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.

A social science critique on the Looking Glass foundation’s campaign to raise awareness of anorexia - Ilyana Sori

Many public health interventions are created to correct an unhealthy behavior. There are many approaches that can be used to address different reasons as to why people decide to take part in a certain behavior. In the case of one specific public health campaign that helps adolescents fight anorexia, an intervention was created with the slogan “not every suicide note looks like a suicide note”. This campaign was created by the Looking glass foundation, founded in 2002, which is “a Vancouver-based, non-profit organization, whose goal is to develop Canada's first residential centre in British Columbia for the professional treatment of adolescents with eating disorders” (1). This specific public health campaign does not mean to offend or do harm to anyone who battles with anorexia, instead these advertisements where created to raise awareness of this mental and physical illness. While I do agree that awareness is important, I believe that the foundations campaign is flawed in a few ways. First, the advertisements fail to address the fact that people behave irrationally. Second, each advertisement uses techniques from theories that are out dated, such as the Health belief model and finally, large minority groups and males are excluded from the advertisements.
These flaws are especially important to correct because it is critical that more people be able to relate to this campaign. The more people who can relate the more successful the campaign and center will be and the larger the scope of awareness will be. Additionally, the delivery of the campaign should be as powerful as the slogan “Not every suicide note looks like a suicide note”, as well as the idea that “Small signs add up to reveal that girls are suffering from eating disorders.” (2) This critique shows that by using group level models we can strengthen the awareness campaign to fight this deadly disease. The arguments that follow make clear that there are other important factors to consider when creating a public health campaign not just the individual’s behavior or the facts of why the behavior is harmful.

Failure to address irrational behavior
The series of advertisements featured in this campaign range from a poster with a diary entry from a young girl about how she felt that day, to a commercial with a young girl weighing herself in a locker room and marking down the weight she has lost. Every advertisement is dark, gray, shows the extreme side of the disease, and every young girl is alone. These initial reactions to the campaign are negative ones that do not raise awareness for the issue. By using extreme images the advertisements illicit the response of fear in may viewers, which is not a value many people appreciate. This campaign as a whole does not consider certain core values that are important to adolescent girls. Each advertisement also assumes a fundamental attribution error, and labels the girls that are associated with the disease in a negative light. These missing ideas in the campaign account for the fact that people behave irrationally.
Core values are an important factor when considering why people believe what they do, and why they engage in many behaviors. A few core values include beauty, control, youth, happiness, and strength. When a person views a commercial where these values are held high, there is a positive response for that commercial and people will want to be like those featured in the commercial. Commercials that make people question their physical appearance target core values, which is another reason why campaigns like this one should also target positive core values because people with anorexia have trouble mentally dealing with the value of beauty specifically. In the commercials for this campaign none of these values are being portrayed. The extreme aspects of the disease are the only things beings portrayed. Whether this campaign is directed towards those who live with anorexia or their loved ones, positive core values will make both groups of individuals interested in learning more about the organization and getting involved.
The assumption of the fundamental attribution error is the idea that “…people are often quick to draw conclusions about the attitudes and personalities of others- even when plausible external or situational causes for behavior exist…” (8) These conclusions often lead to incorrect representations of the people who engage in a certain behavior. A lot of the stigma that is associated with anorexia is partly because the general public believes that people choose to starve themselves, but a lot of research has already been conducted that proves those stigmas are wrong (2). There is no need to continue showing images and words such as suicide that contribute to the cycle of that stigma.
Similar to the idea of core values is the idea of labeling. These commercials only portray extreme situations and not those instances where the disease is just starting. There is no indication of prevention in any of these commercials or poster advertisements. If these are the only images the public is exposed to, the early signs of the disease that many girls exhibit may not be noticed because there are no images of that stage of the illness. There is a negative portrayal in these commercials of those who have anorexia, which beings the process of labeling. Each story in the commercials shows the girls alone and exposed, images that illicit a strong emotional response from the viewers. These emotional responses may not be productive when they have already labeled girls who have anorexia the way they see these girls in the commercial. People may not see the disease in their loved ones because it may not be this extreme yet.
Use of outdated and incomplete public health methods
Each advertisement focuses on the individual, with the exception of the slogan. The health belief model and the theory of reasoned action are two ideas that are used to create these announcements. These are the most common and most used individual based models in public health. They suggest that the certain behavior a person is engaging in is planned, reasoned and then acted out. As I have previously argued, people’s actions are irrational, therefore the way these models assume people plan and reason before acting is false. This is not to say that these theories should be disregarded completely, they are a good starting point, but they also should not be the only models an intervention is based off of.
