Friday, December 17, 2010

‘Let’s Move’ Campaign Likely to Fail to Move Anyone – Kristina Farah Bigdeli

Childhood obesity is a national issue. It has substantial consequences for American quality of life, lifespan, morbidity, economic expenditures, military readiness, and national security (1). Data from the 2007-2008 National Health and Nutrition Examination Survey (NHANES) indicate that nearly 17% of children and adolescents between the ages of two and nineteen are obese (1,2). From 1980 to 2008, obesity among children and adolescents increased from 5% to 17%, although the increase has slowed in recent years (1,2). Local, state, and federal legislatures and agencies are aware of the problem and are working to find solutions, such as barring the use of food stamps to purchase sodas in New York and restaurant use of trans fats in California (3,4). In January 2010, Surgeon General Dr. Regina Benjamin viewed obesity as an epidemic and issued a “call to arms” aimed at bringing Americans to a “level of health that allows [them] to embrace each day and live their lives to the fullest—without disease, disability, or lost productivity” (5).

Responding to public health professionals’ concerns, on December 2, 2010, the U. S. House of Representatives passed into law The Healthy, Hunger-Free Kids Act, a measure that indirectly addresses the social problem of childhood obesity by implementing changes in schools that benefit from the National School Lunch Program (NSLP) (6). The law establishes a performance-based award of six cents per child in federal reimbursement for lunches in schools that meet Congress’ new nutrition standards, and it invests in enrolling more eligible children in the programs (7,8). The passage of this act, one of first lady Michelle Obama’s advocacy goals for this year, came more than nine months after the first lady launched her campaign to reduce childhood obesity, “Let’s Move.” Unlike the $4.5 billion law, which is does not attempt to directly change children’s behavior (7,8), the Let’s Move campaign commands as much as $1 billion per year in federal funds for ten years, and seeks to “raise a healthier generation of kids” through efforts to modify individual behavior (9,10). To implement the first lady’s proposals, the Oval Office has established a national task force on childhood obesity that draws on the resources of the departments of the Interior, Health and Human Services, Agriculture, and Education, as well as eight other agencies (9,1).

Despite these assets, in its current form, “Let’s Move” has limited potential to reduce childhood obesity. Much of the campaign’s budget will likely go to fund the NSLP and Women, Infants, and Children (WIC), the latter a federal nutritious foods and nutrition education grant program (9,11,12). The remainder will probably be spent in efforts to encourage individuals to get informed about changing children’s behavior. On February 9, 2010, the first lady introduced the campaign and launched the official website and a Facebook page with a speech at the White House, as well as a promotional YouTube video (10,13,14). The video, subsequent speeches, and school visit blogs are now part of the site’s accessible content. Parents and community leaders visiting the site can view the promotional media and take part in the campaign’s five-part plan to “learn the facts, eat healthy, get active, take action, and join us” (10). Despite what may be successful marketing and branding aimed at driving traffic to the website, it is doubtful whether the five-part plan will have much effect on changing the behaviors that lead to obesity. This paper will analyze three fundamental flaws in the Let’s Move public health intervention and offer an alternative intervention model. Specifically, it will address the intervention’s reliance on the Health Belief Model, its assumption that people behave rationally, and its failure to address psychological reactance.

Criticism of Intervention 1: Like the Health Belief Model, Let’s Move Assumes that Individuals Use Cost-Benefit Analysis for Health Decisions

Let’s Move has four goals over the next ten years: “to improve the information and tools that parents need to make the changes that are desired in their families, to improve the quality of food in schools, to improve access and affordability of healthy foods, and to increase physical education” (14). The campaign website’s five-part plan attempts to address the first goal by providing informational resources for parents to “get informed” and “take action” (10). According to Let’s Move’s program, “getting informed” entails learning why obesity is an epidemic, what serious risks are associated with childhood obesity, and how to calculate a child’s body mass index (BMI). The persuasive elements of the section culminate in a “call to action” by the first lady to change children’s health behavior through measures outlined in the “take action” section (15). In escalating alarming facts and statistics to the presentation of a choice to act, Let’s Move draws on the intervention approach of the Health Belief Model (HBM), a seminal social cognition theory that attempts—yet often fails—to predict health behaviors (16).

Developed in the 1950s by Hochbaum, Rosenstock, and Kegels, the HBM theorizes that people rationally weigh the costs and benefits of changing a health behavior before deciding whether to act (16). This line of thinking assumes that “complete” knowledge will weigh more heavily on the side of changing negative behavior, resulting in the “correct” action, a subjective judgment based on the value system of the interventionist (17). The components of the net threat and net benefit sides of the equation are dependent on the individual’s perception of his or her susceptibility to the outcome, the outcome’s severity, the barriers to avoiding the outcome, and the benefits of successful avoidance (16). The result of this analysis constitutes the individual’s “readiness to change” until a factor, called a “cue to action,” activates the readiness, the success of which depends on his or her level of self-efficacy (18). Since the 1950s, social scientists such as Jane Ogden have attempted to test the HBM’s potential use in health interventions and have found that it “does not pass the criteria set for a good theory.” Yet its widespread popularity persists in public health interventions, including Let’s Move (19).

