Diet, Advertising and Social Networking: Critique on a Community Based Public Health Campaign against Cardiovascular Disease in Shanghai – Qing Gu

Cardiovascular disease is a group of disorders of the heart and blood vessels. They include coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease and deep vein thrombosis and pulmonary embolism. Cardiovascular diseases are the number one cause of death globally: more people die annually from cardiovascular diseases than from any other cause. An estimated 17.1 million people died from cardiovascular diseases in 2004, representing 29% of all global deaths. Of these deaths, an estimated 7.2 million were due to coronary heart disease and 5.7 million were due to stroke. 82% of cardiovascular diseases take place in low and middle income countries and occur almost equally in men and women. By 2030, almost 23.6 million people will die from cardiovascular diseases, mainly from heart disease and stroke. (1)
Shanghai is one of the biggest cities in China, boasting over 20 million resident populations. (2) Through the recent years, cardiovascular disease is the number one cause of death in Shanghai. In 2009, the deaths of cardiovascular diseases reached 266.59/10,000,000, representing 34.94% of whole deaths. (3) Since late 2008, Shanghai Municipal Center for Disease Control, a department of public health research and service, has promoted adult’s cardiovascular health through a community based campaign entitled “Healthy Life 2010”. This campaign focuses on increasing awareness of the fact that cardiovascular disease is the number one killer of adult and encourages people to take actions against cardiovascular disease. (4)
Diet is the major target throughout the campaign. Many lines of investigation, including genetic studies, epidemiological studies and interventional studies, have provided evidence for a causal relationship between salt intake and cardiovascular disease. Several prospective studies have investigated the association between dietary sodium and risk of cardiovascular disease. A significantly positive association between sodium intake and stroke has been reported in at least two of these studies; one in overweight adults in the United States of America (5) and the other in a Japanese cohort study. (6) The WHO technical report on primary prevention of essential hypertension and the joint WHO/FAO report on diet, nutrition and the prevention of chronic disease state that the population nutrient intake goal for salt should be <5g/day.(7) China has developed their own goal of <6g/day. In this campaign, a salt measurement spoon was given out to each family in Shanghai. The capacity of the spoon is 2 grams which is the limitation of salt intake for one meal. Besides, each family will get a booklet illustrating the principal of health diet and some recipes.
Physical activity is another target in this campaign. Regular and adequate levels of physical activity in adults reduce the risk of hypertension, coronary heart disease and stroke.（8）In order to encourage physical activity, Shanghai SCDC established health clubs in each community health care center. Membership is open to everyone in the community, including floating population. Club members were gathered together to practice Taiji, Wuqinxi, and other tradition Chinese aerobics. A blood pressure examination was provided monthly by the community health care center. Each member in the health club kept a personal record of blood pressure to show whether they were at risk of hypertension. Doctors from the community health care center attended the club event from time to time to either give a small talk of health life style or just hang out with the members.
Meanwhile, “Healthy Life 2010” resorts to the help of mass media. Reports of the campaign appeared on 6:30 TV news from time to time, featuring experts from Shanghai CDC talking about how many communities in the city were covered. Experts and doctors were invited to give lectures and speeches on a health care TV program, delivering knowledge and information on prevention cardiovascular disease. There was a session of program which encouraged people to call in and ask questions about anything related to cardiovascular disease, from first aid tips for stroke to why diet sodium reduction could decrease the risk of hypertension. The program seemed to be popular and boasted a high audience rating.
So far, the operation budget of “Health Life 2010” has accumulated to 10 million, covering each community throughout the city. Over 6 million salt measurement spoons and health education brochures were given out. (6) From the latest result of evaluation, the result is not so satisfying. Only 23% of people shows raise of awareness of cardiovascular disease. Less than 30% of families use salt measurement spoon on a daily base. The daily consumption of salt per capita shows no statistically significant difference. (6)
Admittedly, “Health Life 2010” applies bunch of classic social behavioral theories and models. With the support from government and mature public health system, the whole campaign runs pretty actively. Then why it turns out to be such a failure？

