The 5-A-Day Campaign Backfires: A Critique of the Health Belief Model in Action – Leigh Friguglietti

A diet high in fruits and vegetables has been associated with a decreased risk of certain cancers, reduced morbidity and mortality from heart disease, decreased risk from chronic conditions and enhanced weight management (1-5).  Yet, most of the US population does not consume the recommended amount of fruits and vegetables.  The 5-A-Day campaign, initiated in 1991, is a nutrition intervention whose purpose is to increase fruit and vegetable consumption for improved public health.  The 5-A-Day program is a collaborative effort comprised of government agencies, private companies, state coordinators, and educators, to strengthen fruit and vegetable intake to at least 5 servings per day for 75% of Americans by 2010 (6).  Despite all the television commercials, websites and billboards that were created to raise awareness about the importance of fruit and vegetable consumption, research revealed that fruit and vegetable intake rates were not improved by the 5-A-Day campaign (7).  In fact, according to Serdula, from 1994 to 2000, the mean frequency of consumption of fruits and vegetables declined, from 3.44 times per day in 1994 to 3.37 times per day in 2000 (8).  The campaign backfired on public health practitioners and had a negative effect on fruit and vegetable intake.

Introduction

For many public health promoters it appears that those for whom the information is most relevant are often the least persuaded.  Thus, people fail to respond positively to potentially vital campaigns.  Such is the case for the 5-A-Day nutrition intervention.   This approach is based on the Health Belief Model.  Furthermore, the intervention holds that there will be an increase in fruit and vegetable consumption if people believe that they are susceptible to cancer and heart disease (perceived susceptibility), that cancer and heart disease are serious (perceived severity), that increasing fruit and vegetable consumption will reduce the risk (benefits), and that the barriers to the change, like cost and access, are not unreasonable (barriers to change) (9).  This paper presents at least three reasons why this rationale is not effective.

Furthermore, the intervention failed to encourage its target audience and has been an ineffective public health intervention to increase fruit and vegetable consumption in the US population.  The campaign did not succeed at changing individuals’ behavior for several important reasons.  First, awareness messages about the benefits of consuming fruits and vegetables are not enough to change a persons’ behavior.  Second, the 5-A-Day campaign neglects individuals’ need for self-efficacy to change behavior.  And lastly, this intervention does not recognize the importance of social norms and their effect on eating fruits and vegetables.

1.  Benefits and barriers; how awareness is not enough to change behavior

The 5-A-Day campaign offers people information through a variety of avenues about the benefits of consuming at least five servings of fruit and vegetables each day, while providing the risks of not receiving the recommended daily allowance of fruits and vegetables.  However, awareness messages about the benefits of consuming fruits and vegetables are not enough to change a person’s behavior.  Steptoe informs us that there is no association between beliefs in health benefits of eating fruits and vegetables and consumption (10).  In fact, many individuals recognize the benefits of consuming fruits and vegetables and intend to consume more, but intention does not always lead to behavior. 

Cost and accessibility, rather than awareness, are the most significant predictors of consumption of fruits and vegetables.  Steptoe says that peoples’ dietary choices are influenced by cost of produce and the availability of food stores (10).  Furthermore, the campaign does not mitigate barriers that impede people from consuming five or more servings of fruits and vegetables a day. Even if people are aware of potential benefits, how can people change behavior if fruits and vegetables are not affordable or accessible?  If people do not have the means to obtain fruits and vegetables, then increasing consumption is not a viable behavior change. 

For example, in a study that examined barriers to fruit and vegetable consumption, a focus group of African Americans reported limited access to fresh produce which consequently inhibited their fruit and vegetable intake.  Predominantly minority and racially mixed neighborhoods had significantly less supermarkets and grocery stores than Caucasian neighborhoods, thus limiting fruit and vegetable intake among low income populations.  Furthermore, the lack of super markets in low-income areas forces residents to depend on small stores with very limited selection of fruits and vegetables (4).  Though people may want to change, barriers thwart some from consuming produce. 

It is important that behavioral interventions incorporate and reflect the realities of peoples daily lives and that interventions reduce these barriers that otherwise impede people from getting the recommended servings of fruits and vegetables.  The 5-A-Day initiative does not improve access to fresh fruits and vegetables nor does it make them more affordable.  A broader contextual model that examines these issues is needed to ensure that first and foremost, all individuals have access to fresh fruit and vegetables.  Behavior cannot change if people do not have the ability to afford fruits and vegetables, or if there is no outlet to purchase them even if they intend to. 

2.  No self-efficacy leads to no change in behavior

            Albert Bandura has defined self-efficacy as our belief in our ability to succeed in situations.  Self-efficacy can play a major role in how an individual approaches goals, tasks, and challenges.  Bandura’s Social Cognitive Theory is centered on self-efficacy, which believes that people will be more inclined to take on a task if they believe they can succeed (9). 

