Adherence to a healthy
lifestyle has decreased in the United States over the past eighteen years.
Fewer people are engaging in physical activity and eating healthy, which has
lead to a public health obesity epidemic. The prevalence of obesity in children
and adolescents in the United States is on the rise (1). Between 1998 and 2010,
obesity rates increased from 7.2% to 12.1% in children 2-5 years old, 11.3% to
18% in children 6-11 years old, and 10.5% to 18.4% in adolescents 12-19 years
old (2). Obesity is defined as having excess body fat.
It can lead to a number of immediate and long-term health effects. For example,
obese youth are more likely to have risk factors for cardiovascular disease
such as high cholesterol or high blood pressure. Obese adolescents are more
likely to have prediabetes, which is an indicator for the development of
diabetes. Furthermore, both children and adolescents who are obese are likely
to also be obese as adults and therefore have a higher risk for problems such
as heart disease, type 2 diabetes, cancer and osteoarthritis (3). Physical activity and
healthy eating habits can prevent obesity, Therefore, public health
interventions should strive to create programs to help people maintain good
habits(1).
Doing
regular physical activity and eating well can help prevent obesity and its
associated adverse health outcomes (4,5). Under the U.S. Department
of Health & Human Services’ physical activity guidelines, children and
adolescents should do 60 minutes or more physical activity daily. Children can
reach this guideline by doing a combination of aerobic, muscle strengthening
and bone strengthening exercises at different intensities. For example, some
activities that children can engage in are bicycle riding, jumping rope or
playing running games, such as tag (6). Unfortunately, fewer than one in five high
school students meets the recommendations to get 60 minutes of daily physical
activity, related to a rise in obesity levels (4). Furthermore, maintaining
healthy eating habits can also prevent obesity. The 2010 Dietary Guidelines for
Americans has recommendations for child and adolescents, such as increasing
fruit and vegetable intake(7). However, a recent
national report found approximately 37% of adolescents report having less than
one fruit or vegetable daily (8).
It is
important that public health practitioners create a social and physical
environment for children and adolescents that will support physical activity
and eating healthy (5). However, many
Americans live in an environment that often makes it easier to be sedentary or
maintain bad eating habits, such as travelling to school on a bus and not
biking, or eating food on the go that does not contain as many fruits or
vegetables (2,4). It is also important
that public health campaigns address these issues from an environmental and
group level perspective, not just an individual’s ability to have positive
behaviors.
One
public health campaign committed to promoting healthy eating habits and
exercise is the Presidential Active Lifestyle Award + program. It is a United
States program that is part of the President’s Council on Fitness, Sports, and
Nutrition, administered through a co-sponsorship agreement with the Amateur
Athletic Union (9).The goal of this
program is to help children and adults build healthy habits by committing to regular
physical activity five days a week and eat healthy over a six week period (9).This program is set up so
that people can create an account online on their own or register as part of a
group. They can log their exercise and eating patterns online or print paper
worksheets to keep track of this information. The program can be implemented on
an individual basis for adults or children and adolescents ages 6-17, as well
as for groups or schools (9). This critique will be
focusing specifically on the PALA+ weaknesses as a campaign to help children
and adolescents live a healthy lifestyle (4,9).
Critique
1: Health Belief Model
The PALA program is
fundamentally flawed in its reliance on the Health Belief model. The health
belief model is an individual level model that posits that people make rational
decisions based on weighing out the perceived benefits of doing a behavior in
comparison to the perceived cost and barriers (10). The model is based on
the fact that people will do a behavior (in this case, sign up for the PALA+
program and maintain healthy habits), based on their perceived susceptibility
about an outcome associated with that behavior, such as becoming obese, and how
severe the consequence would be of becoming obese. However, people might not
think that they are likely to become obese so they might not want to go through
the effort of signing up for the program. On this note, the benefits of the
program might not push them to want to sign up for it if they don’t think they
are likely to be obese. Although exercising and eating healthy have been shown
to prevent obesity (5), there is not
necessarily evidence that the act of going online to record your eating and
exercise habits will make someone lose weight, making the benefits of the
actual tasks involved with the program less clear. People may adhere to some
healthy eating and exercise habits, but they might not see the benefit of
strictly following the PALA+ program’s structure of keeping track of those
habits.
