Challenging Dogma


...Using social sciences to improve the practice of public health

Tuesday, April 24, 2007

The Health Belief Model: Intention is Not Enough to Stop the Growing Epidemic of Obesity – Katie Irving


The epidemic of obesity continues to grow into a leading public health problem in the United States. Despite multiple public health campaign’s attempts at halting the epidemic, between 1991 and 2001 the prevalence of obesity increased by 74% among adults aged 20 years and older (1). The failure of most current initiatives to fight obesity is their reliance on the social and behavioral model called the Health Belief Model.


Education Campaigns
The Health Belief Model focuses on health education and individual behavioral change. In order to accurately weigh the risks and benefits of one’s actions, an individual must be given the knowledge about the risks of their behavior so they can develop an intention to make positive behavioral changes. This intention translates into behavioral change. The model assumes an objective thought process and that people generally have the desire to be healthy. Though intention is crucial to any change in one’s lifestyle, it is not as methodical as the Health Belief Model predicts (2). One must also believe that it is possible to change and must be given the tools to solidify that belief. The public health initiatives utilizing the Health Belief Model have been missing the link of acknowledging the subjective thought process of the individual and the multiple environmental factors that feed into an individual’s ability and desire to change their behavior.

Two programs that use the Health Belief Model to fight obesity are the Massachusetts Metro West Campaign and the Florida YEAH! Campaign. Both of these campaigns focus on educating the community about the health risks related to obesity in order to halt the growing numbers of obese children and adults within the community. Due to these campaigns’ focus on the Health Belief Model, they fail to recognize the environmental barriers to behavioral change, the need for social support, and the importance of self-efficacy.

The Metro West and the Florida YEAH! Campaigns are education interventions. The Metro West Campaign is in the Metro West area of Boston, Massachusetts. It has a website as well as billboards around the community with photographs of obese children and the health risks associated with obesity. The program goal is “to educate children and families in Metro West about the health risks associated with obesity, encourage them to consult with professional health care providers and promote healthy food choices and physical activity”(3). Their website provides links with tabs for “getting active,” “eating healthy,” and “ask the experts.” They also have three sites – one for kids, one for adults, and one for schools. One flaw of the Metro West campaign is the emphasis on the internet campaign which will mainly reach groups who have internet at their homes. Home internet is expensive, and one of the many risk factors for obesity is low socio-economic status (4). Therefore, there is a large group of people who will not be able to access much of this information, and will only be aware of the billboards and a small amount of the educational portion about the risk factors of obesity.

The Florida YEAH! Campaign has similar goals to “focus on awareness and education of its members and partnerships with the local county health departments” (5). This campaign is not as internet based and is more focused on training youths to pass the message of healthy living onto their friends through a specific curriculum. One positive element these two programs have is the ability to raise awareness. Billboards, television commercials, and radio broadcasts will catch people’s attention. There are also clear, educated messages about obesity and its risk factors.

The education portion of these programs is outstanding. However, education is not enough. A study done on the BBC education campaign in the UK found that an education program, modeled from the Health Belief Model, had less than 1% of people actively participating. Many people remembered hearing about the campaign, but there was a clear disconnect between seeing, hearing and actually motivating to change (6). In another study no relationship was found between children’s overweight status and their degree of knowledge about nutrition. The study concluded that a lack of knowledge is not the ultimate cause of obesity (7). Therefore, one flaw in these campaigns is that education and awareness is not enough. In combination with awareness, programs must mobilize the community in effective ways through reduction of environmental barriers, increased social support and methods to encourage self-efficacy.

Environmental Barriers
Environmental barriers to weight loss contribute greatly to the rising number of obese children and adults in society. Barriers include society’s obsession with television, the internet and video games, ineffective physical education classes for children, lack of time for busy adults and busy children, food choices available in school cafeterias and affordable nutritious food choices (8). Campaigns that rely mainly on the Health Belief Model do not address these key barriers that often stand in the way of individuals making behavior changes that will lead to weight loss or decreased weight gain.

Supportive environments have been recognized as essential to an effective weight loss program (9). For example, if children are expected to eat more healthfully at school, environmental factors such as vending machines that sell soft drinks and candy are not supportive of the goal to eat nutritiously. It has been reported that 56-85% of adolescents consume soda daily because of the “competitive” foods sold at their school (10). Furthermore, 14-18 year old girls at school consumed low amounts of fruits and vegetables, and exceeded their daily intake of fat and saturated fats (10). Clearly, the environment in which children are spending the majority of their time is not conducive to making healthy food decisions.

