A1C Campaign; Early Phase Model Not Appropriate-Evan Johnson

Background

 

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. 

 

Conclusion

 

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. 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

1 American Diabetes Association. All about Diabetes: Diabetes Statistics.   Mt.  Morris, IL: http://www.diabetes.org/diabetes-statistics.jsp.

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. http://www.medindia.net/patients/calculators/bloodsugar-HbA1c-convertor.asp

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:  http://www.dlife.com/dLife/do/ShowContent/type1_information/preventing_complications/vision

 

Above the Influence, Out of Touch: A Missed Opportunity to Affect Behavior Change on a Scale Broader than Individual Level – Erin Twohig

Introduction

Above the Influence (1) is a national anti-drug and anti-marijuana campaign designed to get kids to avoid starting and to stop doing drugs. The centerpieces of this effort are national television and print ads as well as an associated website. A typical ad for this campaign depicts a teen who “fits in” to a billboard with a range of school scenes but chooses to walk around one depicting using drugs. Although this campaign has some strengths, such as utilizing popular social networking sites to create networks for adolescents who do not use drugs, the premise of the ad campaigns is faulty and perhaps counter-productive from a behavioral science standpoint. The above the influence website describes itself as “this site helps you to be more aware of the influences around you, and [helps] you carefully consider the risks when you're faced with tough decisions.” (2)

            This campaign is educating adolescents about the risks of using drugs and the pro-drug influences they are exposed to. This intervention has been based on the premise that if adolescents are aware of risks associated with drug use then they will be less likely to use drugs, classically based on the Health Belief Model. (3) Notably, this campaign also uses elements of the Theory of Reasoned action, which emphasizes the importance of social norms in making individual level choices. (4)  Although this campaign clearly considered social science theory in the development of this behavior change intervention, there are fatal flaws in the choice and application of theory.

            The fatal flaw in application is that using these theories fail to take into account the extent of non-fact and non-rational motivations to initiate behaviors. Due to this lack of understanding, the campaign provides reasons not to succumb to the influence of peers but does not provide skills that adolescents can use to overcome these influences. Another fatal flaw is that this ad campaign addresses this issue at an individual level, asking kids to individually say no to their friends. It is a difficult task to rebel against one’s own peers. Finally, because it is telling kids to resist peer pressure, it is actually reinforcing the stereo-type that your friends want you to do drugs and that doing drugs is a way to fit in.

 

Overestimating the Rational Nature of Behavior

 

Interventions that have been successful at targeting resistance to peer-pressure to initiate negative health behaviors have not neglected how powerful peer influences are on adolescent behaviors. A different individual behavior change model, Social Learning Theory, recognizes that learning occurs through observation and repetition of behavior. It then takes advantage of this fact to change behavior. (5) This has been successful in interventions where adolescents were taught in seminars to develop the skills to resist peer influence and this “success depends on working with socially interactive groups” (6) This method is powerful because it teaches adolescents within their peer environment, the environment in which they will eventually make the choice to initiate or resist the behavior. In his book, Predictably Irrational, Dan Ariely describes how research shows that despite intentions to choose healthy behaviors in other setting, when actually in a high pressure decision making setting, people have limited ability to predict how they will react. (7) Through practice of skills to avoid smoking, this intervention acknowledges the strength of such pressures in the peer environment, giving adolescents a better chance of avoiding the negative behavior.success depends on working with socially interactive groups” 6) This method is powerful because it teaching adolescents in their peer environment, the environment they will eventually make the choice to initiate or resist the behavior. In his book, Predictably Irrational, Dan Ariely describes how research shows that despite intentions to choose healthy behaviors in other setting, when actually in a high pressure decision-making setting people have limited ability to predict how they will react. 7) Through practice of skills to avoid smoking this intervention acknowledges the strength of such pressures in the peer environment, giving adolescents a better chance of avoiding the negative behavior.

Although focusing on influences has had success in developing anti-tobacco interventions, there are fundamental difference between the successful anti-tobacco intervention and the Above the Influence campaign. In the Above the Influence campaign, print and media ads merely show adolescents that pressure to do drugs exist, then tries to convince them that the behavior is not worth fitting in. However, in contrast to the above intervention with some measure of success in preventing smoking, merely pointing out peer influence has not been shown to be successful in helping adolescents to resist pressure. (8) This is especially true when the intervention does not provide any useful skills to accomplish this difficult task.

 

The Use of Individual Level Behavior Change Models versus Countermarketing

            In the Above the Influence Campaign, the behavior change emphasis clearly lies on youth resisting peer-pressure, thus this is an individual behavior change model. This differs drastically from a very effective campaign, Florida’s Truth campaign, which aimed to change social norms, thus directly impacting the influences on behaviors. (9) In this model, instead of telling youths that they must resist social norms, it actually aimed to change those social norms.

