“Small Steps” Against a Big Problem: Failure of the Health Belief Model to Successfully Combat Obesity – Jiayang Chien
The US Department of Health and Human Services, in an attempt to combat the ever-growing obesity epidemic, launched the “Healthy Lifestyles and Disease Prevention Media Campaign”, abbreviated the “Small Step” campaign (www.smallstep.gov), in March of 2004 (1). Based on the idea that obesity prevention should not require “extreme” measures such as “joining the gym or taking part in the latest diet plan” (2), “Small Step” is centered around over 100 tips that promote healthier eating and physical activity, designed to be easily incorporated into one’s lifestyle. At first glance, this campaign looks promising. Its homepage acknowledges the structural barriers that prevent Americans from staying in shape, including living in neighborhoods without sidewalks, over-reliance on automobiles for transportation, and being surrounded by foods high in calories and fat (3). The tips are intended to empower people by showing them how to make small, easily achievable changes to their existing routines that will eventually add up to a healthier overall lifestyle. In the long run, these changes will presumably prevent obesity in spite of existing barriers to health.
Careful research went into the production of this campaign. According to the HHS campaign report, the theoretical framework for this campaign included the Consumer Information Processing model, Social Marketing, Social Learning Theory, and the Transtheoretical (Stages of Change) model (1). Using these, the HHS, in collaboration with the Ad Council, designed a series of print advertisements and public service announcements (PSAs) intended to be attention-grabbing, promote self-efficacy, and steer individuals through the stages of behavioral change by giving them incremental steps to work with. The advertisement materials underwent extensive focus group testing with both clinicians and target audience members drawn from high-risk population subgroups, such as African-Americans and Hispanics.
Despite positive feedback from target audience focus groups (1), this campaign has been criticized for being ineffective and disappointing (4). The reasons for this stem from the theoretical underpinnings of the campaign. Although “Small Step” was intended to be modeled on Social Learning Theory, principles of Social Marketing, and other group-based models of behavior, its core components, the 100-plus “steps”, actually stem from the Health Belief Model. Perhaps because the HBM was not intentionally used, its application is incomplete and leaves parts of the model unaddressed. Additionally, “Small Step” suffers from the inherent limitations of the HBM—specifically, that it ignores environmental factors affecting behavior, and assumes that people act in rational ways. Finally, despite best intentions, this campaign is poorly designed to accommodate the broad diversity of the American population, and instead tries to use a “one size fits all” approach to behavior modification. These three factors together make the “Small Step” campaign ultimately ineffectual at combating the obesity epidemic.
1. The Health Belief Model is incomplete and poorly applied.
Upon close inspection, “Small Step” may be more accurately described as a campaign based on the Health Belief Model (HBM) rather than the ones listed by the HHS. The HBM posits that a rational weighing of benefits and barriers determines one’s intention and, ultimately, behavior (5). The target audience of “Small Step”, as described by Ad Council, consists of “Jaded Can’t Doers” who “need to be convinced that a healthier lifestyle is attainable” (1). Based on this, it is clear that the campaign’s focus is decreasing one’s perceived barriers against healthy eating and engaging in physical activity. “Small Step” does not, however, use the complete HBM; it only addresses a few of the barriers that prevent people from adopting healthier behavior, and ignores the benefits of obesity prevention—perhaps assuming that people are already aware of them.
The website mentions alarming statistics on the prevalence of obesity (2 out of 3 Americans are overweight or obese), as well as the health effects thereof (diabetes, heart disease, hypertension), sending the message that every American is susceptible to becoming obese, and that the consequences are severe. Logically, therefore, the primary benefit of weight management is the prevention of these health consequences; yet, these benefits are not explicitly mentioned. The campaign’s PSAs, in an attempt to use humor as an attention grabber, all follow a storyline where some characters find a flesh-colored mass lying on the ground that turns out to be an extraneous body mass (e.g. double chin) that was shed in the course of following one of the “Small Step” tips. There is certainly shock value in this approach, but these commercials do not show any positive effects of following the “Small Step” tips. In fact, one might argue that by focusing on body parts, the campaign is inappropriately emphasizing the aesthetic aspects of weight management, which, if taken to an extreme, could ultimately lead to another type of unhealthy behavior: eating disorders (6). Furthermore, the unappealing visual imagery of disembodied parts may cause audiences to want to change the channel rather than learn more about obesity prevention.