There are also barriers and costs associated with the
program such as time and effort, so this could deter someone from wanting to
sign up if they are busy, do not have access to a computer or do not understand
on (10,11). Particularly, it could
be a barrier for a young child to maintain this program if they have to share a
computer with their family or don’t understand how to use the Internet. Similarly,
the rewards of the program, such as winning a t-shirt or plastic trophy, might
not be enough of an incentive to spend effort and time online with this
program. Furthermore, this model assumes that individuals make rational
decisions about their behavior, and behaviors such as eating and exercise are
often irrational, as described in the Theory of Planned Behavior (11,12).
Critique
2: Theory of Planned Behavior
One of the fundamental
problems with this campaign is that it works on an individual level and not
group level principles. As such, one of the theories that this program is based
on is Theory of Planned Behavior. This theory, an updated version of the Theory
of Reasoned Action, posits that a person’s behavior is determined by their
intention to perform the behavior. This is based on their attitude toward the
behavior, evaluation of subjective norms and their perceived behavioral control
(11,13)
This model assumes that people will make rational
decisions about their behavior (13). However, as explored
in Predictably Irrational (12), people are often
irrational in their behavior. Even if they have good intentions and perceive
themselves to be in control of their actions, they may not carry out the behavior
that was planned. In the PALA+ program, children and adolescents could have
good intentions to exercise and eat well, sign up for the program and feel that
they are in control of these actions. This knowledge may not necessarily
translate into the concrete actions of eating well and exercising. Human
behavior is irrational and planning out activity and self- monitoring on a
website does not necessarily lead to behavioral change, especially for
behaviors that are so sensitive to the social and physical environment that
children and adolescents are in (12). This could be especially
hard for children and adolescents who are susceptible to the interactions of
their friends or may not have as strong planning skills as adults. For example,
adolescents may be influenced by external factors such as their friends all
wanting to go out for pizza on a whim. A teenager might not rationally think
about how this would affect their status in the PALA+ plan because they are
focusing on the social aspect of eating, even if they have good intentions(11). It is also important
to note that the Health Belief Model is similarly flawed in its assumption that
individuals will make rational decisions (11). Furthermore, the
program may not fit in with someone’s subjective norm of their environment if
their friends haven’t signed up or their school does not have an initiative on
it(11).
Critique
3: The Ecological Model
The PALA+ program
focuses too much on individual and interpersonal characteristics, and does not
fully take into account the ecological perspective that emphasizes interaction
between all levels of the life course and environment in looking at a health
problem (11). The ecological model
takes on a multilevel approach, to which the PALA+ program only focuses on a
few aspects of. The PALA+ program does an adequate job of accounting for
individual characteristics (such as knowledge and attitudes) by educating
individuals on the positive aspects of working out and eating healthy on a
person- by person level. People could have the ability to take action and sign
up for the program on their own. However, it does not account for the fact that
individual’s genetics or physiology as part of the ecological model, that may
make them have elevated risk factors for obesity regardless of exercise
patterns or eating (14).
