Introduction
The
5 A Day Program campaign was introduced in 1991 by the National Cancer
Institute and the Produce for Better Health Foundation to spread awareness and
motivate people to eat the suggested five to nine servings of fruits and vegetables
every day. In 2011, the CDC became head of the 5 A Day Program in the United
States so that the Center could provide various resources including leadership,
educational, and technical assistance to the 5 A Day directors. To promote
their campaign, the CDC offered a 5 A Day
Works! publication that was a collection of fifty-four success stories from
5 A Day directors. (1) The campaign’s overall message was that a diet that
includes a vast variety of fruits and vegetables can help people stay healthy
as well as reduce their risk for chronic diseases. However, there are a number
of flaws regarding this campaign.
Critique
Argument 1 – Health Belief Model Lacks
The
Health Belief Model was a model created in the 1950s by social psychologists
Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels. Research was conducted to determine what
motivated people’s health behavior. The
model stated that behavior is an outcome of perceived susceptibility, perceived
severity, perceived benefits, perceived barriers, cues to action, and
self-efficacy. Perceived susceptibility refers to the person’s perception of
whether they are at risk of developing the health problem. The Health Belief Model predicts that if a
person perceives that they are susceptible then they will engage in behaviors
that will reduce their risk of developing that health problem. Perceived
severity refers to a person’s perception of how severe the health problem is.
If a person views the health problem as serious then they will engage in
behaviors to reduce its severity. Perceived benefits refer to whether the
person believes there will be benefits of taking action. If a person believes
that taking action will reduce their susceptibility and the seriousness of a
health problem then he or she will likely engage in that behavior. Perceived
barriers refer to an individual’s obstacles to perform a behavior. If there are
barriers that inhibit a behavior change then the perceived benefits must
outweigh the perceived obstacles in order to perform a behavior. Cues to action
is the component of the Health Belief Model that states a cue is needed in
order to begin a behavior change. Lastly, self-efficacy refers to an
individual’s belief that she can successfully make that behavior change. (2) Behind every public health intervention is
a theory, and behind every theory are assumptions. The number one assumption
behind the Health Belief Model is that people make rational decisions by doing
an internal cost-benefit analysis. The Health Belief Model projects that
people’s decisions are simply a balancing act. They are balancing the perceived
benefits of behaving versus the perceived costs of behaving.
Since
the 5 A day campaign was based on the Health Belief Model, it assumed that
individuals would eat healthily as long as they wanted to. However, the Health
Belief Model simply focuses on the individual and does not account for the many
external barriers that influence health behaviors such as social and
environmental factors. Social and environmental factors include location, time,
money, and transportation. Furthermore, the Health Belief Model assumes that
everyone has equal access to information that allows for rational decision-making.
(3) The 5 A Day campaign did not consider geographic and economic costs and
factors that are often out of a person’s reach such as access to fresh, healthy,
attractive, and inexpensive produce. Linda Thomas, Assistant Professor of
Nursing, argues that the Health Belief Model is a westernized conception of
human behavior. It dehumanizes people
and blames the victims. Often times, the easiest solution is to blame the
victim if he or she is not behaving ideally. The model presumes that the fault lies
with the individual and that he or she is ignorant, which leads to judgmental
views versus understanding the circumstances. (4) This illustrates how the 5 A
Day campaign should not have been based on the Health Belief Model. Because
people might not be eating give fruits and vegetables a day, they are often deemed
as ignorant rather than constrained by uncontrollable factors. Since the Health Belief Model is based
entirely on the individual level, focusing on perceived susceptibility,
perceived severity, perceived benefits, perceived barriers, cues to action, and
self-efficacy, it should not have been used in the 5 A Day campaign to change
people’s behaviors.
Critique
Argument 2 – Framing It the Wrong Way
The
traditional public health paradigm is to analyze the product that people should
want, then use intuition to frame and sell that product to appeal to the desire
for health in consumers. A frame is a
way an issue is presented or discussed in the news and media. It is intended to
encompass the arguments, images, and appeals of the particular issue,
situation, or intervention at hand. (5) Because a frame is a way of packaging
an issue so that it conveys a particular meaning, it can be quite powerful. (6)
A study, conducted by Claudia Menashe and Michael Siegel, analyzed newspaper
coverage of tobacco issues in the United States from 1985 to 1996. For many
decades, public health officials have provided evidence that tobacco use can be
hazardous. However, tobacco use still remains legal, accessible, and acceptable
in society. Public health officials have not been able to battle the influence
of the tobacco industry, because of how tobacco use was framed as a public
health problem. Public health officials
used framing theory in the wrong way. Previous frames have argued that tobacco
kills smokers and nonsmokers, and it was society’s duty to eliminate these
avoidable deaths. (6) However, this method is flawed because health is not a
strong core value in the minds of the American people. Furthermore, tobacco
addiction is often framed as the fault of the individuals. Rarely, is the
addiction ever blamed on the tobacco industry themselves. Tobacco companies are actually the ones
manufacturing and marketing these products to all. Thus, framing it on the
individual level may not be the most effective way to change behaviors.