 

            A study of the impact of the Florida intervention showed that after the national intervention teens were significantly less likely than other teens in the nation to have smoked in the past 30 days or to have ever tried smoking. (10-11) Also, youths in Florida had less favorable beliefs than those nationwide about the tobacco industry even though their beliefs about the social and physical effects of smoking were still similar. Since this intervention focused on rebranded corporate tobacco messages to encourage adolescents to rebel against tobacco companies not the health effects of smoking, this is a good indication that the intervention was responsible for the change in attitudes.

 

            The success of this “anti-manipulation strategy”(10) versus less successful interventions targeting individual resistance to peer pressure (6) may be a good indication that changing social norms has a larger impact than trying to impact the behavior of one adolescent at a time. Given how powerful the desire to “fit-in” as an adolescent is, behavior interventions whose primary aim is to circumvent this powerful desire are likely to be of little use

Reinforcing Stereotypes through the Portrayal of Peer Influences

            Finally, and perhaps most importantly, this ad campaign consistently portrays a friend offering drugs to another friend. This series of commercials may in fact be reinforcing a stereotype that teens do drugs, rather than fighting it. This is directly counter to the most effective type of teen behavior change intervention as seen above (10). By reinforcing the drug-using-teen stereotype this ad campaign is likely to do harm and might be expected to increase rather than decrease teen drug use.           

            In the experience of anti-tobacco advertising, a mismatch of advertising message leads people to “responded with defiance, denial, and other counter-productive behaviors.”(12) There is a strong indication of mismatch of message with target audience with the Above the Influence campaign due to the proliferation of counter-message websites and videos on the web. Above the Influence of Ignorance is one such counter message website, that appears just beneath abovetheinfluence.com in a Google search for the campaign.(13) A YouTube search of Above the Influence seems to yield far more counter ads made by youth than it will yield Above the Influence Ads.

            Adolescents in this country are sending a clear message about what they think about this ad campaign. Another counter website, Highabovetheinfluence.com, is produced by the National Coalition to Remove Misinformation from Media Campaigns. (14) This campaign is clearly not well received by its target audience and there is even a contingent who feels the Above the Influence ads spread misinformation. In order for public ad campaigns to make change in the population, it is clearly a prerequisite that the public trusts and believes the messages in the ads. Without this trust, society will not listen to ad campaigns. This campaign is not only ineffective but is clearly damaging public trust in public health advertising.

            Alarmingly, but not surprisingly then, a five year study conducted by a government contractor found that among current non-using teens " greater exposure to the campaign was associated with weaker anti-drug norms and increases in the perceptions that others use marijuana.”(15) When teens watched these ads, they were more likely to think that other teens did drugs, thus a strong indication that these ads reinforced the negative stereotype. This makes it even harder for youth to be “above the influence” as these very ads have strengthened the influence it seeks to have youth resist. Truly there is more harm than good being done with this campaign.

 

Paper 4 : Building a youth anti-drug counter marketing campaign

The Intervention

This intervention will use social learning theory to develop programs that can teach youth the skills required to choose not to do drugs. This will be modeled after successful school based anti-tobacco programs. However, the core of this intervention will be a national ad campaign based on the same counter-marketing theory that the Truth campaign was based on.

This campaign will use professional marketing consultants to take advantage of the successes of commercial advertising. Also critical, the campaign will employ significant formative research to test potential messages with the target population, teenagers. The campaign will use monitoring and evaluation techniques throughout the campaign. This will ensure that the campaign is accomplishing its stated goals and lend accountability to the program.

Addressing the Irrational Nature of Behavior

 

This intervention will recognize that behavior is not rational and that peer influences are powerful determinants of behavior. This holds true even if the pressure is toward a behavior that is well-known to be harmful. (7)  This intervention will develop a school based corollary to the national ad campaign that reinforces the main messages of the campaign. This school-based component of the intervention will take advantage of the insight of Social Learning Theory, that learning occurs through observation and repetition of behavior. (5) These school seminars will be piloted and employ significant monitoring and evaluation to ensure that it is accomplishing its goals. Only when these small group interventions are successful at changing both attitudes and behaviors will they be implemented at a broader level. The failure, and indeed counterproductive nature of Above the Influence highlights the need to pilot and demonstrate effectiveness before investing substantial resources in that program.

In these seminars, students will learn to develop the skills to resist peer influence in socially interactive groups. (6) Stressing that peer influence are unhealthy has not been successful in helping adolescents to choose healthier behaviors. (8) This method acknowledges the strength of peer influence by teaching adolescents within their peer environment. By giving teens the skills required to resist drug use and teaching them to use these skills with their peers, this intervention is likely to succeed where the above the influence campaign failed. success depends on working with socially interactive groups” (6). This method is powerful because it teaching adolescents in their peer environment, the environment they will eventually make the choice to initiate or resist the behavior. In his book, Predictably Irrational, Dan Ariely describes how research shows that despite intentions to choose healthy behaviors in other setting, when actually in a high pressure decision-making setting, people have limited ability to predict how they will react. 7) Through practice of skills to avoid smoking, this intervention acknowledges the strength of such pressures in the peer environment, giving adolescents a better chance of avoiding the negative behavior.

