Friday, December 17, 2010

Dissecting Nolita’s “No Anorexia” Campaign and An Alternative Anorexia Nervosa Intervention for Adolescent Girls— Clara Gordon

Anorexia nervosa is defined by the Diagnostic and Statistics Manual IV as a failure to maintain 85% normal body weight, an intense fear of gaining weight or becoming fat while underweight, and a “disturbed” perception or experience of one’s body weight (1). The National Association of Anorexia Nervosa and Associated Disorders reports that an estimated 7-10 million American women and approximately 1 million American men suffer from the mental illness of Anorexia nervosa (1). Recent research indicates that prevalence across ethnic groups within the U.S. is equal with Whites, Latinos, Asians, and African Americans all affected (2). Eighty six percent of patients report the disease onset occurring before the age of 20, and 76% report the illness duration as 1-15 years (1). The Renfrew Center Foundation in their compilation of research estimates that 1 in 5 women suffer from an eating disorder or disordered eating patterns along with 70 million people worldwide (3). Anorexia nervosa holds the unique status of being the most deadly mental illness along with being the third most common chronic illness among adolescents in the U.S. (3). Bearing in mind the gravity of these findings, Anorexia nervosa deserves to be treated with a serious measure of respect and professionalism with regard to its portrayal in the media.

The advertisement to be critiqued is Nolita’s “No Anorexia” billboards including photographs of an extremely thin French actress who volunteered for the campaign. The photo subject, Isabelle Caro, is featured in two versions of the billboard bearing the words “No Anorexia” along with the sponsor Nolita’s logo. Caro, then 27 years old and only 31kg, was photographed nude by Oliviero Toscani of repute for his controversial work in photographing AIDS patients in the 1980’s and 1990’s (4). The only elements that comprise these spare but powerful advertisements are Caro’s emaciated frame, the pink text, and Nolita’s logo. The billboards debuted during Milan’s Fashion Week in 2007 to mixed reviews among the public, fashion designers, and models present for the event (4). The billboards, while shocking and eye-catching, are nonetheless ineffective neither at actually addressing the mental health issue of Anorexia nervosa properly nor with a level of dignity or integrity for those who suffer from the disease and do not clinically present just like Isabelle Caro. For these reasons and more, Nolita’s “No Anorexia” advertisements beg a more in-depth investigation and analysis.

While is easy for passersby to appreciate Caro’s unhealthful appearance, in terms of creating an effective public health message to inspire appropriate reactions among a target audience, the ads fall short. To fully consider Nolita’s “No Anorexia” ad, one must discern that target audience. Anorexia nervosa predominantly affects females with onset of symptoms in the adolescent years (1,3). The Guardian UK newspaper reported that, “Flash & Partners, owners of Nolita [clothing company], have said that the image aims to raise awareness of an illness ‘caused in most cases by the stereotypes imposed by the world of fashion’” (4). One can assume from the ads’ unveiling at Fashion Week that the ad intended to reach appearance-conscious women. At the root of it all, it may be unfair to criticize the ads in light of public health theories because they appear created more for shock value than for proactive health promotion; however, the ads nonetheless appear to try and utilize a set of basic public health theories to promote Nolita’s message.

The Health Belief Model: Individuals do not act rationally

Creating a pointed set of images with Caro’s emaciated, malnourished body as the centerpiece assumes that rational viewers will appreciate the full extent of Anorexia nervosa’s damage to her wellbeing and act accordingly to prevent such devastation. This assumption is erroneously based on the premises underlying the Health Belief Model (HBM) of individual behavior change. Developed by the U.S. Public Health Service in the 1950’s, the HBM was designed to examine and predict preventative health behaviors in light of a person’s general health beliefs, their perceived susceptibility to a preventable condition, and their perceived severity of the disease if they were to contract it (5). The HBM postulates that in the context of ample evidence to weigh the costs and benefits of an action, a person will adopt a behavior that ultimately serves to better their health. The HBM views public health problems as complicated by insufficient information, and campaigns that utilize its approach tend to present their information or message in a straightforward, no-nonsense fashion. Placing Caro on display without clothes portrays the full effect of Anorexia nervosa’s toll on her body. The absence of words on the billboard beyond its admonition to avoid Anorexia (and to patronize the Nolita brand), also help create the ads’ stark result and direct message.

