Challenging Dogma


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

Tuesday, May 1, 2007

MetroWest Kids Campaign Misses the Mark: Anti-Obesity Campaign Based on Health Belief Model Fails to Inspire Healthy Behavior – Heidi Elsinger

The MetroWest Community Health Care Foundation (MCHCF) recently launched a new public health campaign aimed at getting parents involved in the fight against rising rates of childhood overweight and obesity. The campaign, The MetroWest (Mass.) Kids Campaign, was born out of collaboration between public health officials and local parents. While the goal of the campaign may very well be on target (1), the campaign itself was poorly designed and thus has little chance to bring about the desired change, a reduction in the number of overweight and obese children in the MetroWest area.

There are three main problems with the campaign’s design. First, the billboards themselves were poorly designed and actually hide the message the campaign is trying to spread. Therefore, the controversial billboards draw attention to the way certain people look, but do little to spread health information. Secondly, since the campaign was designed using the Health Belief Model (2), even when the billboards can be read, the messages on them do not contain the information people need to effectively address the issue. Finally, since the campaign uses billboards to point people to a web site, it does not provide the modeling or social support that people rely on when trying to make changes in their lives.

If the MCHCF is truly dedicated to trying to lowering rates of childhood overweight and obesity, it can look to an unusual source, public health’s long-time scapegoats, fast food restaurants and video game makers, for ideas on how to get people eating better and moving more. While an unlikely ally, these two industries, led by Subway and Nintendo, can teach public health officials how to effectively use social learning and advertising theories to make healthy behaviors appealing.

MetroWest Kids Billboard Design Flaws

Due to design flaws, the campaign’s billboards focus people’s attention on looks rather than health. The billboards are too text heavy, and poor color choices further obscure the message the MCHCF is trying to spread.

The first set of billboards featured an image of an overweight child’s legs and feet on a scale. The background is black and in big, bold red letters the words “FAT CHANCE” grab the attention of people who pass by. In smaller, white lettering the following text appears, “Obese children are a good bet for type 2 diabetes. Heart disease. Stroke. Cancer. Sleep apnea. Depression.” The text then becomes even smaller, and in red font reads, “Obesity is robbing our kids of their future. Anything you can do about it? First step, go to (slightly bigger text) www.metrowestkids.org”

The most visible billboard in the campaign was placed at the intersection of Routes 9 and 30 in Framingham, facing Route 9 eastbound traffic. The billboard was not placed at a traffic light or major intersection, but directly before an underpass on a stretch of road on which cars travel at approximately 50 miles per hour. Since traffic is not usually stopped in this area (even during rush hour), most of the people who see this billboard only see the image and the words “Fat Chance.” Traveling by the billboard, the white text becomes a blur of white and the smaller red text virtually disappears into the background of the billboard. Even if the text was written in a more visible size and color, there is no time for a passenger in a car moving by the billboard to read all of it.

Thus, for a majority of the people who come into contact with this billboard, it simply sends the message that being fat is bad. With none of the health information processed, the billboard becomes a message condoning looks-based biases in people. It is unlikely this will help with any of the conditions listed in the text of the billboard. Further, it could actually worsen depression in people who view themselves as having a “Fat Chance.”

The planned launch of another billboard was called off amid concerns that it was offensive and “showed too much skin.” This billboard would have shown an obese teen’s back with the text, “If that’s your child, what are you waiting for.” According the Kate Billingmeier, Inside Out Communication’s account executive for the campaign, the new billboard may change to be more of a text ad (3). If that is the case, it would likely carry with it the same design flaws seen in the first roll-out of billboards.

Failure of the Health Belief Model to Inspire Healthy Behaviors

Even for those who read one of the billboards in its entirety, the message on the billboards does not provide the information needed to address the problem of childhood overweight and obesity. As the billboards were designed around the Health Belief Model, the message was designed to make raise the perceived severity level of childhood overweight and obesity rather than to make healthy behaviors appealing.

