Challenging Dogma - Spring 2009

Thursday, May 7, 2009

A1C Campaign; Early Phase Model Not Appropriate-Evan Johnson



There are close to 300 million people in the United States, and 23.6 million of them have diabetes.1  This accounts for 8% of the total population.  The total prevalence of diabetes increased 13.5% from 2005-2007. 1 A screening test used for the early detection of diabetes is an A1C count.  This value informs doctors how much sugar, on average, has been attached to your blood cells over the past 3 months.  A normal blood sugar is approximately 120 mg/dL.  Studies have shown that if you keep your A1C count below 7.0, your chances of complications from diabetes are significantly lower.1


In 2007, the Ad Council developed an intervention encouraging people to get their A1C checked.2  This involves a simple blood test that can produce results in about 30 minutes.1  To put forth their message, they designed a commercial that shows individuals being warned of unpleasant events.2 For example, a thief drives by a man packing a car for vacation and informs him that once he leaves, he’s going to rob his house.2  The advertisement makes the analogy between the robbery warning and the A1C value.  The Ad Council’s hope is that viewers will ask their doctors for an A1C check which will inform them of the likelihood they will suffer from diabetes and its complications.  The delivery of this preventative health behavior is flawed in three major ways. 




Perceived Severity


This commercial seems to have been designed largely around the Health Belief Model.  Individuals weigh the perceived risk and severity of a certain health problem and develop an appropriate healthy behavior change.3  A criticism of this intervention is that the perceived severity is not strong.  The ad briefly mentions that high A1C counts may lead complications of diabetes such as heart attacks.  If you would like people to start checking their A1C, this is not the way to go about it.  Most Americans have become numb to the warnings that certain behaviors can lead to heart attacks.  They are also aware of the medical benefits of good diet and exercise.  This ad is just basically throwing another term at the general public and will hardly motivate anyone to take the time to schedule an appointment with their doctor. 


Intention Leading to Behavior


Another criticism of the A1C intervention is maintaining the suggested behavior. One of the major draw backs of the Health Belief Model is the assumption that intention leads to behavior.3  Individuals decide the risk and the severity of the health problem is worthy of a behavior change.  They have every intention of inserting this new behavior into their lives.  The truth is that this new behavior is rarely maintained.  This advertisement might get people to check their A1C the next time they’re at the doctors, but do they make it a part of their annual checkups?  This could depend on what kind of result they receive from the test.  If the A1C value is below 7.0, one set of barriers will emerge.  If the value is greater than or equal to 7.0, a completely different set of barriers is generated that will prohibit the maintenance of the behavior. 


First, let’s assume the result is good, meaning under 7.0.  The individual makes a mental note of his physical status.  He or she will take notice of their weight, energy levels, strength, production, etc.  The problem occurs next year when the individual doesn’t bother with an A1C check because he or she physically feels the same as the year before.  This situation may lead to trouble.  The commercial states that individuals with an A1C of 7.0 or higher have a greater chance of developing heart disease.2  An A1C of 7.0 translates to having an average blood sugar of 170 mg/dL over the past three months.5  This is about 70 mg/dL higher from normal levels.5   Individuals will not be able to distinguish between a blood sugar of 100 mg/dL and 170 mg/dL.1  The person feels fine, so why bother making the appointment?  In order to initiate and maintain this behavior change, individuals watching the commercial will have to blindly accept the 7.0 A1C cutoff value between healthy and unhealthy as they will not have any physical reinforcement telling him or her something is wrong. 


Now what if a poor A1C result is received by a patient?  Again, the behavior maintenance of regularly checking your A1C counts is in question.  The person might not have any physical indicators telling them something is wrong.  A high A1C value alone will not be enough to “trigger” a behavior change.  Studies have shown that a lot of successful behavior changes are the product of some kind of significant “trigger” that pushes a person into action.  This is sometimes referred to as a “cue to action” and is responsible for individuals engaging in a preventative behavior in the Health Belief Model.3  My concern is that the A1C value by itself is not a strong enough factor to guide someone into a healthy behavior and in fact may lessen the chance the A1C check will be performed the next annual checkup. 