Looking at the
interpersonal levels of the ecological model, the program does have an option
for people to sign up as a group with members of their family, classmates or
friends, getting at an interpersonal interaction with behavior change. However,
it does not account for the fact that just by signing up for the program as an
interpersonal group, those groups will actually influence individuals to have healthy
behaviors. It doesn’t take into account the fact that our physical activity
patterns and eating habits are often based on things that are beyond our
control at a community level (15). For example, a child’s
school might not provide adequate recess time, or their family might not be
able to afford fresh fruits and vegetables, which would hinder progress on this
intervention and maintain health behaviors. This program assumes that
interpersonal relationships will support healthy behavior just because they sign
up as a group. However, unless a group’s social norms are to exercise often and
eat well, a singular person in that group may not be able to maintain healthy
habits.(5,14)
Alternative
Approach:
As described, the PALA+ focuses heavily on traditional
and individual level models, which are more limited in scope. The program’s
current use of the Health Belief Model and Theory of Planned Behavior assumes
that individuals will always plan and make their own decisions about food and
activity, particularly if they are aware of the consequences of not exercising
or eating well. Both of these approaches, in addition to the limited take on
the ecological framework, need to be reconsidered and restructured to frame the
intervention from a larger community level (12,14,15).
An alternative
approach to the PALA program would be to tweak the program to incentive people
to sign up for the program in groups or with people in their social network.
The program is built on a strong foundation by having an option for people to
sign up as a group; however, it is crucial to change social norms within a
social network to promote healthy eating habits (16). Getting people to sign
up together is an important first step, but the program will be even stronger
by getting the larger community to maintain the habits. The PALA campaign could
employ aspects of people’s social network, the social expectations theory and
social marketing theory. The impact of obesity and promotion of healthy
behaviors should be thought of from the influence of the environment on
individual attitudes, actions and behavior in terms of nutrition and physical
activity (17). Specifically,
information needs to be communicated from a community perspective with less
focus on placing all of the responsibility on individuals to make positive
behavior, as the decision is often influenced from outside factors (14).
Social
network:
Data from the Framingham
heart study looking at social networks over thirty- two years suggests that
obesity may spread in social networks and groups that depends on the nature of
social ties (16). As described previously,
obesity is largely caused by a lack of exercise and not making healthy eating
choices. One factor that explains why social networks are associated with
obesity is that someone might observe a friend gaining weight and then accept
their own weight gain (16). Children and adolescents
are highly influenced by their friends’ attitudes, values and eating habits
both because of social norms and spending time with one another. The relevance
of social influence also suggests that public health interventions must harness
this same force to slow the spread of obesity and spread positive health
behaviors (16,18), in part because people’s
perceptions of their own risk may be influenced by those around them. Research
has shown that weight loss programs that provide peer support and therefore modify
the person’s social network, are more successful than those that do not (18). Therefore, it is pivotal to
integrate this group-level thinking into the PALA+ program.
The
proposed intervention would be to create incentives if people signed up as a
group- whether that is a school, family, or social group. Although there are
already ways to create joint accounts, there does not seem to be an additional
incentive for people to do this. The current model disregards the research
positing that people’s behavior is largely influenced by other people that they
spend a significant amount of time with (18). As described before, even
if one person signs up on their own- it may not be effective because their
networks are not following the same patterns. Because social networks could
spread positive behaviors, working on maintaining a healthy weight and
exercising would be easier as a collective group; people could work out
together, cook healthy meals together and hold each other accountable to
maintain these behaviors. For example, the PALA+ program could reward groups
who meet their goals with free exercise classes or coupons for healthy restaurants.
There could also be online education modules that explain games and sport
activities for larger groups, that children, teachers or families could
reference to get further ideas. Currently, there is information on the website
for ways that people can exercise on their own, such as doing sit ups, but
there was a lack of group-wide activity suggestions (9).
Social
expectations theory:
A study looking at the
associations of physical activity and healthy eating on social norms suggests
that social norms are important determinants that have a strong influence on
healthy behaviors (19). For example, this
study showed that women who observe many other people engaging in physical
activity or eating behaviors might come to view these behaviors as normative,
or socially desirable, and therefore may adopt the same behaviors due to either
a positive attitude about the behaviors, a shared belief in their value or a
social urge to fit into society (19). Social norms are
considered to be general rules that guideline behavior within groups, and these
influences play a crucial role particularly in adolescents (20,21). If many people are
doing something (such as eating unhealthy or living a sedentary lifestyle
filled with children’s videogames), or thinking something (such as that this
behavior is pleasurable), then their actions and thoughts could convey what
other individuals should think or do (21,22).
