Monday, May 20, 2013

Blue Cross/Blue Shield Minnesota Television Commercials: A critique of the Anti-Obesity Campaign– Mary Barber

Background Information

            Currently in the U.S approximately 68% of adults and 17% of children are overweight, in the state of Minnesota the obesity rate is expected to double if this pattern continues (1). The health insurance company Blue Cross and Blue Shield of Minnesota has taken a controversial approach to the obesity epidemic. The insurance company started tackling this growing health issue in Minnesota in a more serious manner by running new commercials in September 2012 that will run throughout 2013. The commercials depict overweight and obese parents promoting unhealthy eating behaviors for their children. In the past, the company had successfully used comical commercials to promote healthy behaviors such as one showing an old man dancing to hip hop song in a doctor’s office waiting room. Blue Cross/Blue Shield claims they have spent over a decade working on prevention related advertisements and believe these particular ads are stronger (1). Dr. Marc Manley, chief prevention officer for Blue Cross, believes a more serious campaign, finger pointing and all, is what Minnesota needs (2). The company calls the ads a “reality check” for parents with the hope that the advertisements will seriously motivate adults to make a change in their eating behaviors and set a better example for their children (1). One of the commercials being aired depicts two young, overweight boys bragging about how much food each of their dads can eat when one of the father’s walks up with a tray overflowing with fast food. The advertisement concludes with the overweight father looking guilty and the words “Today is the day the set a better example for our kids” on the screen. The anti-obesity ads have received national attention, both criticism and praise. Articles and blogs writing about the new ads received various comments from readers, most of the commentary focused on the idea that as a society we already do enough finger pointing and maybe its time to help individuals solve the problems.
Overview of the critique
            The Blue Cross/Blue Shield of Minnesota commercials regarding obesity are questionable in their overall effectiveness to change people’s behaviors. The public health campaign continues to stigmatize obesity, which further alienates individuals who are overweight or obese. The commercials will also induce psychological reactance in their audience. Viewers of the commercials will likely be provoked to ignore the message and continue to participate in unhealthy behaviors. Although the commercials end with telling parents to act as an example to their children, they do not guide parents on how to lead by example. The commercial lacks concrete educational resources and words of encouragement for the audience. 
Further stigmatizes obesity  
            The commercials further stigmatize obesity with their message.  The advertisement targets overweight people by placing them in the spotlight. Not only do the commercials only utilize overweight actors but also they focus on fast food and unhealthy snacks. Although some may argue that using overweight actors in advertisements is a visual image for change, this is not true when the advertisements further stigmatize overweight people. The director of obesity research at Yale University, Rebecca Puhl, PhD, stated, “by stigmatizing obesity or individuals struggling with their weight, campaigns can alienate the audience they intend to motivate and hinder the behaviors they intend to encourage (3).”  This Yale study also concludes that a stigma in a public health campaign is the enemy because it prevents any type of positive progression (3). In America’s history stigmas have been shown as detrimental to people. For example, the HIV/AIDS stigma become so problematic that it became a obstacle when the epidemic was addressed (3). The HIV/AIDS stigma was counterproductive; it became noticed as a root cause to an individual’s susceptibility to the disease (3). With evidence from past experiences such as the HIV/AIDS epidemic it is crucial that the commercials stop promoting the negative stigma attached to overweight individuals. These stigmas produced in the commercial include; overweight people mainly buy junk food, overweight people mainly eat junk food, overweight people set bad examples, and overweight parents cannot care for their children. These mentioned stigmas are just a few that the commercial has the capability to promote and stimulate in the audience.
 Another study published in Social Science and Medicine found that subtle forms of stigma were most effective on impacting an individual’s health and social well being (4). The commercials produced by Blue Cross/ Blue shield are in no way subtle. The study also found that individuals rarely challenge stigma and often blame themselves for the stigma attached to obesity. The commercials can induce this blame game by promoting the obesity stigma. If these advertisements do not change to become more positive and encouraging, it is likely that more advertisements will continue on this negative path.
Induces Psychological Reactance Theory
            The commercials will trigger psychological reactance in their audience. Simply stated the basis of psychological reactance theory is that people do not like to be told what to do, this commercial concludes by telling parents what to do. The commercials are condescending to parents; they shame parents and make them feel guilty. In the second Blue Cross/Blue Shield commercial the young girl is following her mother, both of whom are overweight, around the grocery store. At one point the mother turns around to check on her daughter and sees she has the same junk foods in her grocery carts. The mothers face turns into sadness and guilt when she looks at her daughter’s groceries. These commercials induce feelings of guilt, shame, and embarrassment on parents in a condescending manner; the ad is trying to tell parents what to do by saying what not do. Although the commercials do attempt to reduce reactants by using overweight actors to relate to the audience this can induce anger in the audience. Researchers at Yale University in Connecticut found that negative messages “instill less motivation to improve health (3).” The study concludes that a message, which induces shame or guilt onto a person, will not help create a change but may backfire. This supports the idea of psychological reactance.
