Challenging Dogma - Spring 2009

Monday, May 11, 2009

Informational Approaches Targeted to Promote Physical Activity- the Breakdown and Futility for Our Obese Population- Julie O’Shea


A sedentary lifestyle or lack of physical activity contributes overwhelmingly to an individual’s risk of disease which has burdened our healthcare system. The lack of physical activity has been demonstrated to be a contributing cause of the obesity epidemic and may contribute to a decreased quality of health in the public [1, 2]. In the United States, heart disease and stroke have been the first and third causes of death for decades [3]. Also in the US, only 25% of adults report performing the recommended activity level (i.e. 30 minutes of moderate or intense activity on 5 or more days), despite the public’s general knowledge in the benefits of regular physical activity [4]. It has been shown that an increase in physical activity level may decrease coronary disease mortality by 5% suggested by a theoretical estimate of the US public health burden [5]. Additionally, physical inactivity is a factor and associated risk with some cancers [6]. Finally, the initiative from the US government, Healthy People 2010 has ranked physical activity as a leading health indicator [4]. Despite the knowledge of the importance of physical activity, public health initiatives directed at this issue continue to fall short in their impact and effectiveness.

Consideration of the Health Belief Model

Applying the health belief model, most approaches have utilized the notion that by providing health information for risk reduction of disease, people will be motivated to increase their physical activity and change their behavior [7]. This frequently does not occur. The Stanford Five City project is an example of a community based informational campaign that has been shown to be ineffective for this reason [8]. The use of the Health Belief Model, poor framing and lack of knowledge of environmental factors contributed to the failure of this community approach.

The Stanford five City project was a community health education program for improving the knowledge, attitudes and behaviors toward physical activity targeting the residents of 2 communities of California [9]. The dissemination of information promoting the benefits of physical activity was included in the intervention in a stepwise fashion over 6 years. Other parts of the intervention included news column, workshops, organized events, media such as TV segments and worksite and school based education programs. The benefits of regular physical activity communicated via educational messages were the key integral motivating factor this intervention was dependent on [8].

This intervention, which has taken its cue from the traditional Health Belief Model, is flawed on this level. The educational programs of the Stanford Five city project have been outlined in the tenets of the Health belief model. That is, if you provide the information of perceived susceptibility and severity of diseases due to sedentary lifestyle, the people in the community exposed to this message will change their behavior. It assumes the individual will have a rational weighing of the message of risk with physical inactivity and thus change their behavior from the intention they have formulated [7]. This idea is based on people making rational health choices and does not account for multilevel variables at play in the people’s lives that may or may not be altered. The barriers of incorporating exercise are not addressed in this intervention. A person’s time commitments to work, family and care giving are not accounted for or resource availability. The way the information was provided to these communities was based on the health belief model of severity and susceptibility. The education of the public was directed on the individual level. Although the campaign delivered the message on varied channels, it did not account for the environmental variables that could impact the individual’s ability to increase their physical activity. The complex behavior of incorporating physical activity into one’ lifestyle was not taken into account in this campaign [10].

Consideration of Framing and Marketing Techniques

The campaign used the benefits of physical activity and the promotion of health as the core value of the campaign. The interventions were not framed in a deep core value to get the topic of physical activity on the agenda of this population. The way in which the community viewed the behavior of exercise can be impacted greatly by framing through mass media images [11]. This campaign framed physical activity in a value of only health promotion and not surprising the public was not impacted greatly by the intervention [12].

There is a wealth of data that demonstrates the effectiveness of utilizing marketing theory and branding [13]. Consumer research regarding the population to motivate behavior change was not adequately performed in the Stanford Five City Project. This was evidenced by the lack of awareness to utilize framing, agenda setting and marketing techniques.

The framing and presentation of information in the mass media, which is inevitably part of any community wide campaign, can actually systematically effect and impact how the recipients understand the information presented [14]. There is no indication that any mass media research was undertaken or performed to frame the health information in a meaningful way in this intervention. When the community was receiving the health information through the various outlets, there was no dramatic heart wrenching or deeply touching aspect of the campaign that hit people where it matters. The health information was not framed in a compelling way in this campaign. When a person’s heart or soul is impacted, behavior can change. Although in the public health domain in the past, we have not discussed the heart and soul of the public. Advertising has been changing the way consumers purchase by these techniques for decades [11]. I argue that when the community wide campaigns adopt a more compelling and soul touching script of a core value of family, freedom or sex, only then will the population adopt health promoting behaviors such as increasing physical activity.