In
their article titled “Framing Theory,” Dennis Chong and James Druckman discuss
framing effects. These occur when (often small) changes in the demonstration of
an issue can produce (sometimes large) changes of public discourse. For
example, when asked whether respondents would be for or against allowing a hate
group to hold a political rally, 85% of respondents answered in favor if the
question was prefaced with, “Given the importance of free speech,” while only
45% were for the rally when the question was prefaced with, “Given the risk of
violence.” (7) This demonstrates how alternatives phrasings of simple issues
can significantly change public opinion regarding an issue.
In
the 5 A Day program, campaigners mistakenly framed and assumed that health is a
very strong core value among people. They promoted the various health benefits
that can result from filling one’s plate with plenty of fruits and vegetables.
However, the general population does not tend to value health as highly as
public health practitioners do. The campaign strove to promote the idea that
fruits and vegetables are essential to one’s health. However, the 5 A Day
campaign lacked an identity that people wanted to ascribe to. Contrary to popular
belief, people often do not value health until they no longer have it. Most
people could not imagine themselves committing to a fives fruits and vegetables
on a daily basis. Thus to them, health is a lower core value than love,
autonomy, security, justice, equality, etc. Framing health as a core value is not
necessarily wrong, but it is limiting and ineffective. If done correctly, framing is an effective way
of changing people’s behaviors. However, the 5 A Day campaign framed its
message inefficiently.
Critique
Argument 3 – Psychological Reactance
By
telling people that they should eat five fruits and vegetables a day, the 5 A
Day campaign would potentially elicit psychological reactance. Psychological
reactance theory states that when people’s freedom is threatened, they
experience reactance and have to take action to restore that freedom
immediately. (8) The way that people restore their freedom is by committing the
forbidden acts. An example of this was shown in the study by Sharon Brehm,
“Physical Barriers and Psychological Reactance: 2-year-olds Responses to
Threats to freedom.” In this study, Brown exposed 2-year-old boys and girls to
1 of 3 different situations involving a physical barrier. The first barrier was
a large barrier with identical free-standing objects behind the barrier. The
second barrier was also a large barrier with dissimilar objects behind it. Lastly,
the last barrier was a small barrier with dissimilar objects. The results of
the experiment showed that boys preferred the object that was behind the large
barrier with dissimilar objects (i.e. the second barrier). On the other hand,
the girls chose the objects behind the non-barricaded, more accessible object,
i.e. the third barrier. (9) The boys
went for the object that they could not easily get to, while the girls tended
to go towards the toy that was available. This implies that at two years old,
boys had already developed psychological reactance. Even though the boys knew
that they could not get the toy, the felt compelled to acquire it because of
its inaccessibility. Thus, the toy’s non-reachability became attractive for the
boys, who wanted it even more.
Another
example that showcases psychological reactance was the study by Richard
Driscoll called “Parental Interference and Romantic Love: the Romeo and Juliet
effect.” This study examined a series of unmarried couples and measured the
degree of parental interference in their relationships. Proctors administered
questionnaires to one hundred and forty couples to test the hypotheses that (a)
feelings of love are highly correlated with trust and acceptance as the
relationships develop over time and (b) parental interference in a love
relationship deepens the feelings of romantic love within the couple. The study
found that parental interference was the strongest predictor of marriage and
continuing relationships because of the motivating effects of frustration and
reactance. The more the parents interfered, the more likely the couples stayed together.
(10) This contradicts what most people
would actually think. Because the parents interfered with the couples, it
caused reactance, and thus the couples wanted to be together even more, i.e.
get their freedom.
As
presented by these studies, the implication of reactance theory is that people
do not like being told what to do. That is precisely why the 5 A Day program
was flawed. The campaigners were telling people to eat five fruits and
vegetables a day, which elicited a reactance, thus leading to the exact
opposite behavior. Therefore, one must avoid reactance to create an effective
program.