The health belief model is based on the idea that perceived severity, perceived benefits, perceived barriers (6) measure the likely hood a person will engage in a health behavior. If the perceived benefits, which are positive outcomes of the behavior, outweigh the perceived severity, which are the negative outcomes of engaging in this health behavior, and there are none or little perceived barriers, then a person will engage in a certain behavior. This is the traditional and most common way of explaining why people have negative health habits. “Over the past four decades, the Health belief model (HBM) has been one of the most widely used psychosocial approaches to explaining health-related behaviors. Initially developed in an effort to explain the widespread failure of people to participate in programmers to prevent to detect disease.” (6) If after forty years, this approach has not been very successful there is no reason to continue using it as the main model for intervention. These advertisements attempt to raise awareness that this is a dangerous disease, but of course the general public already knows that if you do not eat you will suffer health complications and eventually die. This generation is so different from past generations. Issues that were once taboo are now controversial issues that are being debated and discussed to find a resolution, which is another indication that changing times need new and improved models that take into consideration the development of a changing society.
Another theory that presents itself in this campaign is the theory of reasoned action. This theory “…is based on the proposition that an individual’s behavior is determined by the individual’s behavioral intention (BI) to perform that behavior, which provides the most accurate prediction of behavior (Fishbein and Ajzen, 1975). Behavioral intention is a function of two factors: one’s Attitude toward the behavior (A) and Subjective Norm (SN)”. (10) Attitude is generally defined as the positive or negative feelings towards a behavior, while subjective norm is the perceived attitudes other people have of you if you engage in a certain behavior. These two factors of the model are important especially for these commercials because this is a representation of young girls with the disease from the perspective of an organization, which may or may not have expert advice, but as a whole these representations may not be accurate and resonate with everyone who has anorexia. When someone with anorexia views this commercial they may be reluctant to look for help or talk about their problem because it may not be as extreme as the cases shown in these advertisements. If both attitude and subjective norms are positive then the person will consider stopping the unhealthy behavior. The negative images these commercials portray may have an adverse affect for those who have anorexia. They may believe that the general public only sees them as disfigured and dangerously skinny. It is important to label someone that is already sensitive about labels in a positive light, not in a negative one that these girls are portrayed as in these commercials and poster advertisements.
Exclusion of males and minority groups
In this particular intervention the advertisements do their best to portray the way an adolescent teen girl with anorexia would look and act. Throughout the series of advertisements there is no representation of males or a member of a minority group with anorexia. Along with acting irrationally people respond to those that are more similar to them, or situations they can relate to as stated in the idea called principle of communication theory. If the goal of the campaign is to raise awareness that this is a deadly mental illness, why should they leave out parts of the population that are also affected? There seems to be an institutional racism, and as stated in the first argument, an additional labeling problem that should be addressed in order to make this campaign more effective.
None of the advertisements featured include men or people from minority groups, therefore it is not a complete representation of the people that are effect. This exclusion brings the assumption that members of those groups do not suffer from anorexia. Research has been done that shows that people with anorexia come from all different groups in different communities. “Anorexia nervosa,[…], has one of the highest mortality rates among psychiatric disorders” (4) which means that there should be an all inclusive campaign that raises awareness of the debilitating disease. Additionally there should be a representation of the foundations mission in the campaign that it releases to the public. It is also proven that “[…] for thousands of young women and men, the mirror has a darker side. Rather than a true reflection, theirs is a distorted reality.” (9) It is the reality of how the people with anorexia feel that should be addressed in these advertisements because people already know the adverse effects and complications of not eating.
The problems of institutional racism are subconscious but apparent when the campaign is analyzed. “The Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, illustrates how the social hierarchy that exists in society plays an important role in explaining differences in the quality of care provided to People of Color in the United States.” (3) By not acknowledging that people with anorexia can also be found in communities of color perpetuates that idea that there are different diseases that affect the white community and communities of color. This idea leads to doctors and other health professionals incorrectly diagnosing or treating children who show signs of anorexia, who are not white young girls from a middle class family. They may see the acting out the result of behavioral problems or rebellion, when that is not the case.