The commercials also attempt to pressure parents to choose different foods and lead by example, this pressure may cause the parent to adopt the opposite attitude and allow their children to eat anything. Another study done at Yale University had over one thousand participants view current public health obesity campaigns in the United States. The study found that participants were more likely to provide the campaign a better rating if it was motivational (4). Comparatively, the negatively rated campaigns shamed the participants and created a negative environment where change was unlikely (4). This study supports idea that the negativity in the commercials will induce psychological reactance in viewers. Overall, the commercial threatens a parent’s personal freedom, which in turn could cause them to continue with the undesirable behavior.
Provides No Concrete Solution to the Problem
The commercials do not provide any educational solution to the obesity problem. At the conclusion of the Blue Cross/ Blue Shield Minnesota commercial the only resources and information given is the company website with the words “obesity affects us all.” Dr. Marc Manley, BCBS chief prevention officer, stated that the intent in creating the ads was to show good parents having moments of realization that they needed to change their own behavior in order to send the right message to their kid (6). Viewers did not respond well to the commercials, on a blog one viewer commented, “ I think that we do a lot of finger pointing in our society instead of trying to help individuals solve challenges (7).” The reaction was common among respondents that the commercial failed to provide the tools to actually help the audience.
The commercial brings the audience to the contemplation stage of the transtheoretical model behavior theory where they will begin to think about making a change.  A study on adolescents done by Laura Mauriello found the stability of the action and maintenance stages of the model were key in promoting healthy behavior (8). The more resources provided in the previous stages the more stable the action and maintenance stages (8). The problem is that the commercial does not help induce people into the preparation stage, which is where an attempt will be made to take concrete steps for a healthier lifestyle. The commercials do not adequately prepare the audience; it does not guide towards a specific plan.
The American Dietetic Association concludes that media messages need to include an active and behavioral focus on choosing the rights foods (9). The association goes on to say that half of American shoppers are searching for nutrition information and education within their media and social outlets (9). The commercials do not help these American’s on their search for information; therefore Blue Cross/Blue Shield is failing to actively help society. The obesity Action Coalition also had something to say regarding the ads: CEO Joe Nadglowski’s stated, "The vast majority of people understand that they struggle with their weight, actually are trying to do something about it, but unfortunately for all of us that have ever struggled, we know that it is challenging (7)" This highlights the notion that people are aware they are overweight, but they need the tools to make the change. In the Minnesota Blue Cross/Blue Shield commercials no concrete resources are provided. The company is perpetuating the obesity epidemic by failing to educate the audience with positive, informational messages.
Proposed alternative intervention
            The campaign to prevent childhood obesity should be an educational approach focused on motivating and guiding both adults and children. The commercials would encourage parents and children to lead active healthy lives. A change to the commercials would depict children and parents together participating in physical activity while eating and drinking healthy snacks such as carrots or water. At the conclusion of the advertisement resources could be provided, not to benefit a particular company, but to benefit the individuals health. 
            The actors in the commercial would come from every background and be of every shape and size to decrease the obesity stereotype. The parents would be actively helping their children participate in the games as well as eating behaviors. This would promote the theory of planned behavior, the behavior would benefit both parent and adult therefore the behavior will take place. The conclusion of the advertisement would recommend resources for physical activities, food recipes, and other educational tools. The goal of the commercial would be to help families obtain a healthy, happy lifestyle.
Reducing the stigma of obesity to benefit public health
            Stopping the obesity stereotype in the commercials with a positive, motivating message would reduce the stigma attached to overweight people. The stigmatization attached to obesity is not beneficial for the health and psychological development of individuals (10). A recent study shines light on a frightening statistic: as obesity rates continue to climb weight discrimination has also increased over 50% in the past ten years (11). The Yale Research study found that the stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts (3). The problem is that society regards overweight people personally responsible for their weight problems; society assumes it is the individual’s fault. Mass media campaigns that label children as overweight or fat spur a movement of body hatred and food fear, eventually making them even more susceptible to negative media messages. A more effective approach would be to focus on positive self-images and include self esteem building components (3). By including these factors and reducing the emphasize of personal responsibility the negative views of society can be reduced and the overweight individuals have been shown to have more positive attitudes (3).
Instead of utilizing the negative weight stigma to change behaviors the commercials should first address the weight stigma, to alleviate any negative thoughts, and then move forward with the goal of the commercial. For example, fit families could be playing in the park when an overweight family walks by, instead of taunting them the other families could ask them to join in the game. This could decrease the stigma that overweight people are unable to enjoy physical activity, this is especially important for vulnerable young children to see in the media. Also as the Yale Research study determined, unhealthy eating behaviors should be discouraged for all people (3). The commercial should feature all of the families refusing unhealthy snacks such as soda instead reaching for healthy alternatives.  To decrease the stigma appearance based media efforts should be avoided, instead replaced with health focused, positive messages.
The usage of the theory of planned behavior  