The Stanford Five project in the early 1980s did little to determine how to alter the people’s behavior. The research that was performed was not integrated in a multilevel system to determine other variables and factors that were preventing the participation of community members.

Consideration of the Environment

The health education intervention occurred in the two communities of Modesto and San Luis Obispo. The intervention did not include a multilevel analysis of contributing factors which discourage physical activity such as availability of a public park or trail system in these communities. Neighborhood features that do not encourage physical activity have been shown to consistently demonstrate an increase body mass index among residents of those neighborhoods [15]. The Stanford Five Project did not put on the agenda sidewalk or park renovation in their intervention. Without access or availability to a park or playground, families are limited in their ability to incorporate physical activity into their lives. In addition, active commuting to school can be an overlooked source for youngster’s activity [16]. The proximity of public parks to residential communities has been associated with physical activity. Parks are common places to exercise and park use and proximity to the park can be predictors of exercise level of the individual [17].

How one interacts with their built environment and the impact of one’s place can directly impact a person’s health [18]. How livable the community is for the population, the availability for walking and bicycling paths and neighborhood design can all impact health promotion [19]. The Stanford Five Project, although determined the community’s attitude toward physical activity with questionnaires, it did not analyze or begin to look at the level of the environment. Whether traffic, lighting or sidewalk maintenance had at all been examined, these urban design factors can be an influencing variable on the physical activity level of the population [20]. In a study by Craig, when university education, income and poverty levels were controlled for, the environment score, which included features of the neighborhood including routes, transportation, visual aspects, safety and crime, was positively associated with walking to work [21]. The environmental barriers to walking were not considered as potentially threatening to physical activity in Modesto and San Luis Obispo in the intervention discussed.


This campaign based off a health belief model approach, framing the behavior change in only a health promotion value and not examining the built environment and other environmental factors has contributed to its woeful results in attempting to improve the physical activity level of the population in these 2 Californian cities. The recent highly publicized increase in obesity rates and health care costs, although have put physical inactivity on the agenda, has not dramatically shifted the approach of what was performed over 20 years ago. Our profession must be innovative in their design and execution of a more compelling way to change the lifestyle of the population to improve physical activity rates. The approach of increasing physical activity in our culture must include policy of environmental approaches, outreach on a more compelling level framed in a way to have impact and must evolve from a health belief model of providing the information and falsely thinking people will change. The Stanford Five City Project took place in the early part of the 1980’s, it is a good warning for a more refined approach to take public health intervention to the next level to produce results and improve the health of the community. Our nation’s population lives in a high risk environment which the public health community must not ignore.

Written Assignment #4

Get Moving or Get Trapped Campaign


As discussed, the Stanford Five City Project campaign, a community based informational approach campaign to increase physical activity, has been inadequate and ineffective. The following proposal could solve the previous flaws in the Stanford Five City Project and impact the public’s inactivity and improve the health and wellness of the community. My proposed intervention, ‘Get Moving or Get Trapped’, will be described and could unburden our system with the complications of diseases associated with physical inactivity.

This campaign will be different in a variety of ways. The ‘Get Moving or Get Trapped’ campaign will be modeled on the Diffusion of Innovation Theory rather than the Health Belief Model. The information to increase physical activity will be communicated over time throughout the social system. [22] Various revered members of the community will be delivering the message to increase physical activity for the diffusion to occur more rapidly and most efficiently. The program will not use good health as the core value, but freedom. It will frame physical inactivity as a form of prison, using ad campaigns and propaganda to change people’s perception of how they view walking and biking. This will be combined with a dramatic change in public policy and infrastructure and urban development. Urban planning will be incorporated into the campaign. The community will be beautified with parks, walking and biking paths and a reliable transit system to increase commutes without vehicle use. The mass media approach, diffusing the idea of increasing physical activity via community members, framed in a new way using mass advertising and the change in the built environment combined, will allow for the public to adopt the lifestyle change of increasing activity through walking and biking and be an effective alternative intervention.

