Monday, December 13, 2010

Why 5 A Day Campaign Can’t Work? A Better Alternative Choice: Transition from Health Believe Model/Theory of Reasoned Action to Advertisement Theory/M

Unhealthy diet was estimated to cause more than 35% of cancer death. (1) Besides, strong evidences showed there is an association between more intake of fruit/vegetables and reduced risk of cancers, including esophagus, pharynx, stomach, oral cavity, pancreas, colon, rectum, lung, larynx, bladder, endometrium, cervix and ovary. (2-7) A review study conducted in 17 countries with very diverse populations, such as the Netherlands, China, India, and the United States, showed that 128 of 156 studies revealed fruit and vegetable consumption had a statistically significant protective effect on cancers. (8) This review study also showed that those persons with a lower consumption of fruits and vegetables generally have a cancer risk at least twice as high as those with a higher consumption level. In 2005, only 20.1% of high school students reported eating more than 5 servings of fruits/vegetables daily in the United States. (9)
5 A Day campaign is a national theory-based program proposed by National Cancer Institute (NCI) in 1991 aimed to encourage consumption of at least 5 servings of fruits/vegetables every day for general population- but especially focus on deprived areas and the youth- as a result, to promote a healthier life of general population. (10) By the means of showing different colors of fruits/vegetables in the website and television, it tries to convince people that eating with more color means eating with “good foods”.
Although the 5 A Day campaign was once considered as based on social marketing theory because it claimed to distribute messages through appropriate channels (11). But when taking into account of how it works in the reality, it was clearly found that the 5 A Day campaign actually is based on models of health behavior: the Health Belief Model (HBM) and Theory of Reasoned Action (TRA). According to these two individual-level models, human behaviors are very rational and predictable, even can be completely planned. Therefore, people tend to engage in health behaviors after weighing the benefits and costs of the behavior. (12)
The 5 A Day campaign was based on the HBM because it believes that if people are educated of positive results (becoming health) of the behavior (eating fruits/ veggies) then people will tend to do this behavior (eat more fruits/veggies to become healthier). So the 5 A Day campaign sent a message that if you eat different colors of fruits/veggies everyday then you will become healthier. But this message is just too ideal to execute. The TRA developed by Fishbein and Ajzen in 1975 and 1980 suggested that a person's behavioral intention depends on the person's attitude about the behavior and subjective norms. Three general components are behavioral intention (BI), attitude (A), and subjective norm (SN): BI = A + SN. (13,14) According to this rationale, if a person intends to do a behavior that he/she thinks is good then it is likely that the person will do it. So according to the TRA, people will tend to eat more fruits/ veggies if they think that is a good behavior. People can judge of whether the expected outcome is good or bad and choose the good one.
In fact, the 5 A Day campaign had been evaluated for its efficiency of program outcome and found not put into practice as effectively as it was believed to be. This state-level campaign was not entirely successful to encourage population to intake more fruits/veggies.(15) More practically, the 5 A Day campaign was replaced by a new campaign called “Fruits and Veggies: More Matters Campaign” in February this year(2010)(16). However, the contents of the new campaign are still much similar as the contents of the 5 A Day campaign. Therefore, this paper still focuses on the 5 A Day campaign and to figure out why it can’t work in the reality.