Therefore, it is crucial that the PALA program utilizes this
power to instill the social norms in groups of people to engage in a healthy
lifestyle, not just by focusing on individuals signed up for the program and
change their norms on person- by person basis. This relates back to the same
principle of the social network theory that an individual’s network and larger
group can promote good behaviors, so creating a social norm of good behaviors
in this network will enhance maintenance to healthy behaviors (16). The new PALA+ program
can build off social expectations theory because it will incentivize groups to
sign up together so that people are surrounded by peers where keeping track of
exercise and food choices, as well as actually doing these activities, is the
norm. Additionally, the PALA+ program could make exercise and healthy eating
part of social norms in schools and with adolescents by adding a calendar
aspect to the program, where groups could plan to go to exercise classes or
activities together on a regular basis. By making that part of their regular
lifestyle and social interactions, it would shift the norms towards a healthier
lifestyle.
It is also important to ensure that keeping track of
exercise and food habits becomes part of social norms in adolescent and
children populations in a positive way that boosts their self-esteem. Part of
why the program could be currently ineffective for these groups is because
logging these habits elicits could elicit some of the same aspects as dieting,
obsessive eating patterns or disordered eating, which is not a social norm that
is welcomed in young child (23). Although that is more
of a norm in adolescents, it’s important that it is framed from a positive and
healthy way. Therefore, the PALA program should also work to make this
conversation healthy by training health educators (in schools that implement
this program) to facilitate healthy conversation about eating and exercise in
the classroom. This will make healthy
behaviors associated with a positive social norm. Furthermore, this program
should be the social norm for people of all weights, not just those who think
they are susceptible to becoming obese, as seen in the health belief model (11).
Peer pressure plays a role in social norms of adolescents
(22). Therefore, it is also
important to channel this into a positive influence. Perhaps adolescents might
feel pressured to join the program and engage in healthy habits if their
friends are already in it (22). This theory further
strengthens the PALA’s use of the theory of planned behavior. The theory of
planned behavior takes into account the role of social norms for a person to
make a decision, so if the norms are changed to promote positive behaviors, teenagers
intentions behind engaging in healthy behaviors could translate into real
activity (not just making an account online) if their peers are doing so too (11).
Social
marketing and advertising theories:
Social marketing theory is
an innovative, group-level model to create and package a product so that it
appeals to the core values of your campaign audience and fulfills their needs
and values (17,24,25). In creating a public health
social marketing campaign, it is important to research the target audiences’
dreams and aspirations in order to package the program to fit these needs. This
can be done by figuring out core values of the population, such as freedom,
belonging or justice. Marketing campaigns have an element of branding in them so
that all of the elements of the campaign are consistent with the core value and
needs of the target audience. Traditional public health campaigns often market
their programs towards a health core value, however other values have a stronger
pull and could be more effective (17). The PALA+ program has
not successfully utilized social marketing theory to date, but there is
potential for its addition to make the program more successful.
Research has already shown the effectiveness of social
marketing in public health campaigns promoting physical activity, such as seen
with the VERB campaign. This program was highly successful for many reasons,
such as its extensive marketing research to determine youth core values,
mass-media advertising and partnership with local communities to improve
outlets for physical activity. It also capitalized on the influence of a social
network of parents, teachers and friends to promote physical activity (12,17,19).
After one year of this program’s implementation, there was a 34% increase in
weekly free-time physical activity sessions among 8.6 million children ages
9-10 in the United States (17). The same tools used in the VERB campaign could
help make the PALA + program more effective. This campaign tailored the program
to youth values such as fun and being cool, which helped motivated children to
exercise. It did not take on a health belief model approach of just stating the
facts about why exercising is important, which is what PALA+ does (11,25).
