Thursday, April 29, 2010

Small Step Adult and Teen: A Critique Supported by the Social Ecological Model –Michelle Pellicer


Obesity is a significant public health issue that is associated with increased risks of cardiovascular disease, diabetes, some cancers, depression, discrimination and weight related bias, and other morbidities. (1) The prevalence of obesity in the United States is high, exceeding 30% in most sex and age groups and an estimated 17 percent of children and adolescents ages 2-19 years are obese. (2) Because of the burden obesity renders on both individuals and society, it is in the United States government’s best interest to promote interventions and campaigns that can help lower the economic and physiological costs associated with obesity.
Government agencies as well as private groups have been attempting to reduce rising obesity rates since concrete evidence of the obesity epidemic became available in the 1990’s. The government’s primary strategy to combat obesity has been to educate, by suggesting more activity and encouraging Americans to eat more healthily. (3) Unfortunately, there have been very few interventions that have proven to have long-term or demonstrable change. An example of a recent and still active intervention is the “Small Steps” campaign launched collaboratively through the United States Department of Health and Human Services and The Advertising Council. The campaign “promotes awareness of small, realistic, and practical solutions to help adult Americans, and families in particular improve their levels of activity and nutrition.” (4). The message is disseminated through public service advertisements and a website.
The intervention is modeled using concepts from several influential behavior change models including the Social Cognitive Theory and the Transtheoretical Stages of Change Model. (4) Social cognitive theory was developed by Albert Bandura and is based on several core determinants that effect behavior change. Knowledge of health risks and benefits is the first condition that needs to be met before behavior change can occur. (5) Once a person is aware of the risks/benefits associated with a certain behavior they must believe that they are capable of making those changes to actually move forward. (5) Other forces that influence behavior change in this model include expected outcomes about the expected costs and benefits for different health behaviors, health goals and the concrete strategies to realize them, and the perceived facilitators and impediments to the behavior change. (5)
The Transtheoretical Stages of Change theory is also integrated into the “Small Steps” campaign. This model posits that people move towards behavior change in five stages; pre-contemplation, contemplation, preparation, action, and maintenance.(6) The “Small Step” campaign hopes to education people about activity and nutrition with the intention of moving people from pre-contemplation to the contemplation and preparation stage. Although both the Social Cognitive Model and Transtheoretical Stages of Change Theory have shown merit in some public health initiatives they have not been shown to be efficacious in more complex and multidimensional issues like physical activity and changes in diet. (6)
1st Critique
It is has been well established that to effectively combat obesity will require, “overcoming many individual, environmental, community and institutional barriers to healthier lifestyles.” (2). Because the “Small Steps” campaign is a collaborative endeavor, between the US government and The Ad Council, it must comply with the policies of The Advertising Council, which only “represents public service campaigns that are non-commercial, non-partisan, non-denominational, and national in scope”. (4) As a result, the campaign cannot address environmental or social factors and, instead focuses on education and addressing individual barriers, such as “lack of helpful information” and “lack of confidence in the ability to be physically active (low self-efficacy)”. (4)
The primarily educational focus is one of the flaws of the “Small Steps” campaign. Obesity is a huge epidemic and should be addressed more aggressively with a combination of approaches that have proven efficacious in the past. “Research conducted by the US government and its advertising partners had uncovered that most consumers are aware of the importance of diet and activity but are overwhelmed by their obligations.” (7) Nevertheless, the campaign relies heavily on providing information on the benefits of increasing activity and improving diet. Not only is this approach a waste of money but it also may have an opposite affect on behaviors. When the message to eat better and exercise more becomes mundane and unremitting, people may just glaze over the message of the campaign and brush it off as an un-novel and unhelpful approach. (7) Similarly, if a person holds another opinion or does not agree with the values and interests deemed more socially, morally, or economically compelling, they are likely to be averse to comply. (7)
Obesity and a sedentary lifestyle are complex issues that cannot be solved by education alone. A study researching the effects of, “tip #67: take the stairs instead of the escalator”, demonstrated increased stair use in a city where they had heavily propagated the tip. Unfortunately, the results returned to baseline after only 3 months and the impact of this intervention on correcting energy imbalance appeared negligible. (8)
Also, message recipients are oftentimes uninvolved or predisposed (7) so the message should be positive and motivational instead of merely informational. The public service announcements are a direct example of a disconnect, between the viewer and the message. First of all, the ads lack any direct encouragement and do not inspire a “get going” attitude. The message fails to reach people who are in the contemplation or preparation stage of the Transtheoretical Stages of Change Model. (7) More importantly, the PSA’s do not actually offer any information or tips, but direct people to go to the website, which depending on the effectiveness of the ad, may or may not happen.