Critique Argument 1: Autonomy and sense of control were deprived. People don’t like to be taught what to do.
The 5 A Day campaign is based on the theoretical concept that with enough education, people will choose to engage in the healthy behavior of produce consumption- in other words, people will “make the right choice for their own good.” For example, if a person perceived high AIDS threat, then a person will tend to adopt and maintain AIDS-preventive behavior.(17) While education is important, the underlying message is that people should follow the recommendations of the 5 A Day campaign or do the behavior they are told to do. This sounds ideal and practical at first sight. But in reality, this approach just deprives people of their autonomy and sense of control by telling them what is good behavior to follow.
According to the reactance theory, when a specific behavioral freedom is threatened by a social pressure, emotional and behavioral reaction will arise against this social pressure (18). For example, 2 years old boys preferred to approach dissimilar objects behind large physical barriers. In other words, even 2 years old boys tend to response the threats to their freedom. (19) As a result, people tend to violate or contradict the demanded behavior in order to show that they have control of making choice of themselves. By doing so, people try to seize ownership by showing the opposite behavior. This is the similar and common phenomena to see teenagers tries their best to be against the advise of their parents. (20). Therefore, people won’t be willing to follow the rules and suggestions to eat 5 servings of fruits/veggies every day; instead, people don’t want to eat 5 servings of fruits/veggies every day because when they try to break this advice then they can feel more capable to control themselves and regain ownership of making decisions. This phenomena is similar as the one the study showed that, if your parents interference your relationship, then it will cause you have closer relationship than those who don’t have such interference. (21)

Critique Argument 2: Human behavior is irrational
In accordance with its theoretical framework provided by the HBM and the TRA, the 5 A Day campaign assumes human behavior is rational, calculated and predictable. People’s behaviors are completely planned or at least reasonable, because people know good or bad consequences of the behaviors. For example, people know it is healthier to eat fruits/veggies than fries and burgers because the risk of having cancers can be reduced. So according to this assumption of 5 A Day campaign, people will inevitably tend to choose healthier food if they have this knowledge - knowing that high-fat food can cause negative consequences on health such as over-weight and increased risk of chronic disease or cancer.
But in fact, human behavior is not that simple; rather human behavior is much more irrational. Human irrational behaviors are remarkably guided by our expectation (stereotype), ownership and the framing effects. (22,23) In terms of ownership, assumed that people own the behavior of not eating fruits/veggies everyday; when they are asked to give up this original behavior, then more extreme valuable things needed to be provided, such as being more confident of self-looking if they can eat eating fruits/veggies everyday. Another example of human irratioal behavior is that people tend to focus on comparing things that are easily comparable while at the same time avoid comparing things that cannot be compared easily (22).; so this is the reason why people don’t eat fruits/veggies everyday because it is not easy for them to compare eating health can have impact on their health in the future. It is also the reason why people buy over-priced or unnecessary things so easily. Such assumptions make 5 A Day campaign an unsuccessful intervention.
Critique Argument 3: There is a big gap between intentions and behaviors - you know what you should do but you may not do it
The 5 A Day campaign believes that individuals can make their own behaviors with intention. However, in fact, there is a big gap between intentions and behaviors. There is no clear correlation between the attempts that people want to have healthy behaviors and the actual healthy behaviors people will do in the reality. The 5 A Day campaign based on HBM didn’t consider this point and actually this is the biggest limitation. The 5 A Day campaign assumes that through nutritional education, people will learn the health benefits of produce and increase their consumption. This individual-level approach to diet is insufficient. Education and intention is not enough; because there is a disconnection between the intention and behaviors.

Critique Argument 4: Underestimating the social/contextual factors
The 5 A Day campaign tries to address social factors, like finding the coalitions and partnership with this campaign but not successful. In fact, the 5 A Day campaign just oversimplifies the factors that influence people’s behaviors because many environmental, social and contextual factors such as socioeconomic background, cultural and ethnic heritage influence food choices are overlooked by this campaign. It just focus too much on the individual-level intervention.
For example, there may be a huge difference of eating habits for Caucasian-Americans and Mexican- Americans (24). A study conducted in Washington State showed that dietary interventions based on a general 5-A-Day message may be more effective in increasing fruit intakes than vegetable intakes. So targeted interventions that focus specifically on vegetables are probably necessary. (25)
It is also important to consider disparity of accessibility of obtaining fruits and vegetables. (26)But the 5 A Day campaign didn’t address this issue. People who are at the area or neighborhood with “food deserts”- difficult to be accessible to fruits/veggies or the grocery stores; or with low social economical status; then for this specific population, it is difficult to eat fruits/veggies on a daily-based. In summary, the 5 A Day campaign is just too broad to fulfill its goal and too difficult to apply for all population.

