Monday, May 20, 2013

Will Children in Alaska Get Out and Play Every Day? A Critique of an Overly Simplistic Public Health Campaign--Rebecca Song

                  Since 1988, obesity rates in the United States have increased from 7.2% to 11.1% in children 2-5 years old; 11.3% to 18.8% in children 6-11 years old; and 10.5% to 18.2% in 12-19 year olds (1). Childhood obesity has become a wide-spread public health concern which has initiated several national as well as state-level interventions in response to this issue. A recent study published in the Journal of the American Medical Association that used a U.S. nationally representative sample, found that adolescent obesity has a significant association with severe obesity in adulthood with variations in race/ethnicity and sex (2). Therefore, it is crucial to direct efforts towards reducing childhood obesity to avoid or minimize health concerns in the future.
In the state of Alaska, the prevalence of childhood obesity exceeds the national average with 36% of children ages 5-18 above the normal weight. In an effort to reduce these rates in Alaska, the Alaska Division of Public Health launched the “Get Out and Play Every Day” campaign in 2012 to promote physical activity and raise public awareness of childhood obesity. The main goal of this campaign is to have every child complete at least 60 minutes of physical activity each day to “feel great and maintain a healthy weight.” (3) The campaign’s website and advertisements provide facts and statistics on obesity among Alaskan children, the number of hours spent in front of a television or computer and also the economic impact of the yearly obesity-related medical expenses of $459 million dollars. The daunting facts will hopefully encourage children and parents to engage in more physical activity and successfully meet the daily 60-minute goal.
Summary of Critique
            Although the “Get Out and Play Every Day” campaign provides important public health facts to raise awareness of childhood obesity and intends to encourage children to be active, it relies on components of the traditional Health Belief Model that will ultimately make this campaign unsuccessful. It assumes that individuals are in complete control of their health and they will easily change their behavior to meet the campaign’s 60 minute-goal (4). The campaign does not address important external factors that are potential barriers to achieving 60 minutes of physical activity a day nor does it provide alternative ways to stay healthy if physical activity is not possible due to either a disability or other constraints. Lastly, the campaign places the responsibility to be physically active not only on the individual child, but also on parents who may not model healthy lifestyles themselves and can trigger psychological reactance in their children.
Critique 1: Using the Health Belief Model as a foundation
            The “Get Out and Play Every Day” campaign is built on components of the Health Belief Model (also known as a value expectancy model) which focuses on the individual as the primary source of behavior change. It assumes that the targeted audience will engage in healthy behavior if they value the outcome and believe that the behavior is likely to result in that outcome. The Health Belief Model also hopes to change an individual’s behavior through rational decision-making to prevent the adverse outcomes, which in this case is obesity (4). The campaign assumes that all children and parents value health (good health) and therefore the presentation of statistics on childhood obesity and creating videos stating that the life expectancy of Alaskan children is declining will trigger a rational decision-making process to adopt a healthy lifestyle.  The answer to solving this problem is simple and viable in the campaign’s eyes – children just need to get out and play for 60 minutes every day. However, every Alaska resident does not place a value on health so the campaign’s strategy of simply presenting facts to raise awareness and preaching this one solution will not be effective. If there is little or no value placed on health, it will be difficult for children to fully comprehend the benefits of physical activity and how it will shape a healthy future for them. Though the tone of the campaign promotes a sense of urgency and the health consequences are severe, the individual must perceive the susceptibility to the health problem, the benefits of adopting a healthy lifestyle, and value the outcome in order to take action. For example, if a child’s friend does not engage in physical activity and his parents allow him to watch television all day, the child would not feel susceptible to a health problem or see a perceived benefit to physical activity because there is no immediate risk to him or his friend. Also, humans tend to act irrationally and are inclined to act on intuition or emotion so one cannot assume that shocking statistics will motivate an individual to change his or her behavior through rational-decision making (5). The campaign’s message is targeted directly to the individual without promoting confidence, success and empowerment.
The Health Belief Model only focuses on the individual and does not address the external social and environmental factors that contribute to childhood obesity. An individual is a product of his or her environment so one cannot expect to change an individual without changing the environment that surrounds him or her (6). The “Get Out and Play” campaign’s failure to address the multiple levels that influence a child’s values and behavior make it a weak and ineffective campaign. Studies suggest that health outcomes are associated with social and environmental factors and tend to be lower in less active communities (7). The lack of consideration of external factors that also influence a child’s behavior change weakens the “Get Out and Play Every Day” campaign and make it ineffective.