Secondly, the ads lack optimism since the participants in the ads are detached third parties who are coming across the successes of imaginary participants. (7) The passiveness and lack of open optimism creates ads that are at best humorous and at worst unsuccessful. If the Social Cognitive and Transtheoretical Stages of Change Models are to be used, the creators should recognize that people lie on a continuum across the stages and must not only be given information, but positive reinforcement and motivation to improve beliefs of self efficacy and prepare them to initiate or maintain behavior change.
2nd Critique
As previously mentioned, The Ad Council’s policy, “represents public service campaigns that are non-commercial, non-partisan, non-denominational, and national in scope”, therefore cannot address environmental or social factors and focuses more on individual factors. (4) Although changing the physical environment to encourage behavior that prevents obesity may seem to be an insurmountable challenge, it is a viable and possibly more effective opportunity than entirely neglecting environmental components of the obesity problem. While this goal may not be realistic to the scope of The Advertising Council it is certainly under the jurisdiction and obligation of the US government to be more assertive in the battle against obesity. The “Small Steps” campaign is fundamentally flawed in its lack of attention to environmental influences on obesity.
Americans are consuming too much dietary fat and sugar and not enough fruits and vegetables, and their intake of micronutrients does not satisfy dietary recommendations. (9) The results of this kind of diet are found to be associated with greater energy intake, higher body mass index, and obesity. (9) Too compound the issue, labor-saving devices have reduced physical labor, allowed most people to commute to work, and increased sedentary behaviors. There is also a lack of convenient and safe spaces to exercise. (8) Although, much can be changed at the individual behavioral level to lower obesity rates, it can be argued that what needs to be changed is the environment that promotes behaviors that cause obesity. (10)
It has been shown that diet has more of an impact on obesity than does the amount of physical activity one does (physical activity has a protective effect on individuals consuming a fat-rich diets). (10) Consequently it seems as though, focusing on diet may be a more direct and effective approach to reducing obesity rates. One environmental factor that promotes overeating is portion size. (10) While the “Small Steps” campaign does not try to make any institutional changes, it does try and educate people about increasingly larger portion sizes at restaurants and encouraging people to notice how much they eat in an effort to limit “passive overeating”. (10) While making this information available to people may increase awareness, it is not likely to create change because it fails to recognize that larger portions are being heavily marketed by the food industry and are ubiquitous within our current culture (10-11)
Another concern having to do with the environmental conditions that promote obesity, is that the “Small Steps” campaign fails to recognize is that environmental influences are not distributed equally among the population. In the US, low socio-economic status groups are more likely to be obese than their high SES counterparts due to access to resources, knowledge of nutrition and health, food choices, and physical activity at work and in leisure time. (12) While the “Small Steps” campaign attempts to increase knowledge and online resources, it does little to affect the availability of food choices and the circumstances that prevent physical activity in low SES individuals. It is remiss to suggest people eat more fruits and vegetables in low-SES communities, where there is an unlimited supply of convenient, relatively inexpensive, energy-dense foods and an absence of healthy foods. (10)
While environmental factors are extremely important contributors to the obesity epidemic, individual behaviors should not be overlooked as both a facilitator of obesity as well as a possible means for remedy.
Critique 3
Both the Social Cognitive Theory and the Transtheoretical Stages of Change Theory are both founded on the idea that people act rationally, that is with their best health interest in mind. (5-6-13) The theories posit that once the knowledge of the certain benefits/risks of a certain behavior are known and perceived beliefs of self-efficacy are high, behavior change will take place. Unfortunately, this is not always the case. Most people, are aware eating a healthy diet and exercising will lower their chance of being obese and have the ability to make choices around this knowledge. Yet, most people do not carry out these behaviors. Given the complex and unique network of experiences, hopes, fears, attachments and obligations that motivate people and create the psychological schemas that inform their activities, models that attempt to come up with a set of common psychological counterparts that maintain a behavior is problematic at best. (6) To assume people will choose behavior change and maintain it because information on the subject is provided is misguided and ignores the psychological complexities that surround diet and exercise behavior.