Will people change diet preference for health?
“Health Life 2010” assumes that based on the awareness of the proved evidence between diet sodium reduction and reduced risk of cardiovascular disease, people are willing to use salt measurement spoon when cooking and decrease daily salt consumption, and thus live a healthier life. Considering diet preference is such a personal choice related to culture and tradition, the Health Belief Model cannot be used in such an inappropriate way.
Change is not something that comes easily to most people. In order for a new behavior to be adopted, people need to believe the benefits of the new behavior outweigh the consequences of continuing the behavior. (9) This enables barriers to be overcome and the new behavior to be adopted. A necessary motivation of diet salt reduction is the belief of long-term health consequences of food choice. It should be strong enough so that people are willing to sacrifice their existing preference and habit. Do people really care about the health outcome in the future? For the old people, as they might be tortured by certain chronic disease, their motivation is deeply rooted. They will probably give up their eating habit even if it has been decades long. However, for the young people, who appear to be dynamic and rebellious, the situation is totally different. Because young people tend to perform risky behavior, like to be independent, and care only for the live at the moment, they discount future health problems and do not consider themselves at risk for chronic disease. (10) As a result, their motivation is weak.
The barrier also stands in the acceptance of behavior. Considering Chinese eating style, the measurement spoon is anything but operative. Literally, Chinese people don’t separate food. They like pick up food with chopsticks from large plates in the middle of the table. A normal Chinese dinner contains four courses and a soup. How can people accurately estimate the dose for each course with such a roughly designed measurement spoon? What’s the appropriate way to decide the does for each meal? Should it be a 2-2-2 style or 1-2-3 style? Another interesting concern is that the salt does depends on how many people the meal serves. All these information are so confusing that even if people are willing to reduce salt intake, they might be frustrated at the very beginning.
Another means by which the salt reduction scope is limited is through its ignorance of socioeconomic variables. As a city embraces 20 million resident people and a large number of floating people, socioeconomic status should be an important concern, which diet style is tightly related to. Self-cooking is a tradition with thousands years history in China. However, because of the hectic life style and impact of western culture, this tradition has been changed a lot. People choose restaurant for convenience-Lots of people often work overtime, willingly or not, they order fast food or take-out. People choose restaurant for relaxation-Pretty good flavor, atmosphere and service. People choose restaurant for acceptance -Fast food companies spare no efforts to make their products full of fun, easy to buy, and relatively cheap. They convey an idea of energy and coolness. The acceptance of fast food among young people is becoming higher. For all these people eating outside, the measurement spoon really doesn’t work. On the other hand, people with low income still preserve the old-fashioned way of cooking. They put vegetables and meat in saturated salt water to prevent decay. Actually this salted food has a special kind of flavor which makes it pretty attractive. Obvious it’s impossible to measure the salt does in the salted food on a daily base.

Evaluation of the advertising campaign
Advertising is a persuasive process which engaging human emotion. It makes promise to motivate people by effective communication. It features vivid evidence. Advertising is powerful mean in promotion of public health since it upgrades the focus from individual level to group level. “Health Life 2010” relies a lot on advertising. Health information is provided through booklets, TV news and programs. However, such kind of communication is so far from positive and exciting that the result turns out to be a failure.
The biggest problem is that information conveyed is rather tedious and irrelevant. The idea of how many communities were covered by the campaign is not at all useful. It has nothing to do with the raise of awareness or behavior change. People get bored with such emotionless report. Instead of an incentive of the promotion, the awful advertising barriers people from being part of the campaign.
The lectures and speeches given on TV is not a brilliant idea, either. We must admit that the lecturers are very professional, however the information they convey is far more from attractive. People get scared about the symptoms, but this doesn’t mean that they think they’ll get the same health outcome.
In addition, “Health Life 2010” fails to specify the target of the audience. With the aim of promote cardiovascular health for all the adults in Shanghai, it at least should reach as many people as possible. Why they pick up the 6:30 TV news is rather confusing, for the audience rating is not even top in ranking of news program. (11) For the TV lecture program, the major audience is those who have cardiovascular disease and people who care much about their health condition. It is believed that they are more informative than the majority of the population and their live style is healthier. They have better compliance with the doctors’ instructions and tend to conduct initiative communication with health care professionals. In a word, the TV lecture functions as the maintenance of the high awareness population, but fails in evoking the interest of the rest of the population.
The reach of the message is further restricted because the campaign use TV as the only channel to disseminate information. According to a recent survey, nearly 60% of urban population in China gets informed from website. (As one of the biggest cities, the percentage is believed to be higher.) Internet use is positively related to income level and education background. (12) The absence of online advertising render the “Health Life 2010” information less accessible or even unattainable to people with high income and good education background.
The billboard, magazine, and newspaper are also good resources that “Health Life 2010” should have paid attention to.