Also, if people know their A1C count is higher than suggested; this will be a definite barrier towards future testing.  The stress involved with obtaining the blood sample and then waiting for your doctor to inform you that your blood sugar level is above the acceptable range might be too much for some people.  If people are expecting stress, chances are they will become stressed once they step foot inside the doctor’s office. As Dan Ariely states in his book entitled Predictably Irrational, “If we acknowledge that we are trapped within our perspective, which partially blinds us to the truth…”6  This kind of negative reinforcement is a strong supporting factor towards not participating in the new preventative behavior.  To make matters worse, this barrier would be strengthened if the individual was currently feeling no adverse health issues. 


Lastly, the Ad Council’s intervention is assuming people reason in rational ways.  The viewing audience will weigh the risks and severity and in turn will make a rational decision to perform the healthy behavior change.   Informing the public that a preventative measure is needed to avoid serious health risks in the future will not cause individuals to spring into action.  Dan Ariely discusses people’s choices towards preventative health behaviors in Chapter 6 of Predictably Irrational.    “So while our long-term health and longevity depend on undergoing such tests, in the short term we procrastinate and procrastinate and procrastinate.”


Health Belief Model is too Shallow


As stated before, this commercial is largely based on the Health Belief Model.  One weakness of this model, which is the third major weakness of the commercial, is that it’s very shallow.  It does not dive into the background of the A1C test.  It does not address the cause of the high A1C nor the ways to lower the value.  It doesn’t tell the viewer what the A1C is measuring.  The commercial does state that a value of 7.0 or higher increases your chance of heart disease, but it doesn’t mention why this is such an important factor.


One of the first steps in a more advanced behavior model, named Precaution Adoption Model, is a “pre-contemplation” stage in which an individual becomes aware of a health problem through education.8  This stage is not part of the Health Belief Model and is a definite reason why the intervention is considered weak.3  Simple background information provides support that may strengthen individual’s intentions, which in turn, could lead to maintaining a behavior change. 


Not only does the Health Belief Model lack social norms and interactions, but it is not addressing the environment variable that is present in the upper echelon models.8  Environment is a crucial component to any social model that addresses behavior change.  In the A1C commercial, all the individuals are middle class people in their 40’s, driving nice cars, living in nice houses, and ordering shrimp at restaurants.  The Ad Council’s attempt to target this one demographic weakens the commercials effectiveness towards others who might have an entire different set of barriers to deal with.  Individuals with a low social economic status will definitely have a hard time connecting to the images they see in this commercial.  Also, without adequate information regarding A1C testing, the importance of the 3 month average blood sugar test will be lost.


On a more positive note, the Ad Council does try to improve on the Health Belief Model by injecting some social structure into the advertisement.  The burglar stops to warn the Dad of the robbery while he is packing the car for a family vacation.  The ambulance that drives by the family in the car has a warning message informing the couple that their A1C count is greater than 7.0.  It has been well established how important the social component is to behavior change. 




The intention of the A1C campaign put out by the Ad Council was to initiate the action of individuals receiving A1C checks at their doctor’s office.  The message would be set forth by a commercial that was largely designed according the Health Belief Model.  This is the correct tool for a campaign without a ton of public knowledge; the idea being to get the suggested health behavior in the minds of the general public to entice some motivation.  I argued that this is not the correct approach to combat a disease as well known as type 2 diabetes.  The ground work has already been layed down.  The effectiveness of the Health Belief Model is moderately attenuated at the awareness level that type 2 diabetes has reached.  The advertisement addressed in this paper is piling on yet another term for the general public to link to diabetes.  The perceived severity of diabetes is downplayed by mentioning the risk of heart attacks; a condition any healthy man in his 30’s is subject to.  This message will impel few into action.  I believe more sophisticated interventions are needed to motivate individuals who have been hearing about heart attacks, diabetes, exercise, and diet for at least a quarter of their lives. 