Psychological aspects and eating disorders are common in obesity including Binge Eating Disorder, characterized by self-perception of loss of control of eating as well as anxiety and depression. (14) Impulsivity also plays a particularly important role in obesity and related eating disorders. Four facets of impulsivity that relate to eating are urgency, lack of perseverance, lack of premeditation and sensation seeking.(15) It is thought that obese people tend to suppress thoughts (e.g. thoughts of food) which may make those particular thoughts hyper-accessible, which in turn causes distress and increased food consumption. This may explain why obese people overeat, despite their intentions to control their food intake. (15) This may not apply to all obese peoples, but if it’s a common enough phenomena then simply giving tips on diet and exercise are incredibly inadequate and more appropriate for people who are not yet obese and are looking for ways to stay healthy.
Another aspect of the irrationality that influences behavior related to obesity is the strong aversion to paternalistic approaches to guide lifestyle choices. (7) Previous attempts to regulate or influence eating habits have encountered fierce opposition because they interfere with the core conceptions of self-identity.(7) Most assessment of health interventions focuses on people’s involvement with the message and knowledge gained but it appears that when health information is concerned, individuals appear to rely on automatic processing, depending on past knowledge or experience with similar messages to assign meaning to a present message. (7) The complexities of eating behaviors, people’s aversion to paternalistic interference of their lifestyle, and pre-wired conceptions of health interventions, make using a rational paradigm to circulate health information futile and unnecessarily costly.

New Direction
Obesity is a serious public health concern that is fraught with many complexities. The United States government and Ad Council’s current campaign “Small Steps” is an attempt to lower rates of obesity by offering nutrition and exercise information. Unfortunately, the campaign is flawed in the following ways; the content of the campaign is far too education-based and not proactive enough to create any demonstrable or long-term change; the campaign pays too little attention to environmental factors that impose significant influence on obesity and obesity related behavior; and the campaign is based on social behavior theories that assume people act rationally when it comes to health choices and behavior. Although a primarily educational approach to preventing obesity is inadequate in and of itself, coupled with other approaches, may create more of an impact on the obesity epidemic.
An Obesity Campaign Based on the Social Ecology Theory
As already demonstrated, the obesity epidemic is a complicated issue that requires a multifaceted approach to create success. One particular social behavior model that has shown promise in the area of public health is the social ecology theory. (16) The main underpinning of social ecology theory is that for an intervention to be “effective with demonstrable behavior change and public health impact, the design of health interventions must nestle within the social and ecological landscape of local communities.” (17) The Social Ecology Theory cites two major areas of influence on an individuals and communities health behavior. One area influencing the health of individuals within a community, are the psychosocial variables of attitudes, norms, and self-efficacy, which are shaped by an individuals beliefs. The other area exerting influence on behavior change comes form the environment. The environment contributes to behavior change in the form of enabling factors such as skills and abilities, local and external investments, and constraints on agency. (17)
Individual Level Interventional Approach
Attitudes, norms, and beliefs of self-efficacy are shaped by an individual’s beliefs. The best way to change existing beliefs or create new beliefs that are conducive to obesity prevention, is to educate as well as provide appropriate psychological and behavioral support. The “Small Steps” campaign educational material is helpful to individuals who perhaps only need a small nudge in the direction of healthy behaviors, but is not adequate. One way to expand and take advantage of the campaigns knowledge is to make sure the message is getting to young children. It is well established that many health behaviors begin in childhood so if a child is well aware of beneficial behaviors and is eating nutritional meals at school it is more likely that these positive health behaviors will continue throughout their lives. Similarly, it is important that schools continue to have time for children to engage in physical activity and perhaps even expand physical education programs or have requirements for additional physical activity programs after school or during school. The emphasis on nutrition and exercise at an early age can help future generations create attitudes and norms that are supportive of healthy lifestyles. There is also some evidence that it is often more effective to target children rather than parents when trying to influence the entire family’s/household’s behaviors (13)