Currently, the PALA+ program does not harness its social
marketing capabilities. It is marketing the campaign to the values of health by
focusing on it as a way to be active, however, this are not necessarily the
core value of the youth and adolescents they are trying to target (25). Instead of framing the
campaign to the core value of health, PALA+ could focus on core values of freedom
and identify- values of youth empowerment (26).They can frame the
intervention towards the core value of freedom by empowering adolescents that
they have the ability to make their own physical activity and food choices by
choosing what activities work for their
lifestyle. These kinds of messages could be conveyed throughout the website’s
material. The PALA+ can also center itself around the value of identity, by
promoting people to sign up in groups and make it a social norm for people to
exercise and eat well(22) .
Similarly, the campaign could build off advertising
theory. Advertising theory focuses on a promise from the brand to the customer,
backed up by support through visuals and stories, which get at core values in
the target audience (25). Research has shown
that when messages are given from someone who is relatable to the target
audience, people are more likely to do what the messages tell them, have
increased compliance and not react against the message (27). The PALA+ could
utilize these tools through a few simple additions to their program. The
program could put up personal stories and pictures on their website from
children and adolescents who found the program to be successful. This speaks to
children adolescents feeling a sense of belonging, the core value described
above (26).
PALA+ advertise the program and instill identity through
the use of mass-media, which will integrate aspects of social networking and
change social norms (16,22). A way to do this is
that when adolescents join the PALA+ program, a notification could go up on
their Facebook page advertising that they’ve joined or won an award for
participating. There could also be a tool to share the program with their
Facebook friends and invite them to join. This would not publicly display their
activity and food data, but just state that a person has joined. This will make
it more of a social norm to be a part of this program, create a sense of
belonging to the program. It should increase registration, based on research
showing that people are largely influenced by their peers (20,22,24).
Conclusion:
In conclusion, the PALA+ program demonstrates a solid
foundation of a campaign to increase physical activity and healthy eating as a
way to combat conditions such as obesity. However, its extensive use of
traditional, individual level models limits its capabilities to take off as a
highly successful intervention. There is potential to make it a much more
effective program through use group-level models. Specifically, designing the
program in a way that integrates the social network theory, social expectations
theory and social marketing and advertising theories are crucial to helping the
PALA+ program soar, and instilling healthy behaviors among the youth of the
United States.
REFERENCES
1. King DE,
Mainous AG, Carnemolla M, Everett CJ. Adherence to healthy lifestyle habits in
US adults, 1988-2006. Am J Med [Internet]. Elsevier Inc.; 2009 Jun [cited 2014
Apr 30];122(6):528–34. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19486715
2. National Center for Health Statistics.
Health, United States, 2011: With Special Features on Socioeconomic Status and
Health. Hyattsville, MD; 2012.
3. Childhood Obesity Facts [Internet].
Centers for Disease Control. 2014 [cited 2014 Apr 20]. Available from:
http://www.cdc.gov/healthyyouth/obesity/facts.htm
4. Letsmove.gov. White House Task Force on
Childhood Obesity Report to the President | Let’s Move! [Internet]. [cited 2014
Apr 20]. Available from:
http://www.letsmove.gov/white-house-task-force-childhood-obesity-report-president
5. Obesity Prevention Source [Internet].
Harvard School of Public Health. [cited 2014 Apr 18]. Available from:
http://www.hsph.harvard.edu/obesity-prevention-source/
6. Physical Activity Guidelines for
Americans: Chapter 3 [Internet]. Health.gov. Available from:
http://www.health.gov/paguidelines/guidelines/chapter3.aspx
7. ODPHP. Dietary Guidelines for Americans,
2010 | [Internet]. 2014. Available from:
http://www.health.gov/dietaryguidelines/2010.asp
8. Centers for Disease Control. Nutrition
Resources for Health Pros: Data and Statistics [Internet]. DNPAO. 2014.