By providing facts and statistics as justification for behavioral change, Let’s Move incorrectly assumes that, once properly informed, the benefits will outweigh the costs and parents will modify their child’s behavior. Parents visiting Let’s Move’s website will first learn the facts about the severity of childhood obesity and its associated risks, as well as how susceptible their children are by calculating their BMI (15). From here, Let’s Move assumes they will rationally balance the equation in favor of change and move on to the action plan. Drawing on the HBM, Let’s Move’s strategy hinges on possession of the “correct” knowledge that will lead to a positive health decision (17). Yet decisions are influenced by many more factors than mere information, such as the individual’s social, economic, political, and cultural status, as well as his or her tendency to behave rationally (20).

Socioeconomic, sociopolitical, and cultural factors provide a frame through which individuals interpret their surroundings (20). David Marks argues that the HBM and other traditional models are ineffective without consideration of these factors and that social scientists should use them in assessing communities for future interventions (20). Let’s Move fails to consider these factors. According to Linda Thomas, public health professionals that apply the HBM homogenize individuals “without regard for their sociopolitical and historical experiences”; therefore, they are ineffective in heterogeneous populations, such as the target audience of the first lady’s campaign (17). The website provides facts for parents and stops there; without socioeconomic, sociopolitical, and cultural frames for the heterogeneous audience to interpret the information, Let’s Move’s use of the HBM will not convince parents to make positive decisions regarding their children’s health.

Based on its adherence to the HBM, Let’s Move assumes that individuals behave rationally; however, according to Dan Ariely’s Predictably Irrational: The Hidden Forces That Shape Our Decisions, people are anything but rational. In a state of arousal, 21% more of the subjects studied will slip a woman a drug to increase the chances of sexual intercourse (21). Studies have shown that people holding warm objects, compared to those holding cold ones, tend to judge other people as more interpersonally warm, competent, and trustworthy (22). Another study concluded that 51.6% of smoking cessation attempts is unplanned, and yet another concluded that among “smokers who have made a quit attempt between six months and five years previously, the odds of success were 2.6 times higher in unplanned attempts than in planned attempts” (23,24). Each of these behaviors demonstrates that people cannot be expected to behave rationally, which is evidence against Let’s Move’s informational approach.

Criticism of Intervention 2: The Optimistic Bias and the Illusion of Control Undermine Let’s Move and the Health Belief Model

Despite Let’s Move’s questionable assumption that giving parents information about childhood obesity will lead them to make rational decisions, there is evidence to suggest that they will often act irrationally. Tom Gilovich holds that when making decisions, people “rely on a number of simplifying heuristics, or efficient rules of thumb, rather than extensive algorithmic processing” to approximate rationality (25). Two theories have been advanced to explain why an individual’s attempt to approximate reality may result in an irrational outcome: one concerns a bias toward optimism; the other an illusion of control. Both theories undermine the plausibility of the HBM model—and consequently of Let’s Move—by reframing the question of “perceived susceptibility.” Perceived susceptibility, the most influential component of the HBM, is one factor in an individual’s net threat calculation, and involves a person’s perception of the likelihood of contracting a disease (26,16).

Interventions based on the HBM attempt to increase perceived susceptibility to tip cost-benefit analysis in favor of positive health behavior. Specifically, Let’s Move offers statistics and a way to calculate BMI in order to increase parents’ perception of their children’s susceptibility to risks associated with obesity. One study of smokers, however, shows that people tend to rate their susceptibility to health risks lower than that of their peers, regardless of their empirical knowledge about risk (27). Individuals often overestimate the chances that good things will happen to them and underestimate the chances that bad things will happen to them (28). Parents following Let’s Move’s rationale for modifying their children’s risky health behaviors will likely imagine their children in a lower risk category than the statistics presented. Optimistic bias, also known as unrealistic optimism, is an irrational influence on perceived susceptibility that decreases the net threat in HBM’s cost-benefit analysis.

Perceived susceptibility is also reframed under the theory of the illusion of control. First described by Ellen Langer, this effect describes the tendency for people to expect a probability of personal success in a given task that is disproportionately higher than the objective probability would warrant (29). Parents following Let’s Move’s recommendations will tend to overestimate their ability to control their children’s health behaviors and underestimate their children’s susceptibility to obesity. Following the reasoning of the HBM, the lower the net threat, the less likely a person is to change their behavior. Therefore, Let’s Move’s reliance upon perfect information to persuade parents to change their children’s behavior may be ineffective because people are irrational when it comes to making decisions and carrying out cost-benefit analysis.