Critique 2: Barriers to Get Out and Play
            The “Get Out and Play Every Day” campaign fails to consider the physical, environmental and social barriers and limited access and resources for families. If barriers to affordable, safe, and achievable physical activity exist, the intervention will not be successful even if the individual intends to be healthy. Sallis and Glanz (2006) found that the recent changes in the “built environment,” such as the lack of sidewalks and long distances to schools, parks and recreational facilities, promote a sedentary lifestyle (8). For many Alaska residents, highways are the only roads that connect recreational facilities and schools, even in the largest city of Anchorage. Although Anchorage is the largest city in Alaska that holds half of the state’s population, it is not a densely populated city with a well-functioning public transportation system or sidewalks that connect neighborhoods which is a barrier to physical activity. Studies show that walking or commuter cities tend to have lower obesity rates but Alaska’s “built environment” discourages people to integrate this simple exercise into a daily routine and also establishes driving as the social norm (9). There is a social stigma against those who are seen walking, especially during the winter, because Alaska’s “built environment” caters to drivers. This social stigma will discourage people from walking because spectators may associate them with a lower socioeconomic status or someone without the means to buy a car.
            Alaska’s “built environment” as well as its natural environment can be unsafe for children to participate in outdoor activities. Alaska is a rural state that is not densely populated so a simple exercise such as walking around in the neighborhood may be a safety risk. There is a lack of local neighborhood parks or safe spaces for children to play because most funding and attention is placed on the National and State Parks. During the seven month long winter, Anchorage has an average of five hours of daylight with below zero temperatures. These weather conditions will discourage parents from letting their kids outside but instead allow them to watch television indoors because it is safer. The campaign’s website has announcements on local events to promote safe avenues of physical activity, however, they do not occur every day and several of these events require a fee to participate which may not be feasible for some families. This campaign focuses on the simplicity of exercising 60 minutes a day when in reality, there are many barriers to achieving this goal.
Critique 3: Dependence on Parental Involvement
            The campaign emphasizes the importance of parental involvement in a child’s level of physical activity and places responsibility on the parents to plan activities and motivate their children. They suggest that scheduling time for family exercise is just as important as scheduling a doctor’s appointment. The campaign’s message is based on the assumption that all parents have the time and capability to spend an hour a day to do family activities together. However, this campaign would not effectively change behavior of parents who work nights, multiple jobs, have busy schedules because their value is not in health and have other priorities such as, providing for the family financially. Parents simply may not know how to build in time for physical activity with the family because being active may be a new concept for them. The campaign does not adequately equip parents with the necessary tools or realistic examples of achievable activities or how they can motivate their children to exercise. Moreover, the emphasis on the simplicity of the goal has the potential to create feelings of failure among parents who cannot schedule time to be active together. Parents will lose confidence in their ability as caregivers and may give up on incorporating physical activity into the family routine.
If the campaign is placing responsibility on the parents, there must be behavior change in the child as well as in the parent’s behavior because the lifestyle of the parents is a determinant of a child’s health outcome. Agras et. al. (2003) assessed five independent risk factors for the development of overweight children and found that an overweight parent was the strongest risk factor (10). The findings in the study support the Social Learning Theory, which states that people learn new behaviors from modeling and observing in their environment. Children are more likely to learn through observational learning and if parents are adopting an inactive and unhealthy lifestyle themselves and do not promote health as value within the household, it will negatively impact the children’s behavior.
Parents that value health that attempt to instill that value in their children by scheduling family activities may trigger psychological reactance in the child and actually deter them from exercising or playing outside. Psychological reactance is a motivational state that people experience when there is a perceived threat to their freedom and autonomy and they try to restore it. Although parents are encouraging something positive for the best interest of the child, the child experiences a stronger force of reactance in an attempt to restore the threatened freedom and could create an issue that is more severe (11). For example, if a parent limits the number of hours that a child can spend watching television and tells them to play outside instead, it will trigger psychological reactance and children will do the opposite. Children’s resistant to physical activity will probably make parents give up easily if their schedules are already hectic as it is and relapse into their old ways. Using parents as a model and motivator for children can actually have a negative effect thus generating an ineffective campaign.
Shifting the Focus of the Intervention
            The Get Out and Play Every Day campaign must develop a framework based on theory-based interventions that use a multilevel approach. The campaign should broaden its strategy to a community level intervention and involve stakeholders that can contribute to combating childhood obesity in Alaska rather than placing all of the responsibility on the individual or parents. There should be a message of empowerment in the campaign to increase self-efficacy because it will build confidence in the children to believe they can achieve their goals. Lastly, the use of role models and community leaders that the children can identify with should be mobilized to deter psychological reactance and increase the likelihood of adopting a healthy lifestyle.