Improvements to the Health Belief Model Approach


            To address the three main weaknesses of in the Ad Council’s intervention, I will propose a new strategy.   This new intervention will increase the perceived severity, improve the maintenance of the recommended new behavior, will implement more social factors, and incorporate a more sophisticated decision making process in order to reduce the shallowness of the model. 

            The new intervention will start with community bulletin boards that will display one of the extreme health conditions, other than heart attacks, associated with high blood sugars.   The all white canvases will also display a statistic linking diabetes to the condition.  For example, diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.9  The bulletin board will also briefly display  benefits of A1C testing and list the dates and times of local community testing centers.  The message can also be displayed via small posters hung at post offices, main intersections, shopping centers, etc.  The actual A1C tests will be performed by a few nurses and nursing assistants.  The results can be made available in about 20 minutes.  Public Health counselors will be on hand to answer any questions that people may have.  To add legitimacy to the operation, perhaps the town Mayor or Selectman/Selectwoman could also participate.  This will strengthen the community interaction and add a “social norm” element to the activity.  The results of each A1C can be discussed with the participants.  If they are high, they can schedule an appointment with their primary care physician.  If it is normal, the counselors can emphasize that it should be checked again during their routine annual doctor examinations.  I believe this approach will add the necessary social context, urge individuals into action, and eliminate a few of the potential inhibiting barriers. 


Enriched Behavior Model


As the Health belief model is too shallow for implementing a new long term health behavior.   The new intervention will focus around the Precaution Adoption Process Model.8  This model has 7 stages.8  The strength of this model is that it takes into account a number of processes involved when moving between the different stages.  The barriers that are encountered at one stage are completely different than the ones confronted at another. As this is an important element to this model, the stages must occur in order.8  Additionally, by using an advanced model as the initial framework, the new intervention will inject elements of individuals’ social environment.


The first step of this “advanced” model is the awareness that a problem actually exists.  This is called the “precontemplation’ stage and it is crucial.  The Ad Council’s advertisement seemed to be geared solely on this stage.  It lets people know that high A1C values are a problem and in turn, allowed individuals to progress from stage 1.  The next level, stage 2, includes people who are aware of the issue but are not going to do anything about it.  This stage contains people who do not believe the perceived severity and/or perceived risk is high enough to warrant action.  Unfortunately, this is where the Ad Council’s campaign loses its effectiveness.  The new campaign provides awareness through bulletin boards and posters that provide a more information about the importance of the A1C test and its correlation with Type 1 and Type 2 diabetes.


A goal of the new intervention would be to get individuals into stage 3 where the individuals are “engaged to act”.  To make the leap from stage 2 to stage 3 requires acceptance of perceived severity and perceived risk.  I believe perceived risk is not an issue.  Since the United States has a large obesity rate, the media is littered with information about the potential causes of diabetes.  The risk is well understood.  The perceived severity is not a strength of the Ad Council’s advertisement.  The general public needs to know that heart attacks are not the only adverse condition on the horizon for people with poor control.


Boosting Perceived Severity


The Ad Council needs to ratchet up the severity of Diabetes to motivate individuals from stage 3.  Even though heart attacks are an extremely serious condition, sadly, the threat of their occurrence has become ubiquitous.  The intervention needs to inject a few health conditions, which do not already have such a large prevalence in the United States.  The intervention should utilize the bulletin board showcasing ability of the fact that having continuous high blood sugars can lead to blindness, kidney failure, and amputations as its deterrent.  If you notify the public of these complications, it may trigger some action.  If you look at the current treatment options for kidney failure, blindness, and foot nerve damage, these complications trump the surgical treatments of heart disease in the realm of severity. 