Addressing the flaw of the Health Belief Model

The program will not be based on the Health Belief Model, but an alternative model, the Diffusion of Innovation theory. This model allows for a process by which the intervention will be communicated over time through various modes to the public. [22] It will be a social change among members of the public. The message of increasing physical activity will be delivered by high profile members of the community, who are considered a highly credible source. Typically when television ad campaigns are from a trusted source those members of the society are used as an agent for change. [23] In the ‘Get Moving or Get Trapped’ campaign multiple people will participate in the ad campaign on various channels to deliver the message of walking to destinations, increasing activity and changing their physical activity. The information will be diffused to the public and disseminated with this message in a continually reinforcing way.

The message of increasing physical activity delivered by these trusted individuals can be a very efficient jump start to any public health initiative. When a small subset of the population begins to adopt the behavior and increase their activity by walking, the initiative can spread quickly through the social network. [24] This efficiency can be dramatic since opinion leaders in the community can influence the majority of the public and facilitate rapid behavior change through the diffusion process. [25] In my intervention celebrities, community leaders and positive newsworthy individuals will be utilized to deliver the message to increase physical activity. The idea of walking to work, school or errands will be the main message to increase activity. This idea will be diffused rapidly by the opinion leaders since it will be considered better than sitting in your car in traffic. The alternative innovation will appeal to people and be considered a better idea which has shown to increase diffusion of a behavior. [25] The public will therefore increase their level of activity.

Addressing the flaw of Framing and Marketing Techniques

As the message of increased walking will be diffused via the ad campaigns there will be a mass media approach that frames the increase in physical activity not in a value of health, but freedom and alternative lifestyle. The commercials’ will frame driving, being stuck in traffic as being in a prison, a prison of your mind, body and spirit. Walking and/or biking to work, school or the store will be portrayed as a way to exercise your right to be free, your right as an American. The ads will show that sitting in our car is a form of oppression, a way to be trapped. The ‘Get moving or Get Trapped’ campaign will use the framing theory to change how physical activity is viewed which will impact the community. [11]

When the TV stations and radio stations begin to flood the airwaves with this campaign, people will begin to walk to work and school and increase their physical activity without thinking of their health, but their freedom. Their desire to not be trapped, not be stuck, stuck in the car or stuck in a body, will compel and motivate them to incorporate walking into their everyday life. It will become habitual and be adopted as a lifestyle change.

Addressing the flaw of the Environment

As this diffusion of this idea to walk/bike is rapidly catching on, along with the framing of walking as a way to exercise your freedom, the community environment will be examined and modified. In this intervention, ‘Get Moving or Get Trapped’, the community will be studied and areas of improvement will be targeted. Available evidence has demonstrated that if the built environment promotes biking and walking it will help create more active healthier individuals. [26] The access to bike paths, walking trails and recreational facilities has been associated with increases in physical activity levels. [27] The urban design of the neighborhood in the community can impact and influence how active the population will be. [21] In our proposed intervention a task force will study the community and perform focused research on traffic, safety, lighting, sidewalk availability and aesthetic of routes. After this information is gathered, any area without sidewalks or appropriate lighting will be redeveloped for more pedestrian traffic. If safety was determined to be an issue this will be targeted for community development with an increase in police activity patrols on foot and bike. A trail system which will link residential neighborhoods to shopping districts, office parks and any public transportation system available will be implemented.

Additionally a beautification program will be part of the ‘Get Moving or Get Trapped’ campaign. Flowers and trees will be planted in public areas to increase people’s desire to walk and enjoy their environment. The community will want to walk to be part of the growing group of individuals who are using the new sidewalks, benefitting from the changing community aesthetics and therefore their physical activity will increase. The feeling of belonging to a community can motivate individuals to have pride in their neighborhood.


This alternative intervention has addressed the flaws in the previous campaign in a skillful and productive manner. By taking advantage of the diffusion of innovation theory, the idea of changing physical inactivity will catch on like wildfire, especially with the advantage of key opinion leaders in the community. By framing the ad campaign in a value of freedom and not health, the desire to be free and not a prisoner will be more compelling then changing their physical activity for health reasons. Finally, by orchestrating changes to address deficits in the built environment, which detract from walking and biking, the public will change their physical activity level in dramatic ways. As described, the ‘Get Moving or Get Trapped’ campaign could impact a community in a powerful way to shift and alter lifestyles to incorporate walking as a way to increase physical activity and ultimately improve the community’s health.


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