The entire “Small Step” approach is based around the idea of overcoming barriers to achieve healthy behaviors; it is an unfortunate irony, therefore, that many of these “simple and free” tips ignore the two largest barriers that prevent individuals from making good lifestyle choices in general: money, and time. For example, “instead of eating out, bring a healthy, low calorie lunch to work” requires that the person has time to prepare said meal ahead of time, which is not always a realistic expectation. Telling people to “order smaller sizes” when eating out ignores the economic incentive to super-size. Even physical barriers to healthy behavior are often ignored. “Use a snow shovel instead of a snow blower” or “wash the car by hand” may be an option for younger adults who are already in good physical shape, but such un-ergonomic strenuous labor could injure others. Tips like “walk kids to school” or “get off a stop early and walk” assume that most people live in towns where schools are located close to residences, where there are sufficient sidewalks, and where there is public transportation. Unfortunately, due to prevailing land zoning practices, such walkable areas are scarce in the US (7), which is the real barrier. Furthermore, in order to substitute more active modes of transportation for driving, people must budget more commuting time into their daily routines, which adds rather than subtracts barriers to increasing physical activity.
In failing to acknowledge these additional barriers to effective prevention of obesity, the “Small Step” campaign conveys the message that people make poor lifestyle choices simply because they do not know any better. As a result, many of the tips presented on the website or in the PSAs come across as patronizing, much like a disapproving teacher chastising students for failing to follow the rules. Such an approach is likely to alienate rather than engage people, so that they are turned off not only by the campaign, but the message that it promotes (4). Then, even tips that may be of real help (e.g. “Be sensible. Enjoy the foods you eat, just don’t overdo it”) fail to reach their intended audience.
2. Limitations inherent to HBM mean limitations for “Small Step”.
Even when correctly and comprehensively applied, the HBM suffers from several major limitations that make it a less-than-ideal model for many public health campaigns. The “Small Step” campaign, being based on an incomplete rendition of the HBM, therefore also suffers from these constraints, making it ultimately ineffective.
One of the limitations of the HBM is that it assumes human behavior to be based on rational decision-making; this goes along with the aforementioned assumption that people do not make healthy choices because they do not know how to. “Small Step” bases the entire campaign on knowledge: “We are bombarded every day with conflicting information about our health… It's no wonder that many of us throw up our hands and give up. But if we want to live long and fulfilling lives, it's essential that we learn the real facts about health, nutrition, and physical activity” (3). The campaign neglects the psychological and emotional components of behavior, which may actually be more influential than the rational. People have a tendency to crave food—especially high-calorie, high-fat, high-sugar foods that are most likely to cause obesity—when under stress. Issues of body image and self-esteem, which, as previously mentioned, may be exacerbated by the “Small Step” PSAs, play a major role in preventing overweight individuals from becoming more active. Indeed, in failing to recognize that emotions are strongly tied to behaviors, “Small Step” has made the mistake of using visually gross images of disembodied body parts in their PSAs, thereby inadvertently associating obesity prevention behavior with feelings of disgust.
Another criticism of the HBM is that it assumes people are in full control of their behavior, and that intention necessarily leads to behavior. “Small Step” does recognize that many individuals struggle with self-control when it comes to food, but does not provide lasting solutions to this problem. For example, tips such as “store especially tempting foods, like cookies, chips, or ice cream, out of immediate eyesight, like on a high shelf or at the back of a freezer” or “eat off smaller plates” are ways for people to trick themselves into better portion control. However, food storage habits need to be maintained over long periods of time to be effective, and smaller plates may be compensated for by second servings—which is addressed separately in another tip: “Before going back for seconds, wait 10 or 15 minutes”.
Another prevalent recommendation in the campaign is that people substitute low-fat, low-calorie ingredients for what they may normally use or eat. For example: vegetable oil instead of shortening, low-fat milk instead of cream in coffee, and diet sodas for regular sodas. While this does make obesity prevention appear less threatening and, therefore, easier to accomplish (since people are not forced to give up their preferred foods), in the long run, this approach may backfire. Ingredient substitutions often alter a food’s taste or texture, making them difficult to maintain. Additionally, simply attempting to create low-fat versions of inherently high-fat foods does not address the larger problem, which is that people crave these high-fat foods in the first place. Rather than relying on psychological tricks to deal with the self-control issue, it may be more effective to acknowledge it and tackle it head-on.