Articulation of Proposed Intervention: “Love F & V” Campaign
The “Love F & V Campaign” was developed based on alternative theories of human behaviors, mainly based on advertisement theory and marketing theory. This campaign was aimed to create an image that people can make their own decisions to eat fruits and vegetables. So it is always your choices to be cool if you can eat fruits/veggies everyday! Besides, the “Love F & V Campaign” also disseminates a message that fruits and vegetables are fun to eat and buy.
First, three advertisements (AD) will be shot by celebrities who represent healthy and beauty. Scenes used in the AD are based on the advertisement theory and marketing theory, including: (a) a character chats with families or friends with laughter at the same time eating and sharing different fruits or vegetables to each other on the table, then a slogan showed up saying: “Sharing things you love to the one you love is the best thing you want to do in the world”. (b) a celebrity holding two big characters “F” & “V” (as “Fun” and “Voice” instead of “Fruit” and “Vegetables”) with on one hand while the other hand holds an apple, saying: “I love my choice, how about you?” then bite an apple and smile with confidence and pride. (c) asking celebrities to tell a story of themselves how they feel more confident and comfortable of their better looking when they keep the habits of eating fruits/veggies everyday. These stories are used to support the core values- autonomy and self-control – of this campaign.
Also, based on the principle of “commitment” of the social norm theory, once people become part of a group, then their attitude will become positive to this group because they will feel they are part of it. So like the successful non-smoking campaign “Crush babies” (27), the “Love F & V” Campaign also has a website for people to sign in. People who eat at least 5 servings of fruits and vegetables a day can become one of the members of the “Love F&V” group. Members can join the competition held every week to becomes the coolest F&V baby and can be put on the pictures on the first webpage of the “Love F & V” Campaign.
The “Love F & V” Campaign tries to persuade people that eating fruits and vegetables is a cool thing to do because you make your own choice. And the “Love F & V” baby is a symbol of representing attractive and charming. So being one member of the “Love F & V” campaign is proud and cool and means you are charming.
Besides, in terms of being a nation-wide program, the “Love F & V” Campaign will try to accommodate to be an area-specific campaign, which means, there is more flexibility within this campaign because species and prices of fruits/veggies are different according to the different areas and populations. Based on the Diffusion Theory, you can get the entire population to do the desired behavior as long as you can find a group of people first doing this. (28) So, the “Love F & V” Campaign will create five branches in different areas of the United States, including east coat, west coat, southern, northern and midwest areas. Sending vending machines with fancy packages of fruits/veggies will be an option to do along with promotion groups to advocate the function of the vending machines.
Fruits and vegetables will be designed to being wrapped with ice cream cone (but there is no ice cream inside of course) or ice cream cup or fancy plastic bag like Doritos or Lays upon buyer’s choices in the vending machine. The vending machines have freeze equipments inside in order to keep fruits and vegetables fresh all the time. There are more than five different colors of bottoms of the vending machine and each bottom presents each different fruits and vegetables; for example, red bottom representing “strawberries” or “apples” while yellow bottom represent “banana” or “mango” depends on the seasonal supplies. Every time when people press the bottom for their own choice, then the vending machine will pick up one package of fruits and vegetables, place them into the container the buyer choose. The last step of buying fruits/veggeis from the vending machines is that, outside the container, buyer can choose which sticker you want to tape on it; stickers are the figure of mood, like “smile”, “excited”, “nothing special”, “feel good”, “feel green”, “got red” or “feel blue”. Free diet diary is placed besides the vending machine for the first week of every month in case that people can record mood and choice of fruits and vegetables everyday. More details of this new campaign will be described below.