Limitation of Social Networking
“Health Life 2010” strongly suggests the interaction between community members and primary health care professionals. The membership of community health club provides an incentive system to physical activity. A healthy relationship with the primary health care professionals helps to identify risk of cardiovascular disease, to set goals for achieving cardiovascular health and to be informed of health living suggestions. This is how social networking model supposed to work - Health behavior spread through social networks. People gain support from groups they belong, which maintains the persistence of health behavior. (13) Yet as the campaign underestimates the influence of social environmental factors, the application of social networking has some demerits.
The interaction between the club members is a community based event. If you want to practice Taiji with others or keep a personal record for blood pressure, you have to be there at certain time slot. Obviously, this is a large barrier for the working population. The absence of meeting looses the networking of the health club, deteriorates the positive support from other members, and rules people out as a result. The survey shows that the majority of the health club members are old people. (4) The only reason is that they have time to hanging out.
Another concern is though Taiji and Wuqinxi are great physical exercises, they are no longer popular. Taiji and Wuqinxi is two kinds of ancient martial art with thousands years of history. They are of slow pace and need relatively long period of time to perform well. One of the advantages for these two exercises are they don’t have any requirement for infrastructure. This saves a lot for the operation budget, but the restrictions are large. Young people don’t get excited about these exercises. The acceptance is rather low. People get bored even before they have learnt how to practice them. No confrontation, no sweating, no self fulfillment, it’s rather hard to retain the interest of the young population.
Lastly, health care club doesn’t appeal to the floating population. People need time to establish the network, especially an effective and tightly supported network. For the floating population, it’s hard to fulfill this requirement. On the other hand, part of the floating population in Shanghai has low income and poor educational background. They are family based people who have little interest in social network. Even if they join the health club, they tend to be confused of the professional information doctors deliver.

Taking Environmental Factors into account
To promote cardiovascular health in adult is a broad operation. Any campaign won’t succeed without a careful concern of social environmental factors. Any expectation that programs with moderate and temporary effects that reach small numbers of people will create population-wide increase in health behavior is unreasonable. (14) The theory of ecological approach places a spotlight on the relationship between environmental and behavioral determinants, and assumes that the relationship is reciprocal. Researchers have shown that ecological approach is effective in the promotion of physical activity and management of obesity. (15) Ecological approach divides the environmental variables into following levels: personal factors, institutional factors, community factors and public policy.
With the help of ecological approach, “Health Life 2010” can define the target population more specifically. Instead of taking the whole adult population as a whole, they can be divided into subgroups such as the old, the young, and people with low income. So far, the campaign works well among the old people, because most of the endeavors are family based. Old people spend most of the time staying at home and neighborhood, like self-cooking, and hanging out with neighbors. For the young people, actions should be taken on a broader base. Booklets could be given out at restaurants, fast food stores, and supermarkets. Make the healthy food more accessible. If possible, dishes with lower calories and sodium might be highlighted on the menu with an attractive discount. For those people with low income who preserve the old fashioned way of diet (salted food), an operative and creative recipe might be welcome. Instead of telling them salted food is unhealthy, show them what is cheap and delicious. In a word, ecological approach can work well to define the personal factors and helps a lot in delivering clear messages, which reinforce the belief of the target population in behavior change.
For the promotion of physical activity, health club is not such a good idea. The reason why club seems to be so appealing is that it is exclusive and selective, not compulsory. People have fun when they hang out with others who share the same hobbies. It is ridiculous to push people be in a part of social network. It’s highly recommended to allocate a part of the operation budget to enhance the infrastructure in the neighborhood and worksite, for example, provide some basic fitness equipment – more popular and accessible than ancient Chinese martial art. Organizational and institutional interventions have the ability to reach large numbers of people and span numerous levels of influence. A study proved that worksite interventions that include group competitions have had positive influences on increasing physical activity as they promote cohesiveness. (16)

