Sunday, May 5, 2013

Health Belief Model Falls Short On The New Branded 5-A-Day Program

On The Issue of Obesity
Over the past two decades, the number of obese and overweight individuals has increased dramatically. More than a third of adults in the United States and approximately 17 percent of children and adolescents under the age of 19 are obese (1). The growing number of obese and overweight individuals in the United States and around the world has become an incredibly pressing issue in the sphere of public health. Extensive research has shown that being overweight or obese can cause conditions such as cardiovascular disease, type II diabetes, cancer and other major health complications (2,3). Future projections predict that in fifteen years, 80 percent of the adults in the United States will be overweight or obese (4).
The Updated 5-A-Day Program: Fruits and Veggies-More Matters
With eye-opening statistics and projections an overwhelming number of initiatives have been taken in public health to promote healthy eating and living. Intake of fruits and vegetables can potentially prevent chronic disease and aid in weight management.  But despite the number, the actual effectiveness of these programs has fallen below expectations (5). One such program that falls in this category is the “Fruits and Veggies-More Matters” campaign.
Fruits and Veggies-More Matters is an initiative that was started in March 2007 to reflect the recommendations provided in the 2005 Dietary Guidelines for Americans (6). Fruits and Veggies-More Matters replaced the “5 A Day for Better Health” (5 A Day) campaign, which recommended individuals to eat at least five fruits and vegetables everyday. The goal of replacing the 5 A Day approach was to re-brand the campaign’s message and persuade consumers to eat more fruits and vegetables by eliciting emotional responses. With the new campaign, individuals are encouraged to eat at least 7-13 servings (3½-6 ½ cups) of fruits and vegetables a day (6). However, even with the increased recommendations and the impact of social media and branding in mind, the effectiveness of the Fruits and Veggies-More Matters approach has failed to make any progress from its predecessor. In a study conducted two years after the program’s initial release, over 50 percent of individuals reported that they did not know the current recommendations for fruit and vegetable intake (6), let alone the name of actual campaign.
Criticism of Intervention 1: Overemphasis of Education and Lack of Progression of Intended Behavior
 From the start of the 5 A Day Program, awareness of dietary recommendation for consuming at least 5 fruits and vegetables a day went from 8 percent to 40 percent in a 10 year period (7,8). Although the awareness of the dietary recommendation was clearly evident, the actual proportion of individuals eating five fruits and vegetables everyday was virtually unchanged (9). The results showed from 1994 to 2005 the change of prevalence of consumption of fruits and vegetables per day went from 24.6 percent to 25.0 percent.
   One of the major flaws of the 5 A Day program, and what continues to be a problem with the Fruits and Veggies-More Matters campaign, is that it puts too much emphasis on education. The message of healthy eating is dispersed through a variety of different outlets such as grocery stores, printed media and public schools to reach as many people in as many influential spheres as possible (11).
 By giving individuals nutritional information and stressing the benefits of a healthier, more varied diet, public health contends that individuals will naturally be more inclined to more fruits and vegetables. However, this is an oversimplification and its basis of the belief stems from the health belief model. The health belief model is an individual-level model addresses a person’s perceptions of the threat posed by a health problem, the benefits of avoiding the threat and the factors influencing the decision to act (10). In the application of this model, it is key to understand how the target population feels about health problem (i.e. obesity, coronary heart disease, or etc.), whether they feel the threat is serious and if they believe action can reduce the problem at a reasonable cost.
It cannot be assumed that simply providing education and cold, hard facts regarding nutrition will lead to change in an individual’s behavior. Even when individuals are given the facts and the figures regarding the prevalence of obesity and overweight individuals and the risks associated with being overweight or obese, many do not take these advisory messages as a perceived threat to their health in the short term, and thus the benefit of eating healthy will not be their first priority. It cannot be assumed that individual’s are completely rational in their decisions and will forgo any external factors that can influence the promotion of unhealthy behavior. If the Fruits and Veggies-More Matters program continues to provide the same educational approach similar to the 5 A Day Program, the success of nutritional education from this program will be continue to fail. There must be a shift from the education regarding benefit of the individual to benefit of the individual’s family and community. Education focuses solely on the individual and his or her action alone cannot be the only channel of intervention.  
Criticism of Intervention 2: The Messenger Fails to Relate to the Audience
            In 2005, research was conducted to develop Fruits and Veggies-More Matters. The individuals who put this campaign together had the framework of social marketing in mind during the program’s creation (7), but failed in specifying certain aspects of the campaign’s branding strategy. Branding refers to names, symbols, designs and core values that represent an idea or movement with the objective of creating a relationship of trust between the product or service and its target population.