From the perspective of the Health Belief Model, the Nolita ads are deplorable in the sense that they imply with the text “No Anorexia” that the manifestation of mental illness is a simple ‘Yes’ or ‘No’ issue. Part of the information analysis assumed to occur within the HBM is that targeted individuals are inspired to consider their susceptibility to the disease (5). Women or adolescent girls may be disinclined to relate their own disordered eating habits to those of Caro because of how extremely ill she appears. Because the current state of their illness is not akin to Caro’s, they may not believe themselves to be on that same lethal path. The second component considered in the HBM is how severe a person would perceive a disease to be once they have contracted it (5). The ads leave little to the imagination with Caro’s body laid bare, but it is worth noting that she is a European film celebrity. Her professional success and renown as an actress serve to contradict the notion of her condition as severely life-threatening. Any person viewing the ad who recognizes Caro may be shocked by what the see but subconsciously downplay the severity of Anorexia nervosa knowing of Caro’s successful career. In the case of many public health messages, celebrity presence or endorsement is viewed as a positive aspect of the campaign, lending to the message’s power and attractiveness. Caro’s fame does not underscore the acuteness of anorexia so much as the possibility to live with it over time. The HBM is widely criticized for its overly simplistic approach to public health problem-solving and campaign development, and Nolita’s ads fall prey to the same pitfalls of oversimplifying a complex and delicate issue.

Psychological Reactance: Why saying ‘No’ inspires ‘Yes!” reactions

Brehm’s Theory of Psychological Reactance from the 1960’s attempts to explain behavior and motivational changes that occur following directives that tell that person not to do something. Brehm noted that even from a young age, people develop preferences that are carried out through behaviors (6). Anything perceived to impede acting upon one’s inclinations is sensed as a fundamental threat to freedom, requiring a counteraction to restore freedom and a sense of control (6). This process of counteraction is referred to as ‘psychological reactance,’ and the magnitude of reactance is proportional to how much a person values the belief or action in question (6). The greater the threat to a behavior, the more likely a person is to commit that behavior again once they have been told to cease doing so.

In Nolita’s ad, the only relevant words caution to viewer to not engage in behaviors related to Anorexia nervosa. If the Renfrew Center’s estimates are not far off in terms of eating disorders and disordered eating’s prevalence of 1 in 5 women (3), Nolita’s message of prohibition is likely to inspire reactance in 20% of the population. Depending upon the fervor with which a person adheres to their anorexic eating patterns, being told to cease will only inspire them carry on with renewed dedication to their behavior, no matter how destructive. Since many women with Anorexia nervosa tend to develop the illness in their adolescent years, a message founded upon saying ‘No’ is especially likely to fail among teens, an age demographic notorious for their mistrust of authority and unwillingness to comply simply because something is “good for them.”

It becomes important to reexamine the target audience in discussing reactance. Young women participating in anorexic behaviors often do so with extreme secrecy, knowing that in starving themselves they are causing damage to themselves on a day-to-day basis (1). Nolita’s ad shows little discretion or understanding of this facet of Anorexia nervosa as evidenced by its brazen images and bold statement to say ‘No.’ Although Nolita insists that the ads were meant to raise awareness, especially among people within the fashion industry, one can hardly accuse designers nor their models of being ignorant of eating disorders with bony models tottering down the runways and featured in advertisements on every corner. Especially because of people with anorexia’s demonstrated drive for privacy in their starvation endeavors, Nolita’s bold advertising intervention demonstrates little tact in broaching the subject with sensitivity, grace, and awareness.

Advertising Theory: A promise and proof

Advertising Theory presents a more modern approach to presenting and selling messages. In the same way that merchandise can assume fantastically irresistible qualities, public health messages can be made to seem alluring. Advertising Theory appeals to the audience’s most basic desires through the use of emotionally stirring images and music, depending upon the type of media. The other defining aspect of a campaign utilizing Advertising Theory is the creation of a promise so grandiose that it cannot possibly be fulfilled. And yet, the backing organization, company, or product behind the campaign inevitably exists to satisfy some fundamental human desire (5). Advertising Theory does not rely upon human logic but rather manipulates the emotional foundation of humans’ more impulsive, generally irrational behavior.

