Sunday, May 9, 2010

From Geneva to Small Town, USA: Why the World Health Organization Global Strategy on Diet, Physical Activity and Health Will Miss Its Target

The World Health Organization (WHO) has proclaimed that the burden of “noncommunicable diseases” is a significant and growing problem in both developed and developing nations. Whereas throughout history WHO has primarily focused on addressing communicable diseases (HIV, malaria, smallpox, etc.), it has come to the realization that this new group of diseases represent a group of emerging silent killers. These diseases consist of coronary artery (heart) disease, diabetes, cerebrovascular disease (stroke), and cancer. In 2001, noncommunicable diseases accounted for almost 60% of the 56 million deaths annually and 47% of the global burden of disease (1). In most countries, clearly identifiable risk factors are linked to these disease processes: hypertension, hypercholesterolemia, inadequate intake of fruits and vegetables, obesity, physical inactivity, and tobacco use. Diet and physical activity are linked to most of these risk factors, and have therefore been targeted for modification by WHO. Similarly, in the U.S. in 2006, the top three leading causes of death were heart disease, cancer, and stroke. The combination of these three causes was responsible for 55% of all deaths in the U.S. that year (2).

Based on these concerning statistics and trends, WHO published a report in 2004 entitled, “World Health Organization Global Strategy on Diet, Physical Activity and Health.” This 21 page document laid out a strategy for addressing the two root causes of noncommunicable diseases identified above: diet and physical activity. The report details a description of the problem, plans for intervention, and proposals for continued research and information gathering to analyze the problem. Unfortunately, as this paper will show, the strategy suffers from the same flaws that have plagued many public health campaigns over the years. In this paper, the WHO report will be critically analyzed in the context of social behavioral theory. Finally, suggestions for modification will be presented which may allow the strategy to attain its intended goals.

Individual Behavioral Change through Policy

The recommendations in the WHO report utilize one of the most time-tested and well-analyzed social behavioral models, the Health Belief Model (HBM). The HBM was developed in the 1950s, when it was developed by the United States Public Health Service to explain why turnout for free tuberculosis screenings were so low (3). HBM describes behavior as an outcome of: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (4, 5). Perceived susceptibility describes a person’s beliefs as to his risk of acquiring the condition. This may be based either on fact or irrational thought. Perceived severity describes a person’s feelings as to how the condition could affect him if he were stricken with the condition. This can involve the purely medical consequences, but also the impact on the person’s daily living situation such as work, school, and home life. The component of perceived benefits refers to the potential good outcomes that may result from undergoing the proposed action. This could consist of minimizing the severity of the adverse outcome, or avoiding it altogether. The perceived barriers are those aspects which tend to prevent the person from taking action. These could be related to emotions such as fear of pain, adverse outcomes, inconvenience, or cost. A cue to action is an instigating event which helps push a person into undertaking the intervention. This might be a personal experience with the illness in question such as a friend or relative becoming stricken, or potentially an educational prompt from a physician or public health campaign. The interplay between these components helps determine the action of the individual. On one side, the perceived cost or severity of disease is comprised of the combination of susceptibility and severity. On the other side, the likelihood of action is comprised of the difference between the perceived benefits and the perceived barriers.

While HBM is felt to be a reasonable model for understanding simple decisions made by individuals, it has been shown to not be adequate in describing many complex health related decisions (6-9). The major problem with the use of HBM in this context is that it assumes that decisions are made on the individual level and are planned rationally based on weighing the data carefully and thoughtfully.

The WHO strategy suggests that, “governments…draw up national dietary guidelines, taking account of evidence from national and international sources,” as well as, “national guidelines for health-enhancing physical activity…in accordance with the goals and objectives of the Strategy and expert recommendations (10).” The suggestion is that if the government makes official guidelines for nutrition and exercise and disseminates them widely to the public, this will change individual behavior by shifting the balance of the perceived costs and benefits. Especially with behaviors that are looked on favorably, such as eating well and exercising, it would be hard to construct a decision tree where the perceived costs outweigh the perceived benefits. In one survey, 97 percent of Americans accept that exercise is beneficial to health and see a need to incorporate it into their lives. This demonstrates the fact that there must be other forces controlling behavior in this type of circumstance. Otherwise, it would be difficult to explain the fact that only about 32.5 percent of American adults report regular leisure-time physical activity (12). It must be emphasized that 32.5% is based on self-reporting, which is likely and overestimation of the actual number. As a marker of activity and diet, about 144 million American adults age 20 and older are considered overweight or obese, and of these more than 71.6 million are considered obese (13).