 

Counter marketing: A tool to bring about societal level change

In this intervention, the higher level theory to be used is counter marketing, a corollary to marketing theory. This theory seeks to change behavior by changing or “rebranding” the image that is currently associated with a behavior or product. Changing the peer environment changes behavior by impacting societal not individual level factors. (5)

One lesson that emerged from the Truth campaign, a successful user of counter-marketing, is that quality formative research with the target population of the intervention is critical. According to the CDC counter-marketing manual, the success of this method depends on understanding the culture, behavior, motivation, interest, and need of target audiences. (15) This campaign will take advantage of qualitative and quantitative research methodologies to ensure that messages developed resonate with youth in the intended manner. Formative research with youths will look to youths for negative stereotypes toward drug use that will not cause youth to rebel counterproductively. (11) Then the intervention will attempt to promote those unappealing stereotypes instead of the message that drugs make you “fit in.”

           

 

Creating new stereotypes to reduce the allure of drug use

This paper previously discussed the ability of  national ad campaigns to impact stereotypes which impact behavior. Potential ads will attempt to recognize and avoid the problem of mismatching message and audience (12). The well matched ad campaign will also function to rebuild the trust that the public needs to have in order for public ad campaigns to make change in the population. Therefore, the ad campaigns developed must have a well matched message to the target audience, avoid rebellion to the message, and convey trustworthiness to its audience. Messages must ring true.

Conclusion

            Models of behavior at a societal norm level, used effectively in marketing of consumer products, would be a better fit for modifying behavior change in young adults. Telling adolescents about the health effects of drug use has not been shown to be very effective. However, as in the Florida Truth campaign, the rebranding of images to encourage a rebellion against the negative health behavior resonates effectively with teenagers. (9) By using a strategy similar to the Truth campaign to change social norms instead of fighting them on an individual level, a national ad campaign to reduce drug use among teens would be more likely to succeed than Above the Influence. Creating a new stereotype could be analogously successful to the Florida model if successful targets for counter marketing could be found through extensive formative research with the target audience.

 

           

References

1.            National Youth Anti-Drug Media Campaign. “Above the Influence.” Office of National Drug Control Policy. accessed 4 April 2009 .

2.            National Youth Anti-Drug Media Campaign. “About this site.” Office of National Drug Control Policy. accessed 4 April 2009 .

3.            Rosenstock, I. (1974). Historical origins of the health belief model. In Health Education Monographs. 2, 328-335.

4.            Salazar, M. (1991). Comparison of four behavioral theories. AAOHN Journal , 39, 128-135.

5.            Edburg, M. (2007). Essentials of Health Behavior. Sudbury: Jones and Bartlett Publishers.

6.            Reid, Donald. (1999). Failure of an intervention to stop teenagers smoking. BMJ, 319, 934-935.

7.            Airely, Dan. (2008) Predictably Irrational. Harper Collins Publishers.

8.            Bruvold WH. A meta­analysis of adolescent smoking prevention programs. Am J Pub Health 1993;83:872­80.Hicks JJ. (2001) The strategy behind Florida’s “truth” campaign. Tobacco Control. 10, 3-5.

9.            Bauer UE, Johnson TM, Hopkins RS, et al. (2000) Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA. 284, 723-728.

10.            Niederdeppe J, Farrelly MC, and Haviland ML. (2004) Confirming “truth”: More Evidence of a Successful Tobacco Countermarketing Campaign in Florida. AJPH. 94(2), 255-257.

11.            Wolburg, Joyce. (2004) The need for new anti-smoking advertising strategies that do not provoke smoker defiance. Journal of Consumer Marketing. 21(3) 173-174.

12.            AbovetheIGNORANCE. “Live above the influence of Ignorance, Marijuana & Hemp Fact.” 2009 accessed 5 April 2009 .

13.            National Coalition to Remove Misinformation from Media Campaign. “High Above the Influence.” 2009 accessed 5 April 2009.

14.            United States Government Accountability Office. August  2006. “Report to the Subcommittee on Transportation, Treasury, the Judiciary, Housing and Urban Development, and Related Agencies, Committee on Appropriations, U.S. Senate : “Contractor’s National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use” accessed 5 April 2009

 

15.            Centers for Disease Control and Prevention. Designing and Implementing an Effective Tobacco Counter-Marketing Campaign. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, First Edition October 2003.

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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