Defense of Intervention Section 1: Increasing self decision-making
Although telling people what to do and taking away choices encourage resistance rather than compliance, it is just not that simple to tell people to do the opposite behavior based on reactance theory. So you cannot just ask people to eat fried chicken because you want them to eat fruits and vegetables. But it will be definitely much better if a campaign can encourage people to make their own choice instead of telling them what to do. People will tend to accept the health actions chosen by themselves. So, the “Love F & V” campaign based on advertisement theory add core values – autonomy and self-control – when you eat fruits and vegetables. According to the assumption of advertisement theory, people will tend to accept the message of eating fruits/veggies more easily because that is the way to be yourself and show your own decision.

Defense of Intervention Section 2: Human behavior is irrational but predictable
Although human behaviors are irrational, but happened in the same way again and again, so luckily it is predictable. By using the principles of “framing effect” in the “Love F & V” campaign , braches in different states can help to create a new way to frame eating fruits/ veggies everyday with vending machines and advertisements. By using the principle of “ownership”, the “Love F & V” campaign tries to persuade people that they can obtain more control even sometimes people don’t really own that control.

Defense of Intervention Section 3: Filling the gap: Eating fruits and vegetables are a symbol of being cool
Based on marketing theory, “Love F & V” campaign match with what the audience want: attractive and charming instead of only “being health”. For example, if you eat carrots, broccoli, banana, – health fruits and vegetables every day, then you will become attractive and charming just like the celebrities or models show in the advertisements. You like to share things you love to the people you love. When you become part of the on-line “Love F&V” group, that means you are cool. Once you have higher motivation to execute the healthy diet behavior, then the barriers between the intention and behavior can be destroyed. Then people can be motivated to become more charming, attractive and more confident by joining the “Love F&V” group.

Defense of Intervention Section 4: More environmental factors recruited
“Love F & V” campaign was designed to be flexible and can be fitted into different sub-versions according to different areas of the U.S, including east coat, west coat, southern, northern and midwest areas. For example, there can be “Love East Coat F&V campaign” for Massachusetts and “Love Southern F&V day campaign” for Texas depends on the composition of the population and varieties of fruits/veggies of each states. Also, the accessibility of vending machine, the technological skills and the way braches can be executed efficiently should be taken into accounts carefully as well.

Although the starting point of “5 A Day campaign” is great, but unfortunately the outcome turns out just not as expected. Basically it is because the wrong underlying theories used for 5 A Day campaign. The “Love F&V campaign” was based on many alternative theories, especially mainly on advertisement theory and marketing theory. It addresses the code values that people want to have and therefore it is just not as simple as a health-promotion movement. The “Love F&V campaign” can solve the problems that “5 A Day campaign” had and can be more effective. Public health professionals always should invest money, time, creative approaches and innovative ideas on the right campaign and find the best one for the general population.