            Researchers have seen the application of self-efficacy in nutrition interventions.  Sorensen reports, that higher levels of self-efficacy are associated with increased consumption of fruit and vegetables (11).  Luszczynska found that self-efficacy is among the factors most strongly and consistently associated with higher levels of consumption.  In addition, an intervention targeting self-efficacy, those who had self-efficacy action plans, compared to those who did not, resulted in an increase of fruit and vegetable consumption.  Self-efficacy enabled participants to change their consumption and consume more servings of fruit and vegetables (12).  Furthermore, Epton found that in a randomized trial, participants that were self-affirmed and encouraged to consume more fruits and vegetables reported consuming significantly more portions of fruit and vegetables over a seven day period than the non-affirmed participants (13).  In conclusion, enhancing self-efficacy results in nutrition change.

            The 5-A-Day campaign does not enhance self-efficacy as a means to change behavior.  In turn, lack of self-efficacy discourages nutrition change.  If people feel that they do not have the capacity to eat five servings of fruit and vegetables a day, then they will not attempt to eat five servings of fruit and vegetables a day.  Individuals need to believe that they can consume five servings prior to embarking on this beneficial behavior change.  Thus, incorporating self-efficacy is absolutely necessary to promote an increase in fruit and vegetable intake.  Furthermore, a self-efficacy intervention would mediate effects of an intervention on health behavior.

3.  5-A-Day campaign ignores the importance of social norms and consumption of fruits and vegetables

            Social norms are behavioral expectations and cues within a society or group.  Generally, they are the rules that a group uses for appropriate and inappropriate values, beliefs, attitudes and behaviors.  Social Expectation Theory boasts the importance of social norms and their influence on behavior (9).  Unlike Social Expectation Theory models, the Health Belief Model is an individual level model that does not consider social context or the role social norms play in health behavior.  A major limitation of the 5-A-Day campaign is that it does not consider or target psychosocial factors and behavioral outcomes.  By not targeting social factors, the 5-A-Day campaign limits its effectiveness, and fails to succeed at changing behavior.

Social context matters in health behavior change.  Social and physical surroundings directly affect individual’s health behaviors (15).  Furthermore, the presence of strong social norms that support fruit and vegetable consumption are pivotal to the behavior change process.  For example, in study that looks at social context on changes in fruit and vegetable consumption, Sorensen reports that change in fruit and vegetable consumption is strongly associated with two social contextual factors; social networks and supportive social norms (11).  Yet, the 5-A-Day campaign does not aim at social norms that support fruit and vegetable consumption, as a result, this campaign failed.   

Research has demonstrated that positive social norms regarding fruit and vegetable intake result in increased consumption (11, 14).  Therefore, rather than focusing interventions on individual attitudes it is important to consider the influence of social norms in human behavior.  There is a need to build strong social norms around fruit and vegetable intake and implement them into interventions for effective health behavior changes.  Perhaps community based approaches (16) rather than individual level models, offer a way of changing overall community norms about nutrition problems, which could be beneficial for influencing individual level improvements in health behavior.    

Conclusions

            The 5-A-Day campaign was unsuccessful at increasing fruit and vegetable intake (7).  Since, the campaign is based on the Health Belief Model, by nature, the campaign is doomed to fail.  The intervention relied on awareness, and awareness of a problem will not lead to behavior change, especially when barriers are high.  The campaign did assert self-efficacy, which is crucial to changing an individual’s behavior. Lastly, the effort did not consider the importance of social norms. 

Thus far, nutrition interventions have focused on heightening public awareness and increasing the populations’ knowledge about the importance of consuming fruits and vegetables.  Although knowledge is an important factor in predicting fruit and vegetable consumption, knowledge alone has not been sufficient to change diet.  Eating fruits and vegetables is influenced by processes at a number of levels, from social norms to practical issues of food distribution and accessibility and individual attitudes, like self-efficacy.  The 5-A-Day campaign does not focus on the previously mentioned factors that clearly affect individuals’ fruit and vegetable intake.  As a result, this campaign has been ineffective at increasing fruit and vegetable intake among the US population.

            There is need to broaden the traditional approach of planning interventions beyond increasing awareness and education.  Developing interventions that consider the environment, social norms and social context on behavior change are necessary.  Interventions that enhance cues to action of health benefits of fruit and vegetable consumption together with increasing self-efficacy and decreasing perceived barriers will have a positive impact on the entire population.

 Proposed Intervention: ‘Something Fresh’

The following intervention was designed with the 5-A-Day campaign failures in mind.  The Something Fresh intervention encourages and makes it easy for all individuals to consume more fruits and vegetables.  This campaign not only improves access to produce, it creates an environment in which people feel like they can consume more fruits and vegetables, and understands the pivotal role family plays in fruit and vegetable consumption. 