The Health Belief Model states that people make decisions regarding health behaviors based on a rational weighing of their perceived susceptibility to a disease and its perceived severity versus the perceived barriers or costs of taking action against the disease and likelihood that the action will effectively reduce the likelihood and/or severity of the disease in question. The model also allows for the use of cues to action to spur action through increasing the perceived threat of an adverse health outcome (2). It is a negatively based model that does not account for things such as the desirability of an alternative action or creating self-efficacy beliefs in the people who view these ads.

Creating self-efficacy, the belief that a person can actually perform the desired behavior, is a key component in changing behaviors according to social cognitive theory. This theory states that self-efficacy is a vital part of people’s motivation because without the belief that they can perform actions that will lead to the desired result, there is little incentive for them to take actions toward the goal (4).

Ignoring the concept of self-efficacy, this billboard campaign is one of the Health Belief Model’s cues to action. It is designed to spur a reduction in childhood overweight and obesity by creating fear of its adverse effects. However, these fear campaigns do not work. A recent meta-analysis of fear campaigns concluded that these campaigns actually backfire when people believe that they have the characteristics that put them at risk. The study also showed that strong fear campaigns only work when accompanied by equally strong message of self-efficacy (5).

Since this ad campaign ignores, and could actually decrease self-efficacy in overweight and obese people, it is unlikely to work. As stated above, the billboards’ most visible message is “Fat Chance.” Since this phrase is commonly accepted in American culture to mean that something will not happen, those viewing these billboards could internalize the message that there is a “fat chance” that they could change their situation and health outcomes.

MetroWestKids.org Unable to Fill Gaps Left by the Billboards

Another vital flaw in the campaign’s design is its reliance on a web site to affect behavioral changes in a population. This strategy depends on a person’s ability and desire to find the campaign’s web site and read the information, while taking human interaction out of the equation.

This design flaw is compounded by a failure to work out a deal with major internet search engines to display the website associated with the campaign. If someone sees the billboard ad, but doesn’t remember the complete web site, a Goggle search of “MetroWest Kids,” and even “Metrowestkids.org,” returns the MetroWestKids.com web site as its top choice. This web site refers parents to summer camp and day care options and has a section on arts and craft activities. It is not linked to the campaign’s web site. Furthermore, specifically searching “MetroWestkids.org” only returns the correct web site within the text of a newspaper article from the MetroWest Daily News. The actual web site of the campaign does not appear as a stand alone option to click in any of the lists returned using “Metrowest” and “kids” as the search criteria. Therefore, the information on the campaign’s web site is as hidden as the information on its billboards.

Again, even if a person successfully navigates to the web page and is able to read its full contents, there is little there that is useful in making health behavior changes. According to the design of the campaign, the consumer has now been informed about the dangers of childhood overweight and obesity by viewing the billboards and is on the “first step” of addressing the problem, visiting the web site listed on the billboards.

The site is broken down into three main areas: one for children, one for parents and one for schools. Each area has a monthly challenge targeted at the designated group as well as some other information. However, the little information that is on the site is too general to be useful and does not address any of the reasons why people are not already performing healthy behaviors or show people that their friends and neighbors are.

For example, the monthly challenge for parents in March was, “March is National Nutrition Month  and we want you to help your family see the rainbow on their plate. Try serving fruits, vegetables, and grains that show a spectrum of colors. Looking for ideas? Find them on our Healthy Eating page.” Unfortunately, following the link to the healthy eating page provides visitors with only two recipes, titled, “Frozen Fruit Pops,” and “5 a Day Salad.” While these recipes may be good and nutritious, they are simply not enough to overhaul the eating patterns ingrained in American society.

Challenges for children and school were equally unhelpful. Children were told in February to do 25 jumping jacks a day, and in March to plan a menu for a day. Schools were challenged to display information on food both months. In February, the challenge was to create a healthy eating bulletin board in one hallway, and in March they were challenged to display books with healthy recipes in classrooms (6).