Making Good on its Intentions


Assuming the horrible consequences of high blood sugars are now realized, the next progression is to stage 4 or stage 5.  Stage 4 is achieved when individuals ultimately decide not to act.  This stage is reached due to the individuals becoming overwhelmed by potential barriers.  The barrier discussed already is minimal physical indications of high blood sugar.  One way to compete with this barrier is through information that can be displayed on the bulletin board and posters.  A list could be created that identifies the top three signs that your blood sugar is too high.  According to the American Diabetes Association, the list would include an increase in thirst, an increase in urination, and lack of energy.1   Unfortunately, this is not a perfect solution as some people wouldn’t develop any noticeable symptoms until their blood sugar reaches around 300 mg/dL.   One individual with a blood sugar of 200, which is still twice the normal level, might not notice any symptoms.  However this is a starting point.  Hopefully, the other information listed on the poster will persuade them to initiate a test.


Another barrier would be the fear of the doctor’s office.  This barrier is eliminated by having community screening sites for individuals who do not have access to doctors or a fear of doctors’ offices.   The A1C test requires a minimal amount of blood and results are available in about 20 minutes.  Individuals may be more comfortable receiving an A1C test in a mall, drug store, or town hall.  While waiting for results, a counselor could answer any questions the visitors have regarding the correlation between diabetes and A1C measurements.  After eliminating the barriers, a person will decide that action is the best decision and move on to stage 5. 


Once stage 5 is achieved and the decision to act is made, this still does not imply that the action will occur.  Stage 6 is where the action actually takes place.  The individual decides to get his or her A1C count measured in either a doctor’s office or community center.  The next challenge will be reaching stage 7;   maintaining the action.  In order to reach this final stage, Dan Ariely suggests that a good way to make sure people perform preventative health care measures is to package them into bundles.7  The workers at the testing site or the nurses at the doctors office can inform people that the A1C test is a simple blood test that does not require any additional blood collection other than what is already collected during a routine doctor’s visit.  This would be added to the other tests , for example cholesterol and sodium levels,  that are performed during an annual physical examination.  The important factor is getting initially tested.  Once that occurs, it will take minimal effort to convince them that it’s needed every time they visit the doctor’s office.


I believe the new intervention addresses the three major issues with the Ad Council’s commercial.  It boosts the perceived severity by providing not so common health risks.  Through the elimination of barriers it helps transform an individual’s position from just intending to adopt a new behavior into actually performing the behavior.  Lastly, the new intervention has social components and is also built around a more sophisticated model.  The enriched model includes two stages of awareness, two stages for engagement, and two stages for the decision to act.  


The Ad Council’s campaign is a terrific start.  It feeds important information to society about a simple routine test that can hopefully prevent an individual from developing Type II Diabetes.  Unfortunately, it was too little too late.  The prevalence of heart attacks and diabetes is too high to make people spring too action from a simple 30 second television advertisement. 















1 American Diabetes Association. All about Diabetes: Diabetes Statistics.   Mt.  Morris, IL:

2 Ad Council. Diabetes – A1C  Warnings One-Restaurant. ISCI CNED-7383 McCann Erickson, Sep 05, 2007 .

3 Edberg M. Individual Health Behavior Theories . Essentials of Health Behav Soc and Behav Theory in Pub Health. 2007:35-39.

4 Ariely D.   Predictably Irrational.  The Hidden Forces That Shape Our Decisions. New York, NY:    Harper Collins, 2008.

5Medindia. Diabetes Tools. HbA1c or A1c Calculator for Blood Glucose.

6 Ariely D.  The Effect of Expectations (pp. 172). In:  Predictably Irrational.  The Hidden Forces That Shape Our Decisions. New York, NY:    Harper Collins, 2008.

7 Ariely D.  The Problem of Procrastination  and Self-Control (pp. 121). In:  Predictably Irrational.  The Hidden Forces That Shape Our Decisions. New York, NY:    Harper Collins, 2008.

8Edberg M. Individual Health Behavior Theories . Essentials of Health Behav Soc and Behav Theory in Pub Health. 2007:44-45.

9dLife: for your diabetes life! Vision Complications of Type 1 Diabetes Westport, CT:


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