, binge eating patterns, and lower levels of exercise, all of which exacerbate weight gain and inhibit weight loss (5, 13). Stigma assumes the condition of obesity is under personal control

Research has also shown that the messages included in the Children’s Healthcare of Atlanta intervention, such as ‘Get healthy, get moving, get a life’, ‘Fat kids become fat adults’, ‘Chubby kids may not outlive their parents’ and ‘Being fat takes the fun out of being a kid’, were viewed as stigmatizing and did not induce motivation to engage in healthy behaviors (5). Therefore, this intervention communicated stigmatizing and shameful messages toward families struggling with obesity. These messages were perceived to be inappropriate and ineffective, and they did not promote any change in behavior among viewers.

 Stigmatization has detrimental effects on both children and adults; experiences with weight stigma negatively impact both psychological and behavioral outcomes (14). Consequently, children who experience weight stigma report they are reluctant to become involved in physical activities at school because of teasing. Teasing about weight among children is also related to lower involvement with physical activity and a preference for sedentary activities (15). A major flaw in this intervention it that it sends messages that promote weight stigma and criticism rather than showing any empathy, understanding, or alternative behaviors to consider. Instead, the message is dark, solitary, isolating, and harsh. These are not elements of a public health campaign that will enable and promote behavioral change.

Additionally, the emotional and social consequences of obesity are less detailed and not well understood. They include ‘low self-esteem, negative body image, clinical depression, and weight bias. Any action or policy that exacerbates these consequences is considered a serious ethical problem’ (16). Weight bias is the inclination of others to form unreasonable judgments based on a person’s weight; it is caused by a general belief that stigma and shame ‘will motivate people to lose weight or the belief that people fail to lose weight as a result of inadequate self-discipline or insufficient willpower’ (16). However, evidence in the literature suggests that weight stigma and bias are not beneficial public health tools for reducing obesity or improving health. Instead, stigmatization of obese individuals ‘poses serious risks to their psychological and physical health, generates health disparities, and interferes with implementation of effective obesity prevention efforts’ (13). Furthermore, because obesity is often viewed as a condition under volitional control, it is a highly stigmatizing condition. This stigmatization is in line with the attribution model of public discrimination. In this model, ‘causal beliefs about the controllability of the condition lead to an emotional response (e.g. stigmatization attitudes). Behavioral consequences in the form of discrimination result’ (17). Negative attributes associated with obesity include labeling obese individuals as unmotivated, unintelligent, and lazy (17).

Given the emotional, behavioral, and social consequences of negative causal attribution and stigmatizing attitudes, it is clear that the Children’s Healthcare of Atlanta intervention is flawed. This approach fails to recognize the detrimental effects obese children face when they are bullied, teased, and judged because of their weight. The campaign’s commercials and billboards exacerbate these problems through their stigmatizing messages.  These messages are aggressive and bullying in nature. Unfortunately, by stigmatizing obese children, this campaign effectively alienates the very children it intended to motivate. Sadly, the psychological consequences these children already face are only heightened by such a divisive public health campaign.

Critique of the Failure to Recognize Social and Environmental Inequality

Society frequently blames the victim rather than addressing environmental conditions that contribute to obesity (16). Atlanta’s public health intervention fails because it assigns blame at the individual level. The intervention fails to account for the geographic maldistribution of food and other resources. This maldistribution is a critical component of childhood obesity that cannot be overlooked.  Because obesity is especially prevalent among poor or minority groups in disadvantaged areas, obese individuals often already belong to marginalized groups and experience multiple stigmatization statuses. Consequently, the stigmatization of obese individuals is inextricably linked to social inequalities (13). Yet social inequality is never referenced in the Children’s Healthcare of Atlanta approach. Instead, the campaign focuses on individual children and families and casts a message of shame and stigma on them. The campaign’s response is limited because it focuses on individual choices regarding nutrition and physical activity and overlooks critical societal and environmental causes of obesity (13).