Criticism 3: Parents Who Use Let’s Move’s Advice Will Trigger Psychological Reactance in Their Children

In Let’s Move’s plan for parents to “take action,” the fourth of five steps on the website, parents can read advice on how to change their family’s rules and activities to eat healthier and exercise more (30). Components of the action plan, however may trigger psychological reactance and foster rather than prevent unhealthy practices in the future. According to Jack W. Brehm’s psychological reactance theory, if an individual perceives that a previously free behavior is restricted, he or she will enter a motivational state directed at restoring the lost freedom (31). Often, the individual will achieve restoration of lost freedom in what Brehm sees as a “boomerang effect” by doing the very behavior that was restricted (31,32). Public health interventions that have followed traditionally restrictive models without mitigating the effects of reactance and the “boomerang effect” have failed, as seen with increased rates of alcoholic beverage consumption in response to interventions aimed at reducing it (33). Aspects of the action plan advise parents to change behavior in a restrictive way: deprivation. This strategy is equivalent to a “loss of freedom” for children, yet the action plan does not offer effective advice on how to reduce the psychological reactance that they may experience (31).

Storing “tempting foods on high shelves or in the back of the freezer,” substituting “water for soda and juice with added sugar,” limiting TV time, and keeping “the TV out of a child’s bedroom” are examples of deprivation encouraged in the action plan (30). Parents who keep tempting foods, drinks, and entertainment just out of children’s reach may unintentionally create an environment of continuous loss of freedom and thus increase the intensity of their children’s reactance. One study has shown that when children cannot have what they want, they experience the emotional consequences of not having it (34). The restrictive parents, therefore, “increase the child’s view of the attractiveness of the unobtainable object,” and increase their desire to obtain it (34). Parents following Let’s Move’s recommendations may face “boomerang effects” in their children coupled with amplified desires for unobtainable foods, drinks, and entertainment.

The plan also suggests scheduling “thirty minute time slots for specific activities like walking” and including physical exercise in daily routines (30). Parents can park their car “further away, count with their children the steps it takes from the car to the destination, note the number and try to park further away on the next stop” (30,35). Depending on predisposition, some children may be more “prone” to interpret regimented schedules and scoring as outside “manipulation” and “loss of freedom and autonomy,” resulting in psychological reactance (36). Without suggestions from the action plan on how to successfully deflect reactance, the parents’ approach and implementation of the lifestyle changes may vary naturally from enabling to controlling. When parents along this spectrum deprive their children of choice and impose regimented schedules and scoring without any mitigating factors to decrease reactance and increase compliance, they will likely cause children to continue or restore their unhealthy behaviors (37).

Children whose parents follow these particular elements of the action plan to change behaviors may react through the “boomerang effect,” not only in response to the loss of freedom itself, but also in response to the characteristics of the parents that deliver the health communication. An authoritative communicator will not induce a positive force of compliance to counteract the negative force of psychological reactance (37). If the children’s positive force to comply is weaker than the negative force to react, the desired behavioral change will not appear, and the children’s liking and desire for denied behavior may increase (37,38). The strengths of both quantifiable forces depend on several factors: the audience’s interpersonal similarity with the communicator, perceived manipulation, and “proneness to reactance;” the communicator’s intent to persuade and the intensity of his or her dogmatic language; as well as the message’s explicitness, dominance, and reasoning, such as justification for making the health behavior change (37,36). Since parents are the target audience of the “Parent Action Plan,” they in turn are their children’s main health practice communicators, and most of the factors for reducing reactance and increasing compliance depend upon their strategies for communication. The first lady’s campaign advises parents to control children by depriving them of their freedom to choose unhealthy food and poor exercise practice, yet it fails to educate parents on how to avoid triggering psychological reactance when communicating those behavior changes.

New Intervention Proposal: Groups, Marketing, Social Networking, Little Emphasis on Health

Still in its fledgling year, Let’s Move risks joining the many ineffectual public health interventions that relied on the HBM and failed adequately to address the problem of psychological reactance. Despite the criticism lodged above, with the support of the White House, Congress, and twelve federal agencies, Let’s Move can be an excellent foundation for intervening in the childhood obesity epidemic in America. It has a national platform, funding, a familiar and charismatic spokesperson to advocate for more funding, manpower, and access to one of the most influential youth networks in the United States: the school system. This paper will now propose a new intervention that leans upon the political framework of Let’s Move, but attempts to mitigate its shortcomings and create a new structure for implementing future public health interventions.