Available from: http://www.cdc.gov/nutrition/professionals/data/
9. Getting Started: Presidential Active
Lifestyle Award (PALA+): Choose a Challenge: The President’s Challenge. 2014.
10. Rosenstock IM, Strecher VJ, Becker MH.
Social Learning Theory and the Health Belief Model. Heal Educ Behav [Internet].
1988 Jan 1;15(2):175–83. Available from:
http://heb.sagepub.com/cgi/doi/10.1177/109019818801500203
11. Edberg M. Individual health behavior
theories. Essentials of Health Behavior: Social and Behavioral Theory in Public
Health. Sudbury, MA: Jones and Bartlett Publishers; 2007. p. 35–49.
12. Ariely D. Predictably Irrational: The
Hidden Forces that Shape our Decisions. New York: Harper Collins Publishers;
2008.
13. Netemeyer R, Ryn M Van. The Theory of
Planned Behavior. 1991;
14. McLeory K, Bibeau D, Steckler A, Glanz K.
An Ecological Perspective on Health Promotion Programs. Health Educ Q.
1988;15(4):351–77.
15. Walls H, Peeters A, McNeil JJ. Public
Health Campaigns and Obesity- A Critique. BMC Public Health. 2011;11(1).
16. Christakis N a, Fowler JH. The spread of
obesity in a large social network over 32 years. N Engl J Med [Internet]. 2007
Jul 26;357(4):370–9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17652652
17. Siegel M, Lotenberg LD, Connell T.
Marketing Public Health: Strategies to Promote Social Change. Jones and
Bartlett Publishers; 2007.
18. Jeffery R. Benefits of recruiting
participants with friends and increasing social support for weight loss and
maintenance. J Consult Clin Psychol. 1999;67(177-185).
19. Ball K, Jeffery RW, Abbott G, McNaughton S
a, Crawford D. Is healthy behavior contagious: associations of social norms
with physical activity and healthy eating. Int J Behav Nutr Phys Act
[Internet]. BioMed Central Ltd; 2010 Jan [cited 2014 Apr 30];7(1):86. Available
from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3018448&tool=pmcentrez&rendertype=abstract
20. DeFleur M, Ball-Rokeach S. Socialization and
Theories of Indirect Influence. Theories of Mass Communication, 5th edition.
New York & London: Longman; 1989. p. 202–27.
21. Beal a C, Ausiello J, Perrin JM. Social
influences on health-risk behaviors among minority middle school students. J
Adolesc Health [Internet]. 2001 Jun;28(6):474–80. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/11377991
22. Thaler RH, Sunstein CR. Following the Herd.
Nudge: Improving Decisions About Health, Wealth and Happiness. New Haven &
London: Yale University Press; 2008. p. 53–71.
23. Patton G. Onset of adolescent eating
disorders: population based cohort. Br Med J. 1999;318(7186):765–8.
24. Grier S, Bryant C a. Social marketing in
public health. Annu Rev Public Health [Internet]. 2005 Jan [cited 2014 Apr
30];26(9):319–39. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15760292
25. Wong F, Huhman M, Heitzler C, Asbury L,
Bretthauer-Mueller R, McCarthy S, et al. VERB - a social marketing campaign to
increase physical activity among youth. Prev Chronic Dis [Internet]. 2004
Jul;1(3):A10. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1253475&tool=pmcentrez&rendertype=abstract
26. Fe S. Core Values: What Motivates Youth.
27. Silvia PJ. Deflecting Reactance: The Role of
Similarity in Increasing Compliance and Reducing Resistance. Basic Appl Soc
Psych [Internet]. 2005 Sep;27(3):277–84. Available from:
http://www.tandfonline.com/doi/abs/10.1207/s15324834basp2703_9
No comments:
Post a Comment