Nolita’s advertisement inadvertently offers core values of the adolescent female population suffering from Anorexia nervosa: Discipline and control. Without realizing it, Toscani’s portrayal of Caro fairly laud’s her attainment of extreme thinness by showing every inch of her. Common psychosocial characteristics of adolescent women with Anorexia nervosa include an extreme need for secrecy and a profound dedication to their calorie-restrictive behavior (1-3). These behaviors demonstrate a need for control realized through daily discipline. While Nolita professed that their intention was to raise awareness for the devastation of Anorexia nervosa’s affects, one could claim that the billboards actually served to glorify Cora as a paradigm of slender perfection. No matter their aims, Nolita crafted and supported a campaign touting the attainments of supreme control and discipline.

Intervention: Savor Life

As discussed above, people do not act rationally to pursue wellbeing with every decision. The Health Belief Model (HBM) would lead one to believe that in light of sufficient evidence, people would choose to act in a way that would prevent disease. In the context of Anorexia nervosa as a mental illness and viewed as a scenario where “genetics loads the gun and environment pull the trigger” (1,3), disease prevention is not as simple as choosing to forgo certain risky behaviors.

The HBM’s criticism is often founded on evidence that people choose instant gratification over decisions that would promote long-term wellbeing (5). Adolescents are a difficult population to persuade with messages regarding future outcomes, and interventions for this age demographic need to be focused upon benefits in the present realm. The Nolita ads likely assumed that Toscani’s photographs would inspire visceral reactions of horror, revulsion, and shame for any actions that might lead to such an outcome as Caro’s. Isabelle Caro herself says that she volunteered for the campaign because, “I’ve hidden myself and covered myself for too long. Now I want to show myself fearlessly, even though I know my body arouses repugnance [emphasis mine]” (7). While the images may have succeeded in garnering attention and indignation from a wide audience, the ads did nothing to show or describe a positive, alternative outcome more salient than Caro’s achievement of being the thinnest of the thin in an age that reveres bony protrusions more than a skeleton actually sheathed in healthy tissue.

An alternative campaign to tackle Anorexia nervosa that addresses criticisms of the HBM would need to include positive imagery of adolescent experiences that a young woman is bound to miss if she succumbs to dealing with an eating disorder. Knowing that humans are, in the words of Dan Ariely, “predictably irrational” (8), the campaign must not attempt to root its message or images in scientific fact. Contrary to the HBM, facts alone do not weigh heavily in the decision-making process behind people’s daily choices. No matter the amount of accurate information available to a person, decisions are not made in a vacuum devoid of psychosocial and environmental factors (5). The campaign must acknowledge competing factors in the media including persuasive fashion advertisements featuring thin models, glorification of slender celebrities, and the pervasive contemporary belief that fleshy bodies are unhealthy bodies.

To overturn the HBM (and move toward a more modern approach to group behavior change based upon Advertising Theory), the campaign should fundamentally appeal to young women’s longing for acceptance and confidence. People with Anorexia nervosa often strive for these ideals through their restrictive behaviors, not realizing that these actions alienate them and erode their self-confidence rather than bolster self-worth and sense of social belonging (1,3). The campaign should begin from the perspective of a young woman in physical and social isolation, acknowledging the emotionally difficulty and sense of separation that Anorexia nervosa imposes upon one’s life. Although separated, she should be surrounding by lighter (in color and emotional theme) images and movies of other young women happily participating in a variety of adolescent-centric activities. Such pursuits should include physical and social endeavors including playing sports, hanging out with friends, volunteering in the community, participating in a school or religious club, working an after-school or summer job, learning to drive, attending prom with friends, and graduating high-school. These images should stir a sense of what it means to be a teenage girl, living life to the fullest. The images should appear bright and positive, as if the young women depicted live a life full of promise and rewarding challenges within the greater communities of their family, school, church or synagogue, and town. Nothing shown in these images will be based in a time period much beyond that of high school to keep examples of a healthy life well lived as relevant as possible to the adolescent population.