            The campaign to help combat obesity in children and adults must promote self-efficiency to be successful. The target audience must believe they are capable of changing their habits and behaviors before the change actually occurs. In the case of this campaign, the parents need to believe they are capable of making a change in their family’s food habits. The theory of planned behavior simply states that individuals are rational decision makers who consider the implications of a behavior before engaging in it. The intent to actually do the behavior predicts whether the future behavior will occur or not. The factors impacting the behavioral intent include attitudes, subjective norms, and perceived behavioral control.
A study published in the Journal of Health Communication by Andrews, Eneli, and Silk (2010) examined the theory of planned behavior in preventing childhood obesity specifically focusing on parents as health promoters (12). The study utilized mothers and children ages 2-5 as participants (12). One finding was that positive attitudes from parents in regards to healthy meals and nutrition could decrease children’s obesity (12). An effective ad would, “inspire behavioral change by highlighting the effectiveness of small actions (12).” Andrews, Eneli, and Silk found that subjective norms promoted by health associations influenced a parent’s behavior. Blue Cross/Blue shield would need to directly present their approval of healthy foods for parents to be receptive to the message. The study also determined that parent’s need to feel in control of their own weight as well in control what they feed their children (12). The commercials need to make parents feel capable of changing their own weight and show that it is possible for anyone to make healthy food. The findings of the study concluded, “it is critical that future health campaigns emphasize the ability of healthy eating to decrease childhood obesity (12).”
Another study evaluated the effectiveness of a theory of planned behavior based intervention program to change children’s BMI’s.  The study split the participants into two groups: the control group and the intervention group (13). The intervention group focusing on overcoming barriers, increasing availability of healthy foods, and increasing parent support (13). The results found that the intervention group had a higher consumption of healthier foods and a lower consumption of unhealthy foods (13). By using the theory of planned behavior the study was able to identify behavioral beliefs and attitudes of the children (13). It found that negative messages resulted in lower levels of excitement and receptiveness for the children (13). This study determines that using the theory of planned behavior has advantages. By determining the associations children make media campaigns can work to change these attitudes and promote healthier messages to children and adults.
These findings from both studies demonstrate that parents do need to be targeted but to change behavior not to chastise and shame. Blaming won’t change a parent’s behavior, instead its crucial to instill to parent’s the importance of health and nutrition.
Provide a structural approach