Something Fresh distributes fruit and vegetables to areas where they are not available and makes produce more affordable for everyone.  If individuals do not have access to a grocery store or do not live in an area with fresh fruit and vegetables available, the ‘fresh van’ delivers produce, including seasonal fruits and vegetables to your home.  Delivery is free of charge for individuals and produce is affordable through the Something Fresh subsidy.  This program also provides incentives for individuals that already have access to grocery stores with adequate produce.  The Something Fresh program discounts the price of produce when individuals’ grocery bills are at least a 30% produce.  The slogan eat something fresh, promotes eating fresh produce and different advertisements encourage people to take advantage of them in order to increase fruit and vegetable intake.  The campaign works through media messages to encourage everyone to eat something fresh.  In addition, the intervention makes suggestions for how to increase consumption that promote self efficacy.  Ultimately the intervention makes people feel that it is possible to eat something fresh thereby consume more fruits and vegetables.  Lastly, the campaign supports family meals and provides serving suggestions in addition to menu ideas for families so as to incorporate produce into family meals.

Reconciliation 1

Most people are aware of the benefits of consuming five fruits and vegetables each day (10).  However, awareness is not enough to change behavior and barriers like accessibility and cost inhibit individuals from consuming fruits and vegetables (4, 10).  Rather than boring consumers with the risks and benefits of fruit consumption like the 5-A-Day campaign, this intervention removes obstacles that individuals face when trying to access fruits and vegetables.  The Something Fresh intervention eases barriers like access and cost, by delivering produce to peoples’ homes and making fruits and vegetables more affordable through discounts.  With this intervention in place, people that want to be healthy, but did not have the means to obtain fruits and vegetables, now have two advantageous options to get more produce in to their homes and ultimately their meals. 

Since perceived barriers proved to be most consistently associated with poor fruit and vegetable intake (10), this campaign removes barriers, so that behavior can change.  Choices people make about eating fruits and vegetables are no longer limited by the produce available to them.  This intervention created a way for people to afford and access fruits and vegetables.  Without barriers that impede behavior change, increasing fruit and vegetable consumption is realistic and attainable behavior. 

Reconciliation 2

Self-efficacy is required for behavior change.  The 5-A-Day campaign does not use self-efficacy, and as a result does not succeed in increasing fruit and vegetable intake.  In the 5-A-Day campaign, if people feel that they do not have the capacity to eat five servings of fruit and vegetables a day, then they will not attempt to eat five servings of fruit and vegetables a day.  Something Fresh utilizes Albert Bandura’s Social Cognitive Theory, which is rooted in self-efficacy, the belief that people will be more inclined to take on a task if they believe they can succeed (9).  This new campaign does not put a number on the servings of fruit and vegetables individuals should get; rather, it encourages individuals to eat fresh fruits and vegetables.  In addition to encouraging consumption the campaign offers materials to people with simple ways to eat fresh.  These materials will help initiate cues to action and will help people plan their behavior change.   

Studies have shown that self-efficacy mediates behavior change (11-13).  The key to the Something Fresh campaign is to make eating more fruits and vegetables attainable, which leads to the belief that people can achieve this healthy behavior, in turn increasing fruit and vegetable consumption. 

Reconciliation 3

Social context and strong social norms supporting fruit and vegetable consumption are pivotal to the behavior change process.  Furthermore, both upbringing and family have a paramount impact on fruit and vegetable consumption (11).  The 5-A-Day campaign does not lend itself to the role social norms play in behavior change.  For this reason, Something Fresh focuses on the social context of families and changing family norms about fruit and vegetable consumption.  One of the goals of the campaign is to increase nutrition knowledge in parents and to make them aware of the importance of fruits and vegetables in a child’s diet.  Increasing Knowledge in parents positively influences the quality of the children’s diet (4, 12, 14).  Furthermore, when children grow up eating fruits and vegetables and they are able to develop a taste for produce that stays with them forever.  In addition, having family meals is positively associated with fruit and vegetable intake (4).  For this reason, Something Fresh targets families because of their important role in the consumption of fruits and vegetables. 

Conclusions

       The 5-A-Day campaign was unsuccessful at increasing fruit and vegetable intake (7) by in large because it is based on the Health Belief Model.  This intervention does not realize that consumption of fruit and vegetables is influenced by processes at a number of levels, food distribution and accessibility, individual attitudes, like self-efficacy and social norms.  The Something Fresh campaign improves on the 5-A-Day campaign because it addresses all of the significant processes that facilitate fruit and vegetable intake.  Something Fresh addresses and eases practical barriers that inhibit people from accessing fruits and vegetables.  In addition, this campaign uses Social Cognitive Theory and self efficacy to encourage people to participate in this beneficial health behavior.  Lastly, this campaign uses Social Expectations Theory because of the importance of social norms in behavior change.  This intervention considers an individuals environment, attitudes and their social context and as a result is a more effective public health intervention.
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