Other environmental barriers that exist but are not directly addressed by campaigns such as YEAH! and the Metro West campaigns, are an individual’s time restraints for cooking and for physical activity, as well as the affordability of healthy food choices. Time restraints for cooking involve the parent’s availability to cook nutritious meals for the family, rather than buying inexpensive fast food or processed food from the grocery store. Some parents who must hold multiple jobs to support a family may not know how to make quick, healthy meals or may feel like they do not have the time to do so. Allocating time for physical activity can also be a barrier. Real and perceived time constraints are strong factors associated with the amount of time girls spend participating in physical activity (11). Therefore, if people do not know how to manage their time to fit physical activity into their schedule, educating them about the importance of being active will not translate into an increasingly active lifestyle.

Social Support
Social support is another important factor to promote weight loss among obese adults and children, which is not addressed in either one of these campaigns. Bert Uchino’s Social Support and Physical Health: Understanding the Health Consequences of Relationships compared weight loss interventions between individuals who were part of a support group to individuals who attempted to lose weight on their own. People who had a support network were more likely to lose weight and to keep the weight off ten months after the intervention (12). In a study of adolescent girls, the second strongest factor associated with the amount of time adolescent girls partook in physical activity was social support from friends and family (13). The Metro West campaign ineffectively attempts to address the need for social support by advising people to contact their health care providers for help. However, health care providers only have ten minutes to spend with their patients, which is clearly not enough to offer clear support. The campaign also mentions talking to a nutritionist or trainers, yet these interventions are ineffective for people who cannot afford to hire others to help them achieve their health goals. The YEAH! Campaign incorporates some social support into their program because they have children promote the healthy living campaigns. However, only the children who decide to act as peer educators receive true social support, as opposed to those being educated.

The social environment in which people live also influences their ability to live healthy lifestyles. Therefore, the emphasis of these two campaigns on individual change fails to address the need for social collective efficacy within a community. One study reported a significant relationship between community-oriented health behaviors and BMI, risk factors for obesity and prevalence of obesity, suggesting that the indirect effects of social influences and social control may contribute to a community’s distribution of obesity (14). The influences referenced are families’ awareness of one another’s behaviors; adults’ ability to express approval and disapproval to fellow community members; and adult encouragement of physical activity and healthy food choices within school cafeterias and other community locations (14). The MetroWest Campaign’s pathetic attempt at involving community through their website sections labeled ‘kids’, ‘adults’, and ‘school’ is greatly surpassed by the heavy emphasis on education. On the other hand, the YEAH! Campaign tries harder to involve the community by having children teach other children about making healthy choices. Nevertheless, both campaigns have limited attempts at community awareness due to their excessive emphasis on education which maximizes their emphasis on the individual but minimizes their effectiveness on the community.

Self Efficacy
The purpose of breaking environmental barriers and incorporating social support into an obesity campaign is to give individuals the feeling of self efficacy: an individual’s belief that they can realize their goal. Weight loss is not an easy process. People do not see results immediately upon starting a new type of diet or exercise regime, which makes behavior change extremely difficult, and causes people to feel hopeless and as if they cannot adapt to a new diet or effectively incorporate physical activity into their lives. It has been reported that strong feelings of self efficacy in children correlate with high levels of activity. In contrast to the Health Belief Model that emphasizes the individual’s perception of a behavior improving or damaging one’s health, it has been shown that health beliefs are not related to actual activity levels, whereas self efficacy is (15).

The stigma associated with obesity can contribute to individual’s low self esteem. Teenagers with low self-esteem and depressive symptoms feel that healthy lifestyles are too difficult (15). As a result, they make less healthy food choices and display less healthy behaviors compared to teenagers with higher self esteem (16). Billboards in the Metro West campaign that state: “FAT CHANCE” and a list of obesity-related illnesses do not give individuals positive emotions towards the ability to change. These billboards could potentially contribute to the stigma already associated with obesity and lead to a decrease in self esteem for many parents and children. The YEAH! Campaign’s teenage speeches from other kids who already follow a healthy lifestyle may not break through to teenagers who have never known how to follow a nutrition plan or a workout schedule. When the new behavior is so far from what an individual is used to, it is hard to believe that change is possible. A study by Roach found that when methods were used to increase self-efficacy in a 12-week weight loss program for young adults, eating habits improved and weight loss increased as feelings of self-efficacy increased (17). Neither the YEAH! Campaign nor the Metro West campaign has tools to increase an individual’s perception of self efficacy.