            Educational resources would be provided to encourage the commercial viewers to learn about healthy habits. When “prevention of obesity in children” is typed into an Internet browser search bar the search results include various government websites providing education tools. The educational tools range from recipes, risk factors, and simplified overview of obesity. For example, The Center for Disease Control and Prevention outlines ways to help a child combat obesity including help kids stay active, remove calorie rich temptations, and encourage healthy eating habits (8). It is tools similar to the CDC that should be promoted when implementing a campaign to change eating behavior
In an investigation into home and school intervention strategies for children the findings support the necessity of educational resources (14). The investigation looked into fifteen intervention-based studies over the past twelve years and determined that seven studies were effective based on their usage of behavioral change techniques. The results determined that intervening in all aspects of a child’s life in an educational manner is the most effective (14). Essentially, this means that public health measures should involve school, home, and community settings. Also along with educators, parents should be involved in raising awareness about obesity and promoting educational resources for their children.
            The review of interventions study also determined specific ways to educate children. One approach was to help children set goals for themselves, this helps change their behavior in a gradual and long lasting way (14). Another approach is to target the right behavior in the right setting (14). This entails targeting physical education in schools and healthy food choices at home. In general, it is crucial that the health nutrition information be introduced and maintained over time.
            Another investigation looked at the overall prevention and treatment of obesity in children (15). An expert committee compromised of individuals from various professional organizations did the investigation. The committee determined that supportive efforts to address the problem along with strong positive obesity prevention messages (15). The committee stressed the importance of messages in schools and communities to revolve around prevention, assessment, and treatment (15). Numerous times the expert committee recommends “actively engaging families” and the importance of “making information and suggestions available (15).”
             The findings from both of the investigations demonstrate the importance of educational resources. The review of interventions and the expert committee study both supported the notion that education is needed on all levels. A mass media campaign is an easy way to reach a wide audience; it should incorporate tools to help people achieve their goals. The previous conclusion to the campaign “obesity affects us all” with the company’s website provides an inadequate source of information. The company website will lead individuals to health care providers and the goals for the company. A more effective message would include something similar to “ we can work together to reach our goals” with educational tools available on listed websites. This phrase sends the message of hope and goal setting, which the intervention based study concluded was important. Also by providing concrete educational tools the audience can easily explore their options.
            Instead of criticizing the choices and appearance of overweight parents a statewide media campaign should focus on motivating and supporting parents. A more effective approach to reducing rising obesity rates in children as well as adults would include a multi-layered commercial. First, the public stigma attached to obesity would need to be reduced. Instead of focusing on overweight parents and children the commercial could depict families of all shapes interacting with one another, showing that being overweight does not make you a bad or different person. Also on a behavioral level the commercial should refrain from inducing psychological reactance in the audience. Based on psychological reactance the commercial trying to tell parents exactly what to do could cause them to continue their bad health habits and even further induce these habits. The theory of planned behavior would be appropriate to use for this media campaign. Parents need to feel confident in their ability to change behaviors in order to change their own as well as their children’s and surrounding family. Following this theory the commercial should include positive, empowering messages for parents and show parents succeeding in helping their children achieve health goals. Lastly, the current commercials do not provide adequate resources to help the audience achieve the desired goals. The lack of resources allows the audience to contemplate the behavior, but does not help them to prepare to tackle the change of behavior and habits. Educational resources are crucial to creating a successful mass media health campaign.
The ideal commercial from Blue Cross/Blue Shield of Minnesota would include various types of people participating in a health conscious activity such as cooking or a physical game. Each person would demonstrate the activities in a motivational and encouraging manner. The commercial would conclude with a positive phrase and tools to further learn about working together to achieve health goals. Public health campaigns run by organization such as Blue Cross/Blue Shield have the ability to send a powerful message. It is crucial that organizations become involved, in a helpful way, in the fight to end childhood and adult obesity.


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15. Barlow, S. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007; 120 S164-S192.

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