The “We Beat Anorexia” Campaign
In order to correct these flaws I believe there should be one commercial that goes along with these current commercials which addresses all the flaws and details that were left out previously. This commercial will feature a large group of kids who have battled with the disease and won. The adolescents will represent each racial and ethnic group, as well as a range of ages and males and females. It will take place on a field where all the adolescents will be standing behind a banner that says “We Beat Anorexia and So can you”. They will also be wearing t-shirts that have a single word on them. Each word will represent a core value that each participant finds significant for them. The song Secrets by One republic will play as the camera scans the crowd showing the words written on the shirts. This is a popular song that many people can relate to along with the ability to relate to the crowd of kids. The words featured will be words such as beauty, security, happiness, family etc. After the camera is done scanning the crowd, it will focus on one of the individuals who will say “Be a part of the crowd, stand up for your right to feel comfortable in your own skin.” Each adolescent will then turn around and show the looking glass foundation logo that is located on the back of each shirt. The shirts will also be red because it is a unisex color that stands out in a crowd and makes an impression if a large group of people are also wearing the same color. A narrator will then have a similar message of hope just like the original campaign at the end of this commercial, with the music fading out. By using the ideas behind the advertising theory, the branding model, principle of commitment, and the principle of communication theory, the flaws the previous advertisements have will be closer to being eliminated.
These models focus on the effects of group behavior and the influence groups and society have on the individual, instead of focusing on the just the individual. With these flaws eliminated it will create a stronger, more effective campaign to raise awareness and increase treatment. There are many reasons why people want to be included in a group, and there are also many reasons why pointing out specific core values are an important way to get people’s attention to raise that awareness and change attitudes.
Advertising Theory to support the cause of awareness
The idea of the advertisement theory is to sell an idea not a health behavior. When a person is told repeatedly that their behavior is not healthy, not normal, they will not respond positively towards the health initiative. When they are instead told to buy into a product or an ideal that is positive and others also agree with, it will be easier to inform the consumer what the initiative is really about. By promising the consumer an ideal, supporting it with positive images and appealing to core values, people will be more receptive and listen to the message behind the flash of the advertisement. It is important to have the right support for the large promise because it is easy to send out the wrong message. In a book called Confessions of an advertising man, the author Ogilvy “[…] argues […] that advertising set within rules can be creative, and also more effective than those without rules. The rules to build a great campaign are as follows. 1. What you say is more important than how you say it: the information you give is more important to the consumer than the way you present it. 2. Unless your campaign is built around a great idea, it will flop: in order for people to be affected by the advertising, it has to be something new original.” (11) Ogilvy’s ideas further support the idea that having advertisements that just state why the health behavior is wrong will not change the bad habits of people.
In the new intervention I proposed previously the advertising theory is used by promising viewers and those with anorexia that there is a way to get help and if they do they will be able to accept themselves physically and mentally. This promise is supported by the adolescents portrayed in a serious manner, where they are not seen in an extreme light because not everyone that has anorexia is at a dangerous weight. The students also have t-shirts that have words that are core values which further. The fact that these teens have all battled anorexia and gained their confidence and health back is another positive support for the promise that others with anorexia can get help and treatment too to continue with their lives in a positive, healthy manner. This theory is the starting point in creating an effective, positive, and powerful campaign to raise awareness of the seriousness of the disease.
In addition to the promise being supported by the group, use of a popular song is also included in this advertisement. Recently One Republic was feature on the Top 40 list of popular music. This association with popular culture also creates a sense of familiarity. It is a catchy song that ties in the message of the campaign and the aesthetically pleasing image of the commercial. Instead of the gloomy, dark, and lonely portrayal of those with anorexia in the current advertisements of the Looking glass foundation, this commercial will have more light because it will be outside and that light will help embody the message of hope.
Core Values Exposed By Using the Branding Model
The second model that is featured in this new intervention campaign is called the Branding Model. In this theory the campaign and advertisements are used to create a set of associations people remember when they think of a specific campaign. “Public health brands have traditionally focused on increasing target audiences’ awareness of various health issues (agenda setting) and increasing awareness and encouraging adoption of preventive behaviours to reduce disease and injury. Following lessons from commercial marketing, public health campaigns can be even more successful by developing brand positionings that go beyond being simply informative, and begin to establish relationships with their target audiences. ” (13) There are many examples of this branding method in anti-smoking campaigns. The association could be a group, a t-shirt, a button, a slogan, or a word. People are usually interested in participating in something that is well known and respected. Core values are also involved in this theory. If the association is coupled with core values it makes the message even stronger. The goal for the branding model is to create something that people will feel they are a part of.