Finally, the HBM ignores many of the external factors influencing individuals’ behavior. As already mentioned, several of these factors (e.g. money, time) are out of the individual’s control and therefore are significant barriers to obesity prevention. But what is often overlooked is the fact that the external environment can also be a valuable resource to promote healthy behaviors. For example, social networks can provide a source of encouragement and support for someone having difficulty managing his or her weight, and in fact, socialization can help motivate an individual to begin or maintain a healthy behavior. Rather than suggesting this, however, “Small Step” recommends some behaviors that are likely to be perceived as strange or eccentric. For example, “skat[ing] to work instead of driving” may negatively affect one’s professional image. Other suggestions, such as “when eating out, ask your server to put half of your entrée in a to-go bag” may conflict with established social norms of the area; in such a case, this request would only annoy the server, give the customer a bad reputation, and perhaps create awkwardness and embarrassment, thereby ensuring that this behavior will not be repeated again. Whether as an obstacle or a resource, external factors do matter and cannot be ignored if one hopes to successfully alter behavior.
3. One size does not fit all of America.
The third and final criticism of the “Small Step” campaign is that it fails to account for the broad socioeconomic, ethnic/cultural, and geographic diversity of the American population. These factors impact not just the individual’s risk of becoming obese, but also the availability of resources with which to prevent it or mitigate its effects.
Socioeconomic status has been shown to correlate highly with poor health outcomes even after controlling for other variables (8). Though the exact mechanisms by which this occurs is not known, the fact that lack of economic resources greatly constrains choice plays a part. Some of the economic barriers previously mentioned (e.g. incentive to super-size meals) are but superficial examples of a much broader issue. Individuals in low SES strata are often employed in high-stress jobs with long hours, or live in neighborhoods where walking may not be safe, and that are avoided by businesses such as supermarkets. Though there are over 100 “Small Step” tips, most of them are not applicable in situations such as these.
Though “Small Step” was launched with the intention of reaching racial/ethnic groups at high risk of becoming obese, such as African-Americans and Hispanics, the cultural diversity of the campaign does not extend any further than including ethnic minority actors and models in the PSAs and print advertisements. Some tips encourage individuals to “try new fruits and vegetables” and “eat ethnic foods”, but the nutritional guidelines and cooking information make no mention of these foods. For someone whose dietary patterns vary from that of the “typical” American, then, it may difficult to see how they fit into the healthy eating picture, and conversely, how obesity prevention applies to them. Additionally, the campaign focuses exclusively on the rational basis for food choices when in reality, eating is a social activity in many cultures. Social and cultural values may factor into which restaurant someone chooses when meeting with friends, or what dishes they cook when having company in their homes. For example, in many Asian cultures, a higher value is placed on meat compared to vegetable dishes.
Geographic diversity is yet another feature of the American population that is often ignored by public health campaigns. Urban and suburban living environments are drastically different in design, with the former being more pedestrian-friendly than the latter. Tips like “walk to work” are simply not feasible in many suburbs where roads have no sidewalks and cars travel at speeds that would make vehicle-pedestrian collisions fatal, and where public transportation is simply unavailable. In terms of food, the different regional cuisines of the country do not always lend themselves easily to obesity prevention. The south, in particular, is known for its high-calorie dishes that heavily rely on creams, butters, and oils. Simply telling people to make ingredient substitutions—which may alter the taste of traditional foods—will not be sufficient to promote healthier eating. Instead, a successful obesity prevention campaign will have to specifically target different regions of the country and think of ways to promote exercise and healthy eating keeping in mind both the physical and cultural geography of where they live.
Fundamentally, the “Small Step” campaign suffers from what one critic calls “small vision” (4). That this campaign fails to acknowledge the larger social, practical, psychological, and emotional influences on behavior has already been discussed. In choosing to focus on individual level behaviors for this campaign, the HHS intended to empower individuals and give them things that they can do in the scope of their own lives in spite of existing obstacles beyond their control (1). But by completely ignoring these obstacles, the campaign’s tips for change become impractical and unrealistic. Furthermore, in failing to account for the diversity of the American population, the “Small Step” campaign alienates the high-risk groups it needs to reach the most: those minority groups with higher risk of obesity, people with lower socioeconomic status, and those who live in areas built for cars, not pedestrians.
These problems can be remedied to a certain extent, with the following recommendations. First, “Small Step” can make its campaign message more appealing and palatable to its audience by emphasizing the benefits of healthy eating and exercise. The current advertisements only address barriers to healthy behaviors, and the imagery used in the PSAs is unappealing. In terms of applying the HBM, the current campaign has only done half the job, which can only be remedied by shifting the focus of the advertisements to the beneficial aspects of healthy behavior. Changing the imagery used in promotional materials to connote positive ideals of health, beauty, and energy will provide viewers with positive motivational cues for healthy behaviors, making the campaign more effective.