Conclusion
Awareness about the issue of obesity is only the beginning of an effective campaign to halt the growing prevalence of overweight Americans. Living in today’s society with many ways to avoid ever being physically active, and many cheap, fast food alternatives to a healthy home cooked meal, fighting obesity is like swimming against a current. The use of the Health Belief Model will never work to effectively change the tide; campaigns must go beyond education and incorporate ways for individuals to overcome environmental barriers, ways for individuals to have social support, and ways for individuals to feel as though they have the strength and the ability to change their behavior.

References

1. The Endocrine Society and The Hormone Foundation. ObesityInAmerica.org. Obesity Trends: http://www.obesityinamer=ica.org/geographic.html.

2. Salazar, K. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal. 1991;39(3):128-135.

3. Metro Community HealthCare Foundation. MetroWest Kids. Framingham, MA. http://metrowestkids.org/foryou/schools.php

4. O’Dea J, Wilson R. Socio-cognitive and nutritional factors associated with body mass index in children and adolescents: possibilites for childhood obesity prevention. Health Education Research. 2006;21(6):796-805.

5. Florida 4-H. The YEAH! Campaign. Gainesville, FL.

http://florida4h.org/Special_Programs/Yeah/4hyeah.shtml

6. Wardle, J. Rapoport, L., Miles, A. Afuape, T., Duman, M. Mass education for obesity prevention: the pentration of the BBC’s ‘Fighting Fat, Fighting Fit’ campaign. Health Education Research: 16(3): 343-355 (2001).

7. O’Dea J, Wilson R. Socio-cognitive and nutritional factors associated with body mass index in children and adolescents: possibilites for childhood obesity prevention. Health Education Research. 2006;21(6):796-805.

8. Kids Health. The NeMours Foundation. http://www.kidshealth.org/parent/food/weight/overweight_obesity.html

9. O’Donnell, Michael P. Creating Workplace Environments to Combat Obesity. http://www.niehs.nih.gov/drcpt/beoconf/postconf/overview/odonnell.pdf

10. Walker, K. Research Brief. The Principals’ Partnership. OR Satcher, D. Healthy and ready to learn. Educational Leadership. 2005;63:26-31. http://www.principalpartnership.com

11. Neumark-Sztainer D, Story M, Hannan P, Tharp T, Rex J. Factors Associated with Changes in Physical Activity: A Cohort Study of Inactive adolescent Girls. ARCH Pediatr Adolesc Med. 2003;157:803-810.

12. Uchino, Bert. Social Support and Physical Health: Understanding the Health Consequences of Relationships. New Haven, CT: Yale University Press, 2004.

13. Neumark-Sztainer D, Story M, Hannan P, Tharp T, Rex J. Factors Associated with Changes in Physical Activity: A Cohort Study of Inactive adolescent Girls. ARCH Pediatr Adolesc Med. 2003;157:803-810.

14. Cohen D, Finch B, Bower A, Sastry N. Chollective efficacy and obesity: The potential influence of social factors on health. Social Science and Medicine. 2006;62:769-778.

15. Strauss RS, Rodzilsky D, Burack G, Colin M. Pyschosocial Correlates of Physical Activity in Healthy Children. Arch Pediatr Adolesc Med. 2001;155:897-902.

16. Melnyk BM, Small L, Morrison-Beedy D, Strasser A, Spath L, Keripe R, Crean H, Jacobson D, Van Blankenstein S. Mental health correlates of healthy lifestyle attitudes, beliefs, choices, and behaviors in overweight adolescents. Journal of Pediatric Health Care. 2006: 20(6): 401-6.

17. Roach, JB, Yadrick M.K., Johnson, J., Boudreaux, J., Forsythe, W. Billon, W. Using self-efficacy to predict weight loss among young adults. Journal of the American Dietetic Associated: 103(10): 1357-1359 (2003)

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