Dissonance inductance techniques to reduce psychological reactance

As eating disorders receive more attention, health care professionals have developed a variety of prevention techniques with varying levels of success. In a recent manuscript by Shaw et al (9), an integral component of most successful interventions is “dissonance induction.” Most programs described in this review of eating disorder prevention initiatives were group sessions moderated by either a health care professional or a trained peer interventionist (9). Moderators achieved dissonance induction through small group discussions of contemporary body image ideals, self-image dissatisfaction, perceptions of dieting, and any negative emotions these topics may inspire. The aim of the sessions is to inspire young women to develop their own thoughts regarding the cultural glorification of unhealthy body images in the media and to take an active stand against succumbing to these ideals as desirable (9). Two successful examples of this model of program include the Body Project and Sorority Body Image Program, a condensed spin-off of the former implemented by trained peer leaders (9). What can be gleaned from the success of these interventions is that there is a strong role for Cognitive Dissonance Theory in the prevention of Anorexia nervosa.

Cognitive Dissonance Theory, as developed by Leon Festinger in the 1950’s, attempts to explain human behavior in the wake of decisions that do not actually align with the person’s inherent beliefs. A person who makes a decision contrary to their personal convictions experiences an uncomfortable emotional state that requires the person to reevaluate their beliefs and potentially change future behavior to avoid another period mental discord (10-11). Festinger’s theory relates to earlier criticisms presented here that Nolita’s ad proved better at inspiring reactance among adolescents more than it did motivate them to contemplate unhealthy beliefs, choices, and behaviors leading to Anorexia nervosa. Critiques of Festinger’s model help public health professionals understand how to best execute the process of creating emotional and mental dissonance among the target audience. Critics agree that people are most likely to acknowledge and work through cognitive dissonance when there are readily available and easy to adopt alternative behaviors and when continuing with an unhealthful behavior does not appear to end in morbidly dire consequences (12). Nolita’s ad takes into account neither of these provisions, and so the ads resulted in more condemnation than praise and without inspiring production behavior change among its target audience. The worst-case scenario is that the ads caused reactance among the most vulnerable of young women, inspiring them to carry on with unhealthy dieting as they wish in an effort to reestablish their freedom.

Reducing psychological reactance to a public health message regarding Anorexia nervosa will be paramount to a new campaign. As described above, young women with anorexia tend to suffer privately and attempt to maintain secrecy surrounding their calorie restriction (1,3). The last thing the campaign should attempt to say is ‘No,’ nor should the message appear delivered from an outside authority figure. Telling people ‘No’ at any age will make them wonder about the benefits of saying ‘Yes’ to a behavior and often cause them to perform a given action purely to rebel against the notion that their freedom is being taken away (6). The Sorority Body Image Program offers proof that interventions demonstrate greater success when a trained and reputable peer delivers the health message (9). Bearing this in mind, the new campaign to address anorexia will feature only stories, voices, and images of young women. To acknowledge Anorexia nervosa’s prevalence across all ethnic groups (2), the girls featured in the campaign will be White, Latina, African American, Asian and others to convey that every girl is potentially affected by this same problem. In sum, never overtly admonishing the target audience to say ‘No’ and delivering the health message through reputable, culturally relevant peers can reduce reactance.

Advertising theory: Making the promise of health and happiness

Nolita’s ad promised one universal outcome with anorexic behavior as embodied by Caro’s gaunt figure. The sponsoring product behind it all was simply a line of fashion garments. Ultimately, the ads appear crass and without consideration for the thousands of non-White women who experience anorexia differently or less acutely than Caro. Nolita attempted to show Anorexia nervosa in a single, worst-case scenario format that drove more people away from its message than invited them to join the crusade against eating disorders. A new campaign for Anorexia nervosa awareness could make better use of Advertising Theory to craft a positive and powerful message to inspire adolescent females to make the choice of health and wellbeing for themselves.

So far, this new campaign will include images on positive adolescent life experiences played out through a variety of happy, healthy girls of multiple ethnicities as seen from the first-hand perspective of another young female. The format of a first-person witness experience allows young girls, no matter their resemblance to the campaign’s young women, to feel as though this ad speaks to them. Advertising theory, as explained before, incorporates two essential elements: a large, mostly impossible promise and proof of the promise’s fulfillment by a given product or behavior. For this new anorexia awareness campaign, the product to be pitched is young female’s adoption of healthy behaviors.