The “Be a part of the crowd” campaign is a brand that advertises awareness and the looking glass foundation itself. The general public will be able to associate this campaign with the slogan and the t-shirts that have the core values written on them. If people with anorexia receive treatment at the clinic they will also be able to receive one of the t-shirts. Being a part of the crowd creates a sense of belonging that patients with anorexia may struggle with. The slogan in itself includes words that hold as core values for many people. People will often associate the word “Right” with the idea of freedom, which is a very strong core value because without freedom there is no control. The positive portrayal of this side of the initiative to bring awareness to the general public will resonate more with people to want to change and create change more than just the harsh images in the original campaign and advertisements.
The general public will in turn associate the initiative towards awareness and treatment for anorexia with the core values depicted in this advertisement. Extreme images will no longer be needed to stress the fact that this is a one of the most deadly mental illnesses that adolescents face today. The brand that will now be associated with treating adolescents with anorexia will be a positive group initiative that stresses the importance of intervention and understanding of the causes and development of this mental illness. Branding this campaign will also take away some of the negative and misinformed stigma that is present when talking about anorexia. People will be more comfortable talking about treating the disease. When attacking the individual behavior, as many times is done when using the health belief model or other individual based models, we are missing a huge part of the social context that is involved in the development.
Two Additional Principles used to support Group behavior
To further support the idea that a group model is more effective than an individual based model is shown with the principle of commitment or the dissonance theory, as well as by the principle of communication. Both principles deal with the fundamental idea that people will act and keep an opinion if they feel that they are a part of a group. Even though there are specific aspects of each principle that distinguishes it from the other they work together to create a strong argument for group models. When used along with other models and theories, such as the advertising theory, the intervention is able to change the ideas of the general public without explicitly telling them to change. This advertisement does not lecture the general public to be aware of the seriousness of the disease; it is an advertisement that creates an association with the initiative, which in turn creates awareness in a positive light.
The idea behind the principle of commitment or dissonance is based on “one of the most fundamental states of conflict in human behavior which can be heightened by decision making is that between the need for openness and flexibility, on the one hand, and structure and consistency on the other. […] as one becomes personally involved in an issue or sees a direct relationship between his self concept and an object or person, the exact nature of this compromise may change. He may wish to interpret such objects, issues, and events in a manner consistent with important beliefs, especially following decisions in which psychological commitment and observable behavior combine to increase personal involvement.” (12) Simply put, if a person decides to engage in a certain behavior, and it turns out that that behavior is harmful, they will change their opinion and view of the situation to support their behavior because the idea of being wrong is more harmful to them than the behavior is.
Another point of the principle that is important to address is “to what extent does one approach a situation less than openly, guided by experience and expectations and recognizing, identifying and evaluating stimuli according to what one “knows” is there?” (12) People are less likely to enter a situation with an open mind when they already have preconceived notions of a situation. They stick to what they know. Along with this principle and the idea that people agree with what they think they know and understand is the principle of communication. The idea behind this principle especially in the case of making a persuasive argument, or when the need arises for awareness, people will relate to situations, if they have a similar experience or a similarity to the person that is presenting the information. It is important to note that people will not respond simply because of the way the message is portrayed, the message must also be important and powerful in itself.
These two principles are specifically used in the “Be a part of a crowd” campaign because there are so many different people involved in the campaign. The children range from different ages and they are all from different ethnic and racial backgrounds. There are many people that are now able to associate with this campaign. Males will also now be included which will raise awareness that males also have anorexia. Once the idea that there are a range of people who have anorexia the mind of a large population in the general public will change because there is now visual evidence in a campaign that the disease affects a wide range of people from different ages. The general public will now be more willing to understand the initiative and be more aware of the campaign because the can relate to a less extreme depiction of anorexia.
Conclusion
When considering in creating a public health campaign, it is important to consider the audience the campaign is being created for, can the act be explained using a group level model in a more effective way, is the advertisement and initiative inadvertently leaving out any members of the population that are also affected, and is message being conveyed the right one, are all important aspects of the campaign to think about. Core values are also an important aspect of gaining the audience’s attention. When people are able to associate, understand and feel comfortable with an initiative there will be a larger educational gain of the problem. That is when it is possible to gain followers and change the ideas of a population.
The looking glass foundation is an initiative that means has positive intentions with the means to change the ideas of a population. It is difficult to have a campaign that is not as effective as the foundation would like it to be. The idea of awareness is already there for the intervention but the flawed aspects of the campaign do not allow it to be a strong and effective message. They do strike an emotional cord because the images portrayed are devastating and concerning. They do not, however, appeal to a positive and hopeful message. These flaws make the campaign incomplete and therefore this campaign does not succeed in its ultimate goal of greater awareness and eventually treatment for those living with anorexia.



















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