Articulation
of Proposed Intervention
The
5 A Day program was flawed because it was derived from the health belief model,
framed health as a highly important core value, and elicited psychological
reactance. The campaign can be adjusted and changed to address the current
flaws in order to promote its ultimate message of getting people to eat more
fruits and vegetables. Firstly, since most people already know the health
benefits of eating fruits and vegetables, the campaign should understand that
people’s health decisions are often constrained. The directors should attempt
to implement subsidies for fresh produce and accessible supermarkets so fresh
produce can be more affordable, available, and appealing. Secondly, the 5 A Day
campaign should not focus on framing its issue around health but rather on the
core values of autonomy and freedom, so that people can aspire to lead a good
life for themselves, their families, and loved ones. The campaign should brand
an identity and a promise to people that if they eat fruits and vegetables,
they will feel empowered. Lastly, in order to reduce psychological reactance,
the 5 A Day campaign should utilize a messenger who is similar to the target audience.
The messenger could range from young chefs in the kitchen to respected
celebrities promoting healthy living.
Defense
of Intervention Section 1 – Providing Access
Instead
of the health belief model, the 5 A Day campaign should not be based on understanding
the reason people behave in certain ways, but it should provide mechanisms to
accomplish the campaign’s desired outcome. The 5 A Day campaign should not just
tell people that they should eat five fruits and vegetables a day, because
people often already know the health benefits. The 5 A Day campaign ought to
view the issue from a micro-environmental stance, by promoting different
outlets that will help people make these healthy decisions. The campaigners should
focus on the price, access, and quality of produce, which as a result will make
food more affordable, available, and appealing. This can be done by implementing
subsidies for fresh produce (which would lower the price for consumers) or
providing low-income families greater access to supermarkets and healthy
quality food, rather than convenience stores and fast food chains.
The
study titled, “Neighborhood Socioeconomic Status and Fruit and Vegetable Intake
among Whites, Blacks, and Mexican Americans in the United States,” conducted by
Tamara Dubowitz, examined associations between healthy food intake and
neighborhood socioeconomic statuses, thus determining whether neighborhood
socioeconomic status explains the racial differences regarding intake of fruits
and vegetables. The study found that neighborhood socioeconomic status was
positively associated with fruit and vegetable intake. Therefore, this positive
association demonstrates that unlike people’s own desires to eat healthily, the
social environment of neighborhoods largely dictates population health and
nutrition for white, blacks, and Hispanics in the United States. (11) Thus, the
effective way to promote healthy eating is to control for these influential
factors.
An
experiment during Michael Siegel’s SB721 class demonstrated the disparity
between the food people eat and the location of their shopping. Students were
asked to purchase various fruits and vegetables in the two neighborhoods of
Boston: the South End and Roxbury. Students who were sent to Roxbury found
bruised apples from the convenience store and shreds of lettuce from Subway. On
the other hand, students who were sent to the South End were able to find shiny
apples and a whole head of lettuce. This experiment represented the residential
disparity of quality and access to food. Low nutritional value food was placed
in poor neighborhoods while high nutritional value food was placed in wealthy
neighborhoods, even though they were located right next to each other. This experiment demonstrated how one’s
environment is a strong predictor of how healthy he or she will eat.
Both
these examples show the persistence and enormity of the socioeconomic and
racial-ethnic disparities in health statuses in the United States. Lack of
behavior change is not always due to absence of desire but external factors
that dictate the change. People often do not have the money to move to a
wealthier neighborhood in order to gain access to fresh produce. Therefore, the
5 A Day program can combat this disparity by not telling people to eat fruits
and vegetables, but rather providing the means for the healthy behavior. Regardless of the peoples’ presently built
environments, the campaign should make the food resources available, whether by
implementing subsidies for fresh produce or providing low-income families
greater access to supermarkets and healthy quality food.
Defense
of Intervention Section 2 – The Power of a Frame and Marketing
Since
the 5 A Day frames its campaign around the core value of health, issues can be
re-framed in a different way by using marketing techniques. As discussed in
class, the marketing paradigm uses research to uncover people’s needs and wants,
create and package the product so that it fulfills those needs and wants, and
appeal to more basic human core values. Marketing companies create a
psychographic profile of the target population so that they know what appeals
to the audience, like the color of the packaging. The companies attempt to
understand who their audience is so that they can cater and fit their brand to
the various personalities. The marketing team must fashion, frame, and package
their product to appeal to people’s aspirations, dreams, needs, and wants.
Furthermore, marketing teams must understand the most important core values of
their target audience, whether it is love, money, autonomy, security, justice,
or health. That is what the public health practitioners did regarding tobacco
use. They framed the tobacco companies as manipulating nicotine levels,
deceiving the public, and perpetrating tobacco addiction to children. Rather
than focusing the tobacco issue as a public health problem, new frames focused
on the tobacco industry’s deceptive or illegal behavior. (6) These frames
appealed to the core values of justice, dignity, and fairness.