1. Doll, R., & Peto, R. (1981) The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. J Natl Cancer Inst, 66: 1193-1308.
2. Block, G., Patterson, B., & Subar, A. F. (1992) Fruit, vegetables, and cancer prevention: a review of the epidemiological evidence. Nutr Cancer, 18: 1-29.
3. Steinmetz, K. A., & Potter, J. D. (1991a) Vegetables, fruit and cancer. I. Epidemiology. Cancer Causes Control, 2: 825-857.
4. Steinmetz, K. A., & Potter, J. D. (1991b) Vegetables, fruit and cancer. II. Mechanisms. Cancer Causes Control, 2: 427-441.
5. Ziegler, R. G. (1991) Vegetables, fruits, and carotenoids and the risk of cancer. Am J Clin Nutr, 53 (supp.): 251S-259S.
6. Ziegler, R. G., et al. (1992) Does beta-carotene explain why reduced cancer risk is associated with fruit and vegetable intake? Can Res, 52: 2060S-2066S.
7. Negri, E., et al. (1991) Vegetable and fruit consumption and cancer risk. Int J Canc, 48: 350-354.
8. Block, G., Patterson, B., & Subar, A. F. (1992) Fruit, vegetables, and cancer prevention: a review of the epidemiological evidence. Nutr Cancer, 18: 1-29
9. Centers for Disease Control and Prevention, 2006
10. Department of Health and Human Services: Healthy people 2000: national health promotion and disease prevention objectives. (1990) DHHS Publication No. (PHS) 91-50212. U.S. Government Printing Office, Washington, DC.
11. Havas, S., Heimendinger, J., Damron, D., Nicklas, T. A., Cowan, A., Befesford, S. A. A., Sorensen, G., Buller, D., Bishop, D., Baranowski, T., & Reynolds, K. (1995). 5 A Day for better health--nine community research projects to increase fruit and vegetable consumption. Public Health Reports; 110(1): 68-79
12. Perkins, M. B., Jensen, P. S., Jaccard, J. Gollwitzer, P., Oettingen, G., Pappadopulos, E., & Hoagwood, K. E. (2007) Applying theory-driven approaches to understanding and modifying clinicians' behavior- what do we know. Psychiatric Services; 58:342–348
13. Fishbein, & Ajzen, I. (1975) Belief, attitude, intentional and behavior: an introduction to theory and research, reading. MA: Addison-Wesley
14. Fishbein, & Ajzen, I. (1980) Predicting and understanding consumer behaviors: attitude-behavior correspondence. Understanding attitudes and predicting social behavior. Fishbein, & Ajzen, I. eds Englewood Cliffs, NJL Prentice-Hall, 148-172
15. National Institutes of Health, National Cancer Institute (NCI). Potter JD, Finnegan JR, Guinard J-X, et al. 5 A Day for Better Health Program Evaluation Report. The Communication Initiative Network, 2000.
16. Centers for Disease Control and Prevention. Fruits and Veggies: More Matters Campaign. 2000.
17. Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1994) The Health Believe Model and HIV risk behavior change. Preventing AIDS: Theories and Methods of Behavioral Interventions. DiClemente, R. J., & Peterson, J. L. eds. NY; Plenum Press
18. Brehm, S. S., & Brehm, J. W. (1981). Psychological Reactance: A Theory of Freedom and Control. Academic Press.
19. Brehm, S. S., & Weinraub, M. (1977) Physical barriers and psychological reactance: 2-yr-olds' responses to threats to freedom. 35(11); 830-836
20. Grandpre J, Alvaro EM, Burgoon M, Miller CH, Hall JR. (2003) Adolescent reactance and anti-smoking campaigns: a theoretical approach. Health Commun;15(3):349-66.
21. Driscoll R, Davis KE, Lipetz ME. (1972) Parental interference and romantic love: the Romeo and Juliet effect. J Pers Soc Psychol. 24(1):1-10
22. Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.
23. Demartino, B., Kumaran, D., Seymour, B., Dolan, R. J. (2006) Frames, biases, and rational decision-making in the human brain. Science 313: 684-687
24. Neuhouser, M.L., Thompson, B., Coronado, G.D., & Solomon, C. C. (2004) Higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among Mexicans living in Washington State J Am Diet Assoc. 104(1):51-7.
25. Trudeau, E., Kristal, A.R., Li, S., & Patterson, R. E. (1998) Demographic and psychosocial predictors of fruit and vegetable intakes differ: implications for dietary interventions. J Am Diet Assoc; 98(12):1412-7
26. Cummins, S., Smith, D. M., Taylor, M., Dawson, J., Marshall, D., Sparks, L., & Anderson, A. S. (2009) Variations in fresh fruit and vegetable quality by store type, urban-rural setting and neighbourhood deprivation in Scotland. Public Health Nutr. 12(11):2044-50.
27. Non-smoking campaign: CRUSH. 2008 or
28. Rogers, & Everett, M. (1983). Diffusion of Innovations. New York: Free Press.

Labels: ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home