A major component in the success of a brand is the messenger. The messenger is the conduit that delivers the message from the organization to the target audience and is key in attracting attention to the idea, personalizing and simplifying complex concepts through modeling as well as reinforcing belief formation through reliable and credible sources. The credibility of the messenger is key to have in order to promote the initiative and communicate the idea of health-promotion initiatives (16).  
In a public service announcement PSA titled “More Matters” the Tacoma Pierce County focuses on the growing, buying and eating more fruits and vegetables and addresses mothers and families as their target audience. The message itself has a good foundation and specifies the particular population they want to address. However, the messenger used to deliver this message is completely ineffective. In the commercial, images of middle-aged women and/or families are shown partaking in healthy choices while an adult male or female dressed up as a carrot, apple and head of broccoli delivers the message. A giant talking vegetable talking in a clearly staged environment is not effective in delivering the message of healthy eating at all. There’s nothing relatable between mothers and families to giant advise-giving vegetable people. The messenger of the campaign should be one that is reliable and can be trusted to convey the core message. The real success lies in communicating real, believable and uplifting human messages. Without this key player, the message of eating healthy will not be taken in seriously by the target audience and will fail to bring about change in behavior.
Criticism of Intervention 3: Overly Dramatic Messages Lead to Opposite Reactant Effect
Another reason that may have lead to the failure of this program lies in the theory of psychological reactance. This theory explains how people become psychologically aroused and when their freedom is threatened by incredibly persuasive messages. After seeing these messages, a reactant behavior results in an attempt to restore the threatened freedom, and is usually the exact opposite of that which was intended in the original message (12).
All of the public service announcements (PSA) provided by Fruits and Veggies-More Matters are prime examples of overly dramatized messages that induce psychological reactance. In a PSA titled “School Daze” a gloomy-toned adult voices over the commercial and addresses how parents should talk to their kids about healthy food choices. The voice-over is accompanied by video clips of three teenagers who sneak out of school to eat food such as a significantly large pizza slices, fries and nachos at a questionable-looking fast food shack. The mood quickly changes and images of fresh fruits and vegetables are shown on the screen along with positive and encouraging words to “eat at least 5-9 servings a day of colorful fruits and vegetables.” The last words that the voice-over says are “Get healthy, America” (13).
The way the PSA was sequenced does not promote positive behaviors. Showing these three teenagers sneaking out of their school portrays this group in a negative light and assumes that teenagers are rebellious and will not listen to their elders. If adults continue to hold this preconception, teenagers will not change their behaviors. In fact, more teenagers will probably consider idea of sneaking out and possibly get fast food as a result of watching this commercial. Thoughts that may occur in a teenager’s mind after they have seen this PSA fall along the line of “who has the right to tell me how to eat?” and may revert to eating unhealthy, yet convenient foods once again. This psychological distress and reactive response is caused by the threat upon the teenager’s freedom to choose whatever what he or she wants to eat.
 If the goal of the PSA was to promote healthy eating habits among teenagers and their parents, a more dynamic approach must be made in which a more positive message is elicited in a way that does not offend individuals. A more practical and meaningful approach would be to show both the parents and the teenagers together eating or preparing a meal together as a family.  The PSA would portray the benefits of not just eating healthy and making good choices as an individual but rather as a family. This approach would emphasize previously held beliefs regarding family importance and reinforce these values in a way that is beneficial to their dietary health.
The messages of the Fruits and Veggie campaigns do not have to be so grim and focus on telling people what they should do and how they should eat. If anything, the campaign should emphasize ways to incorporate healthy eating messages in their everyday lifestyle in more innovative and active methods.
One campaign that did this approach very successfully was the VERB campaign. Center for Disease Control and Prevention’s Youth Media Campaign created a branding strategy called VERB that promoted physical activity among children aged 9-13 years old (14). Instead of pushing the ideas of getting active through exclusively educational methods, framers behind this campaign brand created an identity and a positive outlook for the issue. With VERB, the organizations created what is called an “aspirational brand”, which elicits high emotional desires of the target population. The brand was not just a name; it represented a lifestyle that inspired “tweens” to go out, to find new ways to be physically active and to identify themselves as a “VERB kid.” Evaluation of the VERB brand showed that there was an increased positive attitudes associated with physical activity (14).
Fruits and Veggie-More Matters should learn from this aspirational branding model. To be able to find a way to incorporate the core values of the nutritional education and package them in a way that makes the individual identify themselves positively with will lead to major health improvements in the field of nutrition.