Using Social Learning and Advertising Theories to Promote Healthy Behaviors

Understanding that people’s decisions are not always totally rational, but are influenced by familial and societal norms and values would help public health officials design anti-obesity campaigns that will have a positive impact on their communities. Likewise, lessons learned from advertising can be incorporated to help make healthy behaviors appealing to children of all ages.

Social learning theory states that people develop and maintain their behaviors through observing and modeling the behaviors, attitudes and emotional responses of people around them. According to this theory, people are most likely to perform behaviors that result in desired outcomes and that are modeled by people that are perceived as being similar to the observer and are admired (7). Advertising theory enters public health through social marketing. Social marketing promotes health behaviors by offering benefits the audience wants, reducing the barriers they are concerned about and persuading participation. As such, social marketing gets people to fulfill their own self interests (as defined by the marketers) by promoting the benefits they receive (8).

Several studies and reports have shown that social learning theory and social marketing can be effectively used to promote healthy behaviors. Peer modeling in the home, school and community is cited in several studies as key component to developing healthy behaviors in children (9-14). Government agencies have also begun to recognize and promote the importance of social marketing (13, 14).

Public health officials can learn how to use these theories from two companies that stand out in the ways in which they have promoted healthy behaviors, Subway and Nintendo. Both companies have used basic modeling and marketing techniques to promote their products. These techniques can be used to move people toward healthier lifestyles. Subway’s “Eat Fresh” campaign and tag line promotes healthier fast food. Meanwhile, Nintendo’s new Wii gaming system includes new technology that essentially allows consumers to play sports against an opponent or the system in the comfort of their own homes.

Subway’s “Eat Fresh” campaign stands out in two ways. First, it uses an actual person, Jared, who lost weight eating the company’s products and is portrayed as now being both healthier and happier. Secondly, the “Eat Fresh” tag line is appealing; it certainly sounds better to consumers than a call to eat a “mini whole wheat bagel,” one of the snack options offered up by the MetroWestKids.org web site (6).

People who come into contact with Subway’s campaign can be expected to take two main messages away. The first is one of self-efficacy, “if Jared can do it, so can I.” Unlike the MetroWest Kids Campaign, which sends the “Fat Chance” message, this ad campaign sends the message that everyone can eat healthy food. Whether the people viewing these ads need to lose a lot, a little or no weight, they see someone they can identify with making healthier food choices that led to visible results, and didn’t take any longer or cost more money than other options.

Secondly, healthy food is desirable. While “Eat Fresh” is a quick and simple tagline, it is also one that’s hard to argue with. A person could argue that eating a hamburger and fries tastes better and is more satisfying than eating a salad with dressing on the side. However, you’d be hard pressed to find a person who would argue that s/he wanted to eat old, wilted food that had been sitting under a heat lamp for a half hour or longer because that was better than a fresh sandwich made right in front of you when you ordered it.

Certain aspects of Nintendo’s recent successful launch of its new Wii gaming system can also be used in public heath to further promote health behaviors. The new Wii gaming system has people playing sports on their terms. The campaign got people were they already were, in front of their television sets, doing something they were already doing, playing video games. The difference is that now they are using a system that is a newer, better, more advanced version of what they used to use. These factors worked together to make the system, and its ability to simulate playing baseball, bowling and other activities, desirable.

These factors point to ways public health officials can make healthy behaviors desirable. Joining the lessons learned from Subway’s “Eat Fresh” campaign and Nintendo’s launch of its new Wii gaming system can help public health officials shape future anti-obesity campaigns that will have the desired effect of making the people in their communities healthier.

Officials can identify key people in the community to model healthy behaviors for the community at large. Every community has its Jareds, people who are admired and can positively impact the activities and health behaviors of their communities. By making sure the community sees its social leaders engaging in healthy eating and physical activities, officials can make these health behaviors desirable, and increase self-efficacy about healthy behaviors in their community.