Research recently reported in an American Heart Association scientific statement concluded that ‘access to supermarkets, rather than only grocery or convenience stores, was 1 of 3 neighborhood factors with the strongest evidence for inverse associations’ with obesity and related lifestyle behaviors in disadvantaged populations. The other factors were availability of places to exercise and safety (18). The authors concluded that disadvantaged populations were more likely to live in neighborhoods with suboptimal availability of food stores, places to exercise, aesthetic characteristics, and traffic or crime-related safety (18). The report indicates that perceptions of overall neighborhood safety and traffic safety (eg, related to aspects of road or pedestrian crossings) were positively associated with children’s physical activity. Similarly, objective measures of neighborhood crime were inversely associated with children’s physical activity (18). Unfortunately, Children’s Healthcare of Atlanta’s public health campaign fails to account for the geographic maldistribution of food or the impact of the community environment on physical activity. The campaign provides no information on the environment in which the documented children live. It neglects to account for the geographic maldistribution of food and lack of accessibility to healthy food in disadvantaged areas. Obesity is more than an individual level problem; it is a multi-faceted problem that cannot be overcome by the stigmatizing slogans and tactics of the Children’s Healthcare of Atlanta campaign.

Introduction to Proposed Intervention

A successful intervention against childhood obesity will emphasize specific health behaviors and personal empowerment for health rather than imply personal blame and stigmatize the obese (2). Additionally, it will take on a multi-faceted approach to intervening in the complex problem of childhood obesity. The proposed alternative intervention will also understand the community it intends to serve and will work to improve environmental and academic factors that affect health behavior. Rather than aiming to achieve a specific weight target, the motivator and outcome of interest for these children will shift to health. This alternative intervention can be applied at the municipal and state levels to specifically target disadvantaged communities where obesity affects poor children disproportionately.

Defense of Intervention Section 1: Altering the Framework and Model of the Campaign from an Individual to a Community Level

Unlike the Children’s Healthcare of Atlanta campaign, the proposed intervention will be based on a general framework for the determinants of health and an ecological perspective that embraces the intrapersonal, interpersonal, and community levels of influence (9, 11).

As Marks states in his research, an effective framework for intervening in childhood obesity must realistically represent the ‘constraints upon, and links between individual, community, and societal levels of change’ (9). Unlike the Health Belief Model, which focuses only on individual level factors, a general framework for the determinants of health provides a more enhanced and nuanced perspective. This framework layers the following factors affecting the determinants of health around the individual: individual lifestyle, social and community influences, living and working conditions, and general socio-economic, cultural, and environmental conditions (9). These factors are overlooked by the Children’s Healthcare of Atlanta campaign. The campaign makes no reference to community or environmental effects. Instead, it places children and families in dark, prison-like settings where they are forced to endure the burden of obesity alone. 

Similarly, an ecological perspective emphasizes the ‘interaction between, and interdependence of, factors within and across all levels of a health problem (11). The ecological perspective accounts for multiple levels of influence beyond the individual level, for the social environment, and for reciprocal causation. The idea of reciprocal causation is critical to addressing the childhood obesity problem because it shifts responsibility away from the child and weakens the attribution model of public discrimination and stigmatization (11, 17). Instead, reciprocal causation suggests that children both influence, and are influenced by, other people and their environment (11).

The alternative intervention will acknowledge the ‘primary determining influence of society through the community, living and working conditions, and the surrounding socio-economic, cultural and environmental conditions’ (9). The alternative intervention will embrace a community setting for its commercial video messages, much like the Bring Change 2 Mind organization’s public service announcement filmed in Grand Central Station (see http://www.bringchange2mind.org/videos/entry/change-a-mind-about-mental-illness) (19). Bring Change 2 Mind’s public service announcement is effective because of its open and familiar location, because it links the individuals struggling with mental illness with supportive family and friends, and because it creates a sense of community that is caring and compassionate rather than abrasive and biased.  This type of community is not acknowledged in the Children’s Healthcare of Atlanta campaign.

However, the proposed alternative intervention will link obese children with their family and community members in order to create a supportive and self-efficacious message. Messages intended to motivate individuals to be healthier are more effective when they are framed in ways that foster confidence and self-efficacy to engage in healthy behaviors rather than in ways that imply personal blame or solitary effort (5). Thus, the proposed alternative intervention will rely on these alternative models to expand beyond educational campaigns focused on individual behaviors toward larger-scale, coordinated policies that initiate social changes to help reverse the societal and environmental conditions that create obesity in the first place (13). Specifically, family and community members will be included alongside children in any commercial and billboard advertisements. These advertisements will also be colorful and energetic instead of gloomy and depressing. These effects promote the sense of community effort and encouragement in learning and attaining better health. 