Every
element of a campaign including the name, logo, colors, message, presentation,
and execution has to be especially consistent with the core value that the
campaign is trying to appeal to. Consequently,
the campaign has to align with the needs and aspirations of the target
population. Thus, the goal of the 5 A Day campaign should not command people to
eat more fruits and vegetables; it must be framed in a way to inspire them to
eat more fruits and vegetables. That frame can inspire individuals to lead a
good life for themselves, their families, and loved ones. The 5 A Day campaign should market autonomy
and freedom rather than health as the campaign’s core values.
Furthermore,
every single public health intervention should be branded into an identity that
people will associate with the product and that is coherent throughout the
campaign. A branded message is strategic because it provides a promise. For
example, by eating more fruits and vegetables, people will have the freedom and
autonomy to live their lives versus to be held back by health issues. A
campaign that followed this technique was the 84 campaign. The 84 campaign is a
statewide movement of youth fighting tobacco in the Commonwealth of
Massachusetts. The 84 campaign was successful
because it did not promote health as a reason to not smoke but rather focused
on the individual feeling important. They promoted the idea that one can be a
part of a movement, the 84% of Massachusetts youth who did not smoke when the
campaign started. (12) Once children are labeled and adopt that identity, it becomes
a part of who they are. This campaign
does not belittle youth by telling them what to do. Rather, children are joining
a movement and thus being labeled in a positive way. By using framing and marketing techniques, the
5 A Day campaign can embody an identity that provides people with autonomy and
freedom. As a result, people will more likely adopt that identity and its desired
behaviors.
In
addition to these marketing techniques, an important factor is not to challenge
existing beliefs but reinforce them. Most public health campaigns are trying to
change people’s point of view. The campaign should not try to change value and
beliefs; they must try to reaffirm pre-existing beliefs. It needs to show that
the campaign’s mission is to promote the existing values, because an attempt to
change people’s beliefs actually elicits reactance and reaffirms their beliefs.
Hence, the 5 A
Day campaign should endorse people’s beliefs that if they eat fruits and
vegetables, they will feel empowered to do whatever they desire.
Defense
of Intervention Section 3 - Ways to prevent psychological reactance
The
5 A Day campaign is flawed because it elicits reactance. The way to avoid reactance
is to ensure that whoever is portraying the message in the advertisements are
people who are the most similar to the target audience. In the study conducted
by Paul Silvia “Deflecting reactance: The Role of Similarity in Increasing
Compliance and Reducing Resistance,” he tested the theory of whether
interpersonal similarity could possibly lessen reactance by increasing
compliance and decreasing reactance. (13) In this study, he had four elements of
similarity. One communicator shared the participant’s same birthday, first
name, gender, and year in school. The second communicator did not share any
factors with the participants. And the third communicator was the control in
which people did not know any information about the person. The study found
that in situations of similarity, reactance was greatly reduced. The
high-similarity groups perceived the communicator as less coercive. When similarity
was low, the communicator caused reactance because he seemed threatening to the
subjects’ freedoms. Thus, the source of the similarity was irrelevant; the fact
that the subjects and the coordinators shared some similarities greatly reduced
reactance. This experiment implies that the nature of the messenger is crucial.
The more similar the messenger is to the audience, the less reactance there
will be. Therefore, if the intervention is targeting youth, then youth should
be included in the advertisements. The
exception is the use of celebrities, since they are viewed highly by the
general youth.
Since
the 5 A Day campaign had elicited reactance because it told people what to do,
then it should reduce reactance by having a messenger that is similar to its
target audience. If members of the campaign are targeting the youth, then
similar children should be used so that the youth audience can empathize and
not elicit reactance, whether it is a home video of children in the kitchen
cooking with their parents or an advertisement with their favorite cartoons.
Likewise, if the campaign is aiming to influence adults, then other adults that
share a commonality should be used in the advertisements as well. This could
either be a family member or someone who is honored and well respected in the
community. Whatever the outlet is, the messenger should be similar to the
target audience.
Conclusion
This critique of the 5 A Day program
is an example of a public health intervention that failed to incorporate social
and behavioral sciences could result in program failure. Social and behavioral
theories should be applied to the intervention in order to create innovative
and effective public health intervention programs. Rather than individual
health behavior models, group level models should be used in order to
communicate an important health message to the public. Rather than basing the 5 A Day program on the
Health Belief Model, the campaign should use marketing and framing theory to
reduce psychological reactance, promote autonomy and freedom, and provide
access to the necessary means of living a healthy life.
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