Another way to insure that more people participate in behavior change to prevent obesity is to work within already existing social networks to circulate knowledge. Strong social networks have been identified as important predictors of participation, through socialization, structural connections, and decision-making processes. (13) The opportunity of individuals to observe peers who have successfully changed and maintained behaviors is extremely helpful in improving self-efficacy beliefs. (13)
This idea of social connections also applies to support and treatment of people who are already obese. Psychological assessment of obese persons is advised so that interventions can target self-control problems of impulsive behavior and also address psychological problems such as depression and anxiety that are often associated with obesity. (14-15) The creation or referral of obese patients to support groups may facilitate behavior change in that it creates a social network or people who can offer each other encouragement and are also striving for the same goal. The social group created also facilitates behavior change by shifting some of the personal responsibility of behavior change to collective responsibility, and reducing personal failure and disappointment. (13) While these individually focused approaches improve upon the “Small Steps” campaign, they are not enough to make a significant change in behavior and prevent obesity. Social ecology interventions emphasize that non-regulatory strategies work best when they are also reinforced by regulatory strategies. (18)
Environmental Level Interventional Approach
Modifying the environment and creating regulations that encourage behaviors that prevent obesity may appear to some to be an overwhelming challenge. (10) Although, this approach may be more difficult, the example of the tobacco experience validates the importance of governmental involvement in creating significant change. (19)
One manageable way to begin environmental changes that support healthy habits is to make sure schools are providing meals that are healthy. Although currently school lunches must meet the Dietary Guidelines for Americans, it is up to the discretion of local school authorities to decide what foods to serve and how to prepare them. (19) Making more stringent guidelines and making sure schools receive enough funding will ensure that students are receiving healthy meals at school.
An economic strategy is to tax less healthy, energy-dense foods and subsidizing healthier less-dense foods. These tax/subsidies are most likely to have a measurable effect on children, adolescents, low-SES populations, and those most at risk for overweight. (9) This strategy was used successfully in tobacco control but is less controversial than taxing food, because it is an addictive substance and not essential to life. (19) Another method would be to regulate composition of processed foods or “encourage” companies to improve nutritional content of their food. (20)
Another interesting possibility to improve the environment that encourages unhealthy behavior is to target marketing practices of the food industry. The food industry has specifically been criticized for using large servings of high-fat, high-calorie foods; the failure to provide nutrition information before purchase in restaurants and vending machines; targeting children with high-fat, high-calorie foods by media and toy promotions; and saturating distribution channels, such as schools, with high-fat, high-calorie foods. (11) Although these practices are defended by the idea that consumers are responsible for their own choices, the government has the prerogative and the responsibility to set limits and enforce standards that protect the health of its citizens. (11)
Lastly, there are significant differences about nutritional information, motivation, as well as risk of obesity relative to education, income, ethnicity, and age so the campaign should be appropriate to each of these groups and tailored specifically for certain communities. (11) This “tailoring” is particularly important as it has been shown that, “one size does not fit all”, when referring to public health interventions. (17)
Obesity is a serious public health problem in the US and increasingly throughout the world yet the complexity of influences on obesity and behaviors that can lead to it make it a very difficult problem to address. The US government and The Ad Council have collaboratively created and released the “Small Steps” campaign, an educational approach to combating the epidemic. Unfortunately, the heavy educational focus is a serious flaw of the campaign and does not do enough to make significant or long-lasting behavior change. The “Small Steps” campaign also neglects important environmental influences that may make behavior change, through education, improbable. Finally, the campaign is based heavily on the Social Cognitive Theory and the Transtheoretical Stages of Change Model which both assume people act rationally when dealing with health behaviors. Obesity and associated psychological conditions like impulsivity, depression and anxiety all exert influence on behavior choices that do not always align with the best interest of the person making them. This makes the Social Cognitive Theory and Transtheoretical Stages of Change Model an ineffectual paradigms in dealing with obesity. The Social Ecology Theory is a proming alternative, which combines individual measures to promote healthy behavior change as well as environmental measures to facilitate those changes. The obesity epidemic presents a daunting challenge, but with the correct approach is not a futile undertaking.

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