Recommended Advice for Program Improvements
Although the Fruits and Veggies-More Matters campaign was designed to increase the promotion of eating at least 7 to 13 fruits and vegetables everyday through the use of social marketing strategies, the campaign falls short in its efficacy especially in its foundation of having an effective frame. A frame is a method of packaging and presenting an issue so that it conveys a particular message (18). The foundation of the Fruits and Veggies campaign lies in an education frame that promotes healthy choices. Although health is an important core value in the eyes of the public and policy makers, there are other core values that a more compelling and emotional effect on individuals (17).
A strong value that the Fruits and Veggies-More Matters campaign can take advantage of is the core value of family. Rather than simply educating the family and warning them about issues and complications related to obesity and overweight, the idea of the family preservation should be expressed. Catch phases such as “A family that eats together stays together”, “Eat five a day with the fam” or “Connecting with your kids, one meal at a time” (19) paired images such as families cooking together and eating together can be used in this frame. This framing strategy will in promote healthy eating using a positive and more dynamic approach rather than simply educating families and scaring kids into eating healthier foods.
A successful frame is not complete without an effective brand messenger. Currently, PSA messengers for more matters consist of wide range of spokespeople from professionals in the field of nutrition to adults dressed up in vegetable suits. But each messenger fails to meet the mark of ideal messenger criteria. Two major target populations that the Fruits and Veggies campaign focuses on are parents, particularly mothers, and children. Finding the ideal messengers is key in persuading both populations.
Using celebrities as messenger is one effective way of spreading awareness of a campaign. Celebrities who are familiar faces to the public can endorse health messages and greatly influence the effects of the message on the target population (20). Effective uses of this strategy can be seen in the Let’s Move campaign, which is spearheaded by First Lady Michelle Obama. Let’s Move is a campaign that promotes of healthy eating and exercising to fight against childhood obesity. Obama puts a face to the campaign and immediately makes a personal connection to the target audience by portrayer herself as a mother who, like many mothers in United States, is concerned with their children’s health. In an interview on the NewsHour with Jim Lehrer, Obama said, “This issue [childhood obesity] is critically important to the me for the health and success of our kids, and of this nation.” (21)
Another useful brand messenger could be peer counselors or group leaders in promoting the recommendation to children or young adults. These individuals are respected and trusted by their peers. This particular tactic was designed and used by the 5-4-3-2-1 Go! intervention. This campaign has a similar theme to the Let’s Move campaign in that it also promotes healthy lifestyle choices for children and their parents. The strategy behind the creation of the “5-4-3-2-1 Go! Teams” and the team leaders was to engage individuals to embody the value of healthy lifestyles through individuals such as high school sports stars and other stellar student leaders from diverse ethnic backgrounds. The leaders of these “Go! Teams” were aimed to serve as positive role models for younger children and were “living mascots” who would build awareness for the 5-4-3-2-1! Go brand (22).
The success of these strategies can be explained through the social cognitive theory. This model of social behavior is essentially the idea individuals learn from the behavior of others (10). Using strong messengers that make the audience believe that these role models (i.e. celebrities, group leaders and etc.) can relate personally to them is a useful tactic in changing an individual’s behavior. The program should affirm one’s already held beliefs from a source they can trust and empathize with. This is vital for the success of the campaign.
Additionally if the campaign reaches the right people in the community and uses them as messengers, the results will be greatly beneficial to the campaign. If the campaign reaches and persuades very influential people in the community, the positive behavior elicited will spread to those in their social network and branch out from there on. This phenomenon is explained by the social network theory. This group-level model holds that people do not live isolated lives are very much influenced by the social networks in which they are in, especially with groups such as family, close friends, classmates and coworkers. Eating habits is a behavior that is greatly influenced by the people we are around. A study using data information from the Framingham Heart Study found that individuals who were obese and those were thin, respectively, tend to cluster around the their own groups (23). If the campaign could hone in and change the behavior of an important or central individual in the obesity cluster, behavior can be altered and spread among those in the group.  

Previous dietary campaign promoting consumption of at least five fruits and vegetables per day increased awareness of the dietary recommendations by approximately 40 percent within a ten-year span (7,8). But despite the rise in awareness the actual behavior change of eating more healthy fruits and vegetables barely changed (9). With the idea of social media and branding on their side, the makers of the Fruits and Veggies-More Matters campaign hoped to provide a better idea and increase healthy fruit consumption than their predecessor (7).
However, the Fruits and Veggies-More Matters campaign and its basis in the health belief model falls short in its approach and has a number of areas to work on before real success can be made in its part. The campaign must shift away from the health belief model and individual models of behavior and focus on framing their issue in a manner that elicits positive emotional responses using family and community values. By understanding and stressing these core values and affirming prior beliefs among influential individuals in the community, the success of Fruits and Veggies-More Matters may stand a chance in inducing behavior change and improve upon the poor campaigns that preceded it.

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