Public health officials can also get people where they are, using television as an ally in the fight against childhood overweight and obesity. Instead of focusing on public service announcements, campaigns could focus more on product placement. Inserting healthy behaviors into television shows and movies could have a large impact on the way children make their decisions. For instance, officials can work with producers to replace product placements involving soda and candy with milk, water and fruits. Physical activity can also be easily worked into many television shows and movies by beginning or ending a scene with the characters walking, inline skating, or biking to meet each other or get between places.

Furthermore, officials can use the fact that children are using Wii systems to simulate activities like bowling and playing baseball to get the children to actually participate in these activities. By identifying some of the things that make the simulated activities fun, officials can use those attributes to market the actual activities.

For instance, bowling allows participants to compete against themselves and to chart their progress as their averages go up and their handicaps go down. It also has the added bonus of not requiring a high level of fitness to begin participating and being an activity that can engage people of all ages. Families can take part together, thereby incorporating physical activity into the family’s norms.

A billboard designed using these insights would look vastly different than the one the MCHCF created. It may contain a picture of a group of friends (preferably people actually from the community) bowling, maybe showing someone celebrating with teammates after rolling a strike. Healthy snacks could be on the table by the lane in use. A simple tag line that could be applied to this and other marketing pieces, such as “Live Healthy. Live Strong. Live FUN!” could be added with information from a local bowling alley.

By taking advantage of social learning and marketing theories, public health officials can design interventions that make healthy behaviors desirable by conveying the benefits of the behaviors in ways that will motivate the people in their communities to want to adopt the behaviors. These actions will also work to help people believe that they can perform the behavior and make healthy living an ingrained part of the community culture.

References

1. von Hippel, P. T. Changes in Children’s Body Mass Index During the School Year and During Summer Vacation. American Journal of Public Health 2007. 4: 696-702.
2. Salazar,M.K. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Health Nurses Journal 1991; 39(3): 128-135.
3. Manuse, Andrew J. Obesity billboard idea yanked. The MetroWest Daily News. Jan. 31, 2007
4. Pajares, F. Overview of Social Cognitive Theory and of Self-Efficacy. Atlanta, GA. Emory University. http://www.des.emory.edu/mfp/eff.htmlhttp://www.des.emory.edu/mfp/eff.html
5. Witte, K. and Allen, M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education and Behavior 2000; 27(5): 591-615.
6. MetroWest Community Health Care Foundation. Framingham, MA: MetroWest Community Health Care Foundation. http://www.metrowestkids.org.
7. Kearsley, G. Social Learning Theory (A. Bandura). Jacksonville, FL. Theory into Practice Database. http://tip.psychology.org/index.html.
8. Maibach, E.W., Rothschild, M.L., and Novelli, W. Social Marketing (pp. 437-461). In Glanz, K., Rimer, B.K. and Lewis, F.M. Health Behavior & Health Education: Theory Research & Practice 3rd Edition. San Francisco, CA: Jessey-Bass, 2002.
9. Buttriss, J. et al. Successful ways to modify food choices: lessons from the literature. London, Eng: British Nutrition Foundation Newsletter Bulletin 2004; 29: 333-343.
10. Lindsay, A.C., Sussner, K.M., Kim, J. and Gortmaker, S. The Role of Parents in Preventing Childhood Obesity. The Future of Children 2006; 16(1) 169-186.
11. Epstein, L. Family-Based Behavioural Interventions for Obese Children. International Journal of Obesity and Related Metabolic Disorders 1996; 20(1) S14-21.
12. Hood, M.Y. et al. Parental Eating Attitudes and the Development of Obesity in Children: The Framingham Children’s Study. International Journal of Obesity and Related Metabolic Disorders 2000; 24(10: 1319-1325.
13. Secretary of Health and Human Services and Secretary of Education. Promoting Better Health for Young People Through Physical Activity and Sports. Washington. D.C. Centers for Disease Control and Prevention. http://www.cdc.gov/healthyyouth/physicalactivity/promoting_health/index.html.
14. U.S. Department of Health and Human Services. Prevent and Decrease Overweight and Obesity, 2001: Surgeon General’s Call to Action. Rockville, MD. U.S. Department of Health and Human Services, 2001.

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