Second, “Small Step” should turn the scattered, poorly organized tips that comprise the core of its campaign into a comprehensive, progressive program. This can be achieved by getting rid of tips that are unrealistic or repetitive, reorganizing the remaining tips into categories targeted toward people in specific situations, and expanding certain sections to encompass a wider range of living situations. In this way, the campaign can better serve the needs of a diverse population, including people in different socioeconomic strata, from various ethnic and cultural backgrounds, and who live in diverse geographic landscapes. Instead of a one-size-fits-all approach, the website can allow users to better access tips custom-tailored to their specific needs.
Finally, and perhaps most importantly, “Small Step” must be integrated with broader initiatives at the population level. Behavioral changes can help to prevent or mitigate the effects of obesity, but if the environmental causes are not addressed, then results are likely to be very limited. It is important, therefore, for “Small Step” to present itself not as a catch-all solution to the problem of obesity, but rather, as a part of a larger effort aimed at addressing the fundamental causes thereof. A more detailed discussion of these three suggestions follows.
1. Focus on positive aspects of healthy behaviors.
Imagery is key to marketing any product; indeed, many advertising campaigns are able to successfully sell consumer products by using beautiful models and scripted scenes to associate products with ideals, such as beauty, youth, happiness, and of course, sex. The current “Small Step” PSAs, in an attempt at humor, use images of discarded body parts, which may evoke feelings of disgust among audience members and lead to rejection of the campaign. A better strategy would be to imitate the aforementioned successful advertising campaigns and use positive images to “sell” the “product” of healthy behaviors. “Small Step” could create advertisements in which attractive, healthy-looking people promote the benefits of following some of the tips on the campaign, such as having more energy, feeling better about their appearance, and worrying less about developing certain health problems. By associating healthy eating and physical activity with positive ideals such as health, beauty, and vitality, the advertisements become more palatable and easily accepted by viewers. Moreover, explicitly showing the benefits of healthy behaviors would allow people to more easily visualize the goals of the program, which could provide motivation to stick with it.
“Small Step” PSAs should also send a positive message of empowerment to its viewers. The previous discussion of the campaign criticizes its failure to directly address the issue of self-control, which is a major barrier to adopting or maintaining healthy eating and exercise behaviors. To directly confront this issue, “Small Step” must step beyond the rational basis for behaviors and acknowledge the complex psychological and emotional components of eating and exercise behaviors; in other words, shift from simply telling people what to do and why, to making them feel good about doing it. For example, advertisements can depict people in various situations overcoming the temptation to eat unhealthily or shirk out of physical activity. One or two motivational slogans could be repeated throughout the campaign to further emphasis self-empowerment.
In adopting these strategies strategy, “Small Step” should take care to portray people in realistic situations. Empowerment messages should limit their scope to address only the barriers that can be overcome by individual behaviors (for example, the temptation to take the elevator). Portrayals of unrealistic outcomes of behavior changes may cause the audience to reject the campaign altogether. In some cases, unhealthy food behaviors that lead to obesity may be linked to psychiatric disorders (9, 10). The “Small Step” website should acknowledge this and provide links to resources for these individuals. In a related vein, promotional materials should feature actors who are of normal weight. Currently, media advertising is filled with images of models who glamorize thinness to such an extent that may, many health professionals argue, encourage people to engage in unhealthy, self-destructive behaviors (6, 11). To counteract this alarming trend, “Small Step” advertisements should glamorize people who are healthy and who represent a wide range of body types, to combat not just overweight, but underweight as well. Audiences will more readily identify with images of regular people portrayed in realistic situations, and the overall message of the campaign will thus become more readily accepted.
2. Turn scattered tips into a comprehensive, targeted program.
The 100-plus tips that comprise the core of the “Small Step” campaign are far from perfect. As mentioned previously, many of these tips make assumptions about the socioeconomic, geographic, and cultural situations in which people live, and are therefore unfeasible. Furthermore, these tips are organized in a haphazard way on the website, so that the effort involved in going through the entire list and sorting out which tips are applicable to them may completely offset the convenience of having small, manageable tips to follow in the first place.
To address this problem, “Small Step” should first condense their list of tips down to a more manageable size. Tips that can potentially cause harm or injury (“Use a snow shovel instead of a snow blower”), are generally beyond one’s control (“Choose a checkout line without a candy display”), tend to add stress to situations (“Take wheels off luggage”), or just miss the point (“Get a dog and walk it”) should simply be deleted. Slight variations on the same tip (“Snack on fruits and vegetables” and “Keep a bowl of cut-up vegetables in the refrigerator for snacks”) can be combined to reduce repetition. A shorter list of good tips that can be applied in a large number of situations will make the entire campaign appear more manageable.