The promise the campaign will make is that choosing to Savor Life will lead to happiness, social belonging, and achievement. All three of these represent core values of every human being, although their appearance may be quite different depending upon a person’s age and life experiences. For this reason, the campaign’s images of success, fulfillment, and full social engagement will be focused at the level of a stereotypical teenage girl. Just as Nike does not sell running apparel but rather a sense of belonging to the universal pulse of healthful, active people in motion (5), I Savor Life will portray little to do with consuming food but instead emphasize all the activities and pleasures that are only possible with a well-nourished body. Once again, sample images will include young girls achieving and enjoying such activities as executing a powerful serve in a tennis match, raking leaves in a park with other teens, carrying trays of food to an elderly person in a nursing home, scoring a goal in a soccer game, enjoying a stroll around town with friends, engaging in play with younger people with older people looking on, dancing at prom, and donning a graduation cap. All of these images, without mentioning or promoting food, convey the campaign subject’s vitality and youthful vigor.

At the ad’s end, whatever darker colors have surrounded the lens of the first-person viewer will fade into brilliant color to blend with those of the prior images, breaking the sense of the viewer’s isolation from these experiences of pleasure and success. From there the tagline will appear and be heard via voiceover from multiple girls that, “I choose…” “I choose…” “I choose…” “…to Savor Life” which will be stated collectively by all their voices. From there, a website address and organization name will appear to pique girls’ interest to follow-up on ad’s origins. The promise is that Savoring Life will result in happiness with dynamically visual proof provided throughout the ad to inspire other girls to be their best and do the same.

Nolita’s advertisement featuring Isabelle Caro proved productive in starting a worldwide conversation about Anorexia nervosa, but it still appeared to be more of a publicity stunt for a clothing company than a conscientious cry for the public’s awareness of a health problem. Through careful analysis of the Health Belief Model, Psychological Reactance Theory, Cognitive Dissonance Theory, and Advertising Theory, one could craft a more sensitive, pointed, positive, and effective campaign to address Anorexia nervosa and reach a more appropriate intervention audience. I Savor Life provides a fresh, positive approach to broaching the topic of adolescent Anorexia nervosa through culturally sensitive, positive imagery that entices young women to make healthful decisions to fuel a more productive, satisfying life.

REFERENCES:

1. National Association of Anorexia Nervosa and Associated Disorders. About Eating Disorders. Naperville, IL: National Association of Anorexia Nervosa and Associated Disorders. http://www.anad.org/get-information/about-eating-disorders/. Accessed November 28, 2010.

2. Luana M, Alegria M, Becker AE, Chen C, Fang A, Chosak A, Diniz JB. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implication for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders 2010; Electronic publication ahead of print.

3. The Renfrew Center Foundation for Eating Disorders. Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources. Philadelphia, PA: Renfrew Center Foundation for Eating Disorders. Published September 2002, revised October 2003.

4. Cartner-Morley J. Shock anorexia billboards annoy fashion designers. The Guardian UK newspaper web site. London, England: The Guardian UK, Published September 26, 2007. Accessed November 26, 2010.

5. Siegel M. Boston University School of Public Health Course SB721: Social and Behavior Science for Public Health. Course lecture notes. Recorded fall semester 2010.

6. Brehm JW. A Theory of Psychological Reactance (pp. 377-386). In: Burke WW, Lake DG, Paine JW, Organization Change: A Comprehensive Reader. Hoboken, NJ: John Wiley and Sons, 2008.

7. Medusa blog. Anorexia: Isabelle Caro Still Stick Thin… http://www.2medusa.com/2009/02/anorexia-isabelle-caro-still-stick-thin.html. Accessed November 25, 2010.

8. Ariely D. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York, NY: HarperCollins, 2008.

9. Shaw H, Stice E, Becker CB. Preventing eating disorders. Childhood and Adolescent Psychiatric Clinics of North America 2009;18(1),199-207.

10. Festinger L. A Theory of Cognitive Dissonance. Stanford, CA: Stanford University Press; 1957.

11. Cameron KA. A practitioner’s guide to persuasion: An overview of 15 selected persuasion theories, models and frameworks. Patient Education and Counseling. 2009;74:309-317.

12. Encyclopedia of Psychology Theory into Practice Database. Cognitive dissonance. http://tip.psychology.org/theories.html. Accessed October 18, 2010.

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