Consider beginning with distribution of a White House press release seeking one student in every grade from every school to be nominated by their immediate peers for national recognition based on age-adjusted factors such as their success in school and their community involvement. Most of these factors should be positive characteristics that children and adolescents genuinely esteem, derived from concurrent polling and market-style research. Design an attractive, simple brand for this new, small cohort of esteemed children and adolescents who happen to also be healthy. Create a secure website, accessible only by these “winners” featuring profiles that highlight their interests, fun activities, and successful life choices, including but not spotlighting their positive health practices. Avoid explicit mention of childhood obesity, nutrition, exercise, and health. To the public, only reveal a splash page with a login button. Market the site through new media for a few months as an invitation-only social networking forum for people eighteen years of age and under. Incentivize group membership internally with annual, localized gatherings based on fun activities and trips to popular locations.

Once the preliminary buzz has grown, encourage each initial winner to select three peers to join, contingent upon signing a pledge to live a fun lifestyle. The elements of the pledge’s lifestyle should be healthy practices masked behind terms popular with children and adolescents. For example, include non-smoking in the contract, but position it last in the list of priorities; and include physical exercise, but conceal it in a related activity such as enjoying nature or playing sports. Periodically release more passwords through current members as rewards for meeting challenges and playing games within the website. More importantly, create an external system to invite students in each grade such that the cohort begins to represent a socioeconomic, cultural, and ethnic cross-section of local and national populations. Stagger membership expansion so that it is never obvious how members are invited, and release branded promotional items that the members can design, vote on, and choose themselves.

Once the social network and its brand have become popular, end merit-based membership and slowly adjust the rate of password release to accommodate the demand for them until membership becomes completely available to anyone eighteen years of age and under. Open the site to online advertising, but limit content to products that further the group’s healthy lifestyle. If necessary, use the earnings from the online advertising to continue to market for membership with TV ads that focus on children and adolescent core values. Tell positive stories about individual group members to encourage others to change their health behaviors. Continuously redesign the network challenges, games, local trips, and in-person gatherings to include incrementally more advocacy for better health practices, always secondary to what the members choose to do. Create an alumni network for the adolescents as they graduate from the group, but always keep the two age groups separate.

Defense of New Intervention 1:

Let’s Move relies on the HBM’s cost-benefit analysis and assumes that parents will behave rationally when deciding whether to change their children’s behavior. This new intervention completely circumvents cost-benefit analysis and making decisions by using means of persuasion that take advantage of people’s tendency to behave irrationally in groups. It is more likely to be effective in reducing childhood obesity than Let’s Move because it relies on the irrational outcomes of feelings of belonging and ownership, compelling individual stories, and diffusion of innovations rather than the facts and statistics of the HBM.

If Let’s Move adopted this new intervention and abandoned the assumption that information is necessary to convince people to behave in a way that is beneficial to their health, it would be more likely to achieve the latter three of its four goals: “to improve the quality of food in schools, to improve access and affordability of healthy foods, and to increase physical education” (14). All of these are potential outcomes of group mobilization and diffusion of innovations. The first goal, improving “the information and tools that parents need to make the changes that are desired in their families” would likely be unnecessary.

Defense of New Intervention 2:

Let’s Move’s strategy depends immensely on the power of information in increasing perceived susceptibility, a major component of the HBM’s cost-benefit analysis. As presented above, the theories of optimistic bias and illusion of control undermine the effect of information on perceived susceptibility. This new intervention completely circumvents cost-benefit analysis and eliminates an environment in which the optimistic bias and the illusion of control could result in negative health behavior.

In a cohesive group of children and adolescents engaged in increasingly healthy, mutually supportive lifestyles, notions of threat and risk, already ineffectual in behavior change, would be less likely to arise. By removing the question of perceived susceptibility—and avoiding the topic of health altogether—the intervention would take the responsibility to make decisions about health away from the parents, the trustees of Let’s Move’s approach, and relinquish it to the children, the beneficiaries of the new intervention. Furthermore, with parents completely removed from the equation the intervention would not only have a more direct connection with the at-risk population, but it would also become practically invisible.

Defense of New Intervention 3:

An invisible intervention would greatly improve upon Let’s Move’s strategy by eliminating the possibility of loss of freedom and thereby reducing psychological reactance in the target population. Without an interventionist depriving an individual of freedom, no “boomerang effect” of negative health behavior can occur. As stated previously, the intensity of reactance depends on several factors: the audience’s interpersonal similarity with the communicator; the communicator’s intent to persuade and the intensity of his or her dogmatic language; as well as the message’s explicitness, dominance, and reasoning, such as justification for making the health behavior change. This new intervention addresses each of these possible causes of reactance by eliminating them altogether.

Just as the first lady, a familiar figure, is an appropriate Let’s Move representative for parents, children are the most appropriate health practice communicators for children. Peer health communications are not prescriptive in any way; they are indirect and promote behavior through modeling rather than through a crafted message. This new intervention excludes adults in favor of peer socializing and autonomy, neutral behavioral states that do not induce reactance. Let’s Move, please move toward a more effective intervention that addresses these issues!


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