Five a Day - Diana Vo

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.   

References

1.     Centers for Disease Control and Prevention. 5 A Day Works! Atlanta: U.S. Department of Health and Human Services; 2005.

2.     Rosenstock IM: Historical origins of the health belief model, Health Education Monographs 2:328-335, 1974.

3.     Edberg, Mark Cameron. "Individual Health Behavior Theories (Chapter 4)."Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.

4.     Thomas, Linda W. "A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education."Journal of Professional Nursing 11.4 (1995): 246-52.

5.     Certain Trumpet Program. Framing Memo: The Affirmative Action Debate. Washington, DC: Advocacy Institute, September 1996.

6.     Menashe, Claudia L., and Michael Siegel. "The Power of a Frame: An Analysis of Newspaper Coverage of Tobacco Issues-United States, 1985-1996."Journal of Health Communication 3.4 (1998): 307-25.

7.     Chong, Dennis, and James N. Druckman. "Framing Theory." Annual Review of Political Science 10.1 (2007): 103-26. Print.

8.     Brehm, Jack W. 1966. A Theory of Psychological Reactance. New York: Academic Press.

9.     Brehm, Sharon S., and Marsha Weinraub. "Physical Barriers and Psychological Reactance: 2-yr-olds' Responses to Threats to Freedom." Journal of Personality and Social Psychology 35.11 (1977): 830-36.

10.  Driscoll, Richard, Keith E. Davis, and Milton E. Lipetz. "Parental Interference and Romantic Love: The Romeo and Juliet Effect." Journal of Personality and Social Psychology 24.1 (1972): 1-10.

11.  Dubowitz, Tamara. "Neighborhood Socioeconomic Status and Fruit and Vegetable Intake among Whites, Blacks, and Mexican Americans in the United States." American Journal of Clinical Nutrition 87.6 (2008): 1883-891.

12.  "Home." The 84. N.p., n.d. Web. 20 Apr. 2014.

13.  Silvia, Paul J. "Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance." Basic and Applied Social Psychology 27.3 (2005): 277-84.