Delivering powerful message
It’s exciting that “Health Life 2010” use advertising to reach group effectiveness. This is very creative in history of health promotion campaign in China. However, as the campaign merely chose TV as the communication channel delivering text book instruction, the result is far from satisfying. Advertising is a kind of incentive and motivation. By reaching an emotional resonation, advertising explore the needs of the target population and sometimes even create the needs of the target population. The important factors include what kind of media to choose and how to convey the idea.
As a large health promotion campaign, it’s such a pity that “Health Life 2010” doesn’t have an appealing homepage. The only resource is the tedious news report on TV and confusing numeric analysis from the website of Shanghai CDC. This makes the information not accessible to a great part of the population who are used to get themselves informed through internet. Even if to people who prefer TV resource to internet, the report of number is considered weak. The suggestion is launch a multilevel media campaign. A website featuring popular elements is highly recommended. At least, it’ll arouse people’s interest to browse from time to time. By identifying the specific target, popular magazines, newspapers, and even billboard in the subway station is great source of communication channel.
Another significant thing is that “Health Life 2010” should change the way they disseminate the message. Health promotion campaign is not a process of merely instruction. To some extent, any common individual is able to name several tips of healthy life style. The point is how to persuade the target population to give up their old unhealthy life style, pick up the healthy way and maintain. The suggestion is show the energetic image with healthy life style. Invite celebrities to share their tips of healthy life style. Create beautiful and sexy models in promotion advertising. This gives Health Life a brand new label. There’s no doubt that the advertising campaign will gain a far reaching resonation than a lecture on TV.

Conclusion
One good thing about “Health Life 2010” is that it uses a combination of several social behavior theories and models to address public health problem. But in order to make a great population wide behavior change, it fails to target the specific problem of different subgroup, thus deeply reduce the efficacy of the campaign. Admittedly, the ambition is great, yet the public health professionals should think carefully about the right way to do. Take the social environmental factors as a whole while respect differences of subgroups. Choose the powerful way to conduct effective communication. Step by step “Health Life 2010” will surely change the situation in the near future.





















References
1. WHO Media Center: Cardiovascular diseases http://www.who.int/mediacentre/factsheets/fs317/en/index.html
2. Shanghai Municipal Population and Family Planning Commission
http://www.popinfo.gov.cn/yearbook/2009nj/pdf/text/09-10.pdf
3. Shanghai Municipal Department of Public Health
http://wsj.sh.gov.cn/
4. Shanghai Municipal Center for Disease Control
http://scdc.sh.cn
5. Jiang He. Dietary Sodium Intake and Subsequent Risk of Cardiovascular Disease in Overweight Adults. JAMA1999;282(21):2027-2034
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7. Less salt less risk of heart disease and stroke. WHO 2006
8. Physical Activity WHO
9. Centers for Disease Control and Prevention, 2004
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11. Shanghai Media Group
http://www.smg.cn/
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http://tech.sina.com.cn/focus/cnnic18/index.shtml
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14. James F. Sallis An ecological approach to creating active living communities. Annu. Rev. Public Health 2006. 27:297-322
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16. Elzabeth Richards. A social Ecological Approach of Community Efforts to Promote Physical Activity and Weight Management. Journal of Community Health Nursing, 25:179-192, 2008