Defense of Intervention Section 2: Eliminating Weight Stigma and Shifting the Focus from Weight to Health

 The attribution of obesity to internal causes remains a major source of stigmatization and discrimination of obese individuals. Unfortunately, the Children’s Healthcare of Atlanta campaign negatively labels children and families struggling with obesity and enables this stigma. This approach creates an ideal starting point for the alternative intervention’s approach. Rather than embracing weight stigma and bias, the alternative intervention will introduce a multidimensional concept of the etiology of obesity to the public in order to reduce stigmatization (17).  The alternative intervention will clearly support measures to promote better health behavior and weight control, but it will do so without being anti-obese people.

The idea of achieving better health versus achieving a certain weight is critical to the success of the alternative intervention.  The alternative intervention will use a model that can reduce the distress associated with stigma while simultaneously empowering weight control efforts (13). A growing movement that is currently underway called Health at Every Size shifts the focus from weight management and reduction to health promotion; the primary intent of this movement is to support improved health behaviors for people of all sizes without ‘using weight as a mediator’ (20). The Health at Every Size movement effectively shifts the paradigm from weight to health. This shift is in line with research that suggests individuals, including children, may be more willing to improve their health behaviors when the focus is on health rather than measured body weight (5). The alternative obesity intervention will overcome weight stigma by specifically addressing it directly in its campaign, incorporating anti-stigma messages into its campaign, and by focusing on health as both the primary motivator and desired outcome for behavior change rather than focusing on achieving a set weight (13).

Defense of Intervention Section 3: Ensuring Obesity is Understood as a Community and Environmental Threat Rather than just an Individual Threat

The built environment has decreased opportunities for healthy lifestyle behaviors through factors such as urban design, land use, public transportation availability, density and location of food stores and restaurants, and neighborhood barriers such as safety and walkability (13). There is also increased accessibility of inexpensive foods in disadvantaged areas (13, 18). Unlike the Children’s Healthcare of Atlanta campaign, the alternative intervention understands that environmental change is essential to the solution of obesity; public health efforts must address the multiple forces contributing to the development and maintenance of obesity and recognize that individual behaviors are powerfully shaped by the environment (13).

Research shows that disadvantaged populations are more likely to live in neighborhoods with poor access to and availability of food stores, places to exercise, aesthetic characteristics, and crime prevention and safety (18). Therefore, the alternative intervention proposed will focus on strengthening disadvantaged communities, improving access to essential services, encouraging development, and working with various community and public groups (9). Specifically, this alternative intervention will supplant resources in school cafeterias. Funding will be provided for the purchase of healthier food options that meet calorie and fat guidelines. Food options that do not meet preset nutritional guidelines will be eliminated and replaced with healthy options. Curriculum will include nutrition diagrams as well as tastings of healthy snack options. The tasting is critical because it acquaints students with fruits and vegetables they have previously never seen (4). This curriculum will be a mandatory component of classroom education that all students will be required to participate in and that all teachers must teach. Teachers will be provided basic nutrition education from school nurses or the state’s public health commission office depending on city. Additionally, funding will go to the development of safe parks in these areas so that children have a safe place to play and exercise. Security will be in place to protect children and deter crime. Principals, superintendents, city representatives, mayors, and the state government will work together to oversee this process, and funding will be mandated at the state and federal level.  These tactics are a tacit attack on obesity rather than the outright verbal attack that is used in the Children’s Healthcare of Atlanta campaign. A multi-faceted yet tacit assault is necessary to reverse the trend of childhood obesity. Children, parents, schools and lawmakers need to better understand the environmental effects on health behavior and promote effective alternative behaviors.

Ultimately, unhealthy eating behaviors should be discouraged for all people regardless of weight (13). Policies that make nutritious food more affordable and improve road and landscape design to encourage physical activity are critical to the success of this alternative intervention. Direct funding to support these efforts is critical to the success of this alternative intervention.

REFERENCES

1.  Centers for Disease Control and Prevention. Prevalence of Obesity in the United States, 2009-2010. Atlanta, GA: National Center for Health Statistics, 2012.

2.  Moyer C. Stigmatizing Obesity Undercuts Effectiveness of Public Health Campaigns. American Medical News. September 24, 2012 (Accessed December 9, 2012 at http://www.ama-assn.org/amednews/2012/09/24/hlsa0924.htm). 

3.  Sikorski C, Luppa M, Brahler E, Konig H, and Riedel-Heller S. Obese Children, Adults and Senior Citizens in the Eyes of the General Public: Results of a Representative Study on Stigma and Causation of Obesity. PLoS One 2012; 7(10): e46924.

4.  Tavernise S. Obesity in Young is Seen as Falling in Several Cities. New York Times. December 10, 2012.

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