1. Individual to Community Level
            The Get Out and Play Every Day campaign places the burden of physical activity on the children and parents and does not address community involvement. If this initiative’s focus shifted from an individual to a community level campaign, there will be more positive reinforcements and accountability for individuals to remain active. A community level intervention would involve not only the family but educators, local government, health practitioners and even local business owners. Community-based programs use multiple interventions, targeting change among individuals, groups, and organizations, and they often incorporate strategies to create policy and environmental changes and this ecological approach will increase its success (12). Mittelmark, Hunt, Heath and Schmid (1993) explains that the key characteristics of successful community-based health promotion programs include mobilizing communities to actively participate in achieving program goals; implementing interventions in multiple community settings; using multiple individual-level intervention strategies; and developing environmental interventions (13). The Get Out and Play Campaign must engage the community as a whole in order to successfully reduce childhood obesity because it cannot rely on the individual alone, especially if they do not value health. If the community participates, there will be different avenues to achieve this goal and may the campaign may even expand beyond 60 minutes of physical activity but include things like nutrition and education with community participation. This will also display positive health behavior in the community that children will observe and learn from to adopt a healthy lifestyle. As the community actively participates in this campaign to fight childhood obesity in Alaska, the local government may respond by providing accessible and affordable spaces for safe physical activities such as neighborhood parks, after-school programs, and subsidized sports leagues.
2. Promoting Self-efficacy to Empower Children
            The intervention must adopt a strategy that will promote self-efficacy to build confidence and empowerment in order to be successful. Self-efficacy is an important factor that will affect the likelihood of a person to change his or her health behavior because it is built upon the idea than an individual’s perception on his or her ability to change will determine its success towards that behavior (14). An adoption of physical activity is largely a matter of individuals with stronger self-efficacy because they will expect to reap the benefits associated with being active and likely maintain a healthy lifestyle in the long run.  Children must be empowered to have personal expectations and have confidence to take action and overcome obesity. The goal cannot seem too overwhelming or the children will lack confidence if the goal does not seem achievable. Instead of emphasizing the 60 minutes a day, the campaign should first focus on small incremental steps that are surely attainable such as, walking up two flights of stairs at school or eating one vegetable a day. Parents should also be involved in having a formal contract or rewards for children and constantly give positive reinforcement which will increase a child’s likelihood that they will repeat the behavior. In a study by Andersen et al. (2010), they found that change in self-efficacy for physical activity was related to change in self-regulation which was found to be a potential mediator of the effect of self-efficacy on physical activity. Participants in a community level intervention who gained confidence in their abilities to be active engaged in more frequent goal setting, planning and monitoring behaviors, which led to increased physical activity so shifting the focus from the individual to the community will create a successful public health campaign.
3. The Use of Peer Role Models
            Replacing parents as the primary influencer in a child’s active lifestyle with role models that are identifiable and similar to the children will minimize psychological reactance. Silvia (2005) suggests that a strategy to deflect reactance is to utilize interpersonal similarity between the communicator and receiver of a particular message because it will increase the positive force toward compliance. In an experiment that matched people with a communicator with the same birthday, name, gender and year in school, they found a correlation between similarity of these characteristics and agreement. People tended to agree with the similar communicator when the threat was high and low which suggests that similarity is a strong force that will determine agreeability despite the threat level (16). Schunk (1987) found within existing educational research that peer models had beneficial effects compared with dissimilar-age models. Schunk also found that peer models can enhance children’s self-efficacy for learning better than adult models suggesting that model-observer similarity in age is an important factor for raising self-efficacy. Therefore, peers may be more influential when encountered with difficulties, such as not being able to exercise every day, and are uncertain about their capabilities (17).
The main mode of learning is through observation of other’s behavior according to the Social Learning Theory, so modeling is an important means of shaping a person’s behavior, attitude and beliefs. The use of age-similar role models will create a trust between the communicator so the children will not interpret the campaign’s message as a threat to their freedom and autonomy. Furthermore, humans influence other humans easily because they like to conform (18). If a youth role model frames health in a way that speaks to a child’s set of core values and can identify with the model, they will have a desire to adopt this value as their own and conform to the model’s behavior.  Based on this evidence, the campaign should utilize youth role models and match them with children two or three years younger to increase self-efficacy, effectively spread the campaign’s message and promote active lifestyles.
            The “Get Out and Play Every Day” campaign’s goal is to raise public awareness of childhood obesity and encourage children and families to perform at least 60 minutes of physical activity a day. Instead of aiming to change behavior on the individual level, the campaign should engage the community and broaden this campaign to a community level intervention. The participation of the community will create more opportunities to display positive health behavior that children can learn from and provide accountability to achieve this goal. The campaign should also focus on empowering the individuals to promote self-efficacy and make the individuals believe they can accomplish this health goal. The use of peer role models in addition to parental influence will create similarity among the children and increase the likelihood that children will adopt a healthy lifestyle for themselves. These interconnected interventions will complement each other and form an effective public health campaign to minimize childhood obesity in Alaska.

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