Next, the “Small Step” campaign should organize the remaining tips and present them in a way turns these scattered pieces of advice into a cohesive program. For example, the tips can be categorized based on how easy they can be followed and how intrusive they are to an established routine. “Take the stairs instead of the elevators” would therefore be considered an easy tip, while “Don’t skip breakfast” would be considered harder, because it may require a readjustment of one’s morning routine. The categorized tips should be accompanied by directions; people should begin by incorporating the easier tips into their lives before progressing to more difficult ones, with the eventual goal of adjusting to a healthier overall lifestyle. Providing these directions will allow people to more easily keep track of their progress, and clearly stating the objectives and goals of the program may provide people with additional motivation to stick with it.
Some of the tips can also be categorized based on the specific situations to which they apply, so that people can more easily find tips that are of use to them. For example, tips such as “Play with your kids 30 minutes a day” or “Walk kids to school” could be presented in a special section for parents, along with links to information pertinent to children. Tips targeted towards people who live in the city and take public transportation can be separated from those aimed at people who live in suburban environments. Cooking advice and recipes can be organized according to ingredients or region. These organizational changes would spare people the frustration of wading through all 100-plus tips to find ones that are useful to them, and improve the accessibility of the program.
Partitioning the tips this way will not only make it easier for people to find helpful advice, but also suggest areas that need to be expanded and/or improved. Examples given above illustrate how the current campaign fails to account for the socioeconomic, ethnic, and geographic diversity of the American population. Adding tips targeted toward specific sub-populations would allow the campaign to reach much wider audiences. Examples include: expanding the cooking section to include region-specific recipes and providing nutritional information for ethnic foods; suggesting creative ways to increase walking when the design of the neighborhood is not pedestrian-friendly; adding exercises that can be done by older people without leading to injury. If these tips are presented in clearly-labeled, well-organized categories, then each visitor can quickly find his or her specific niche, and the website will avoid giving the impression of making false assumptions about the way people live. By simultaneously pruning tips that are unfeasible while adding new tips to target special populations, “Small Step” can become more effective without having to expand in size.
3. Incorporate “Small Steps” into larger initiatives.
Small steps for change may have some results, but ultimately, the obesity battle must be fought by group forces rather than individuals. Success stories in the battle against obesity have typically involved population-level initiatives that are brought about by the collective efforts of community coalitions and municipal officials. For example, Michigan’s Building Healthy Communities initiative brought together local transportation officials, zoning and planning departments, universities, hospitals, residents, and farmers to build and improve walking trails, add new equipment to parks, open new farmers’ markets, and distribute coupons to low income families for fresh fruits and vegetables (12). Similar programs are gaining momentum across the country as people are beginning to recognize the environmental factors that affect overweight and obesity.
To be fully effective, “Small Step” must be integrated with such population-level anti-obesity programs, because the fundamental causes of obesity are environmental factors, not individual ones. The current campaign acknowledges the structural contributors to obesity, but fallaciously implies that small individual-level behavioral changes can overcome those factors. The website feebly attempts to integrate with other programs by providing links to other government agencies as well as to local “Steps” programs, but these links are haphazardly organized and sometimes uninformative. Instead, the “Small Step” website could replace those pages with a new section that specifically discusses the importance of population-level initiatives, with better-organized links to local programs and resources, accompanied by brief summaries of the program components. The site could also acknowledge the limitations of individual-level behavioral changes (without implying that they should be abandoned), and suggest ways for citizens to get involved in population-level programs.
While the HHS should be commended for tackling the ever-growing problem of obesity, the current “Small Step” media campaign suffers from its narrow focus. The incomplete application of models of health behavior, use of negative imagery, and failure to acknowledge the structural causes of obesity all contribute to make “Small Step” ineffective. Furthermore, because many of the campaign tips implicitly assume that all Americans live in a homogeneous manner, their applicability is severely limited.
Improving the program would entail an overhaul of the existing advertisements and the website. Promotional materials need to adopt positive imagery. The tips featured on the website must undergo extensive revision. Implementing these changes will allow “Small Step” to be more readily accepted by people of all backgrounds and situations, and result in a more effective campaign.
Most importantly, however, the HHS must recognize that the “Small Step” campaign, while valuable in its own right, is insufficient to combat obesity by itself. Individual behaviors can prevent obesity to a certain extent, but environmental factors that promote physical activity and healthy eating can yield more significant long-term results. Therefore, greater steps must be taken to integrate “Small Step” with broader, population-level initiatives to change the environment so that the US population as whole can lead healthier lives.
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