Overall, the use of an individual level model is an inefficient and inadequate way to influence the behavior of a population. This method requires extensive conscious reasoning and decision-making by individuals, and is not the best approach to affect the health of the entire public.

For these reasons, it is probable that the suggested strategies outlined in the WHO report for implementation of policies to promote physical activity and improved diet will be ineffective.

Self Efficacy and Barriers to Change

Even if an individual decides to undertake an intervention, as in the process of decision making in the Health Belief Model, there is still one additional step before he proceeds. Self efficacy is the belief by the individual that he can accomplish the goal that he sets out to attain. While this is a component of HBM, it is more fully described as a key component of Bandura’s Social Cognitive Theory (SCT) (13). In SCT, an individual learns based on the relationship between behavior, environmental factors, and personal factors. Self efficacy is defined as, “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations (14).” Self efficacy can be developed in several ways, most effectively through mastery of past experiences. Other ways include witnessing others successfully completing tasks, being persuaded that they will be able to complete a task, and in response to emotional states to certain situations (15).

Of particular interest related to the topic at hand is how self efficacy plays into decision making regarding diet and exercise. There are specific factors which contribute to the level of self efficacy of a person, based on previous experience and social position in life. Race, gender and socioeconomic status (SES) are some of the most important to take into consideration (16). Individuals within populations with low SES generally display lower levels of self efficacy. This could be due to both the individual having had negative past experiences, as well as witnessing others from within the same SES group having had negative experiences. This lower self-efficacy in low SES groups has actually been linked to decreased participation in sports activities (17). This has also been shown in older-aged low SES populations as well, and may point to age and an additional determinant of low self efficacy (18). In regards to race and gender, non-whites and women have been shown to have lower self efficacy (19).

In regards to the WHO strategy, the issue of self efficacy becomes a large issue. The report notes that:

“Priority should be given to activities that have a positive impact on the poorest population groups and communities. Such activities will generally require community-based action with strong government intervention and oversight…The prevalence of noncommunicable diseases related to diet and physical activity may vary greatly between men and women. Patterns of physical activity and diets differ according to sex, culture and age. Decisions about food and nutrition are often made by women and are based on culture and traditional diets. National strategies and action plans should therefore be sensitive to such differences (10).”

While it is praiseworthy that these topics are noted in the report, there are no clearly defined strategies outlined to help mitigate these limitations. The reliance on “government oversight” and “national strategies and action plans” is overly vague and leaves significant potential gaps in the strategy. The social groups who are at the highest risk of disease continue to lack appropriate interventions targeted toward them.

Ability to Reign in Private Industry

The WHO report details several areas involving collaboration with private industry in order to increase physical activity and decrease the availability of unhealthy foods. Related to advertising, the report states, “Food advertising affects food choices and influences dietary habits. Food and beverage advertisements should not exploit children’s inexperience or credulity. Messages that encourage unhealthy dietary practices or physical inactivity should be discouraged, and positive, healthy messages encouraged (10).” Also related to the way industry communicates with the public, the report suggests, “As consumers’ interest in health grows, and increasing attention is paid to the health aspects of food products, producers increasingly use health-related messages. Such messages must not mislead the public about nutritional benefits or risks (10).”

While these may be noble goals, the strong competing interests of private industry must be taken into account. The fast food industry made an estimated $142 billion in sales in 2006 in the U.S. alone (20). There is also evidence that sales are increasing, potentially due fast food as a source of low cost meals in the setting of a poor economy (21). Certainly, while private industry attempts to appear to be interested in promoting the public health, there can be little doubt as to where its main motivation rests; the bottom line. Regulation of marketing, labeling, and targeted advertising is a significant challenge in this country. The restaurant industry alone boasts $580 billion in annual sales and employs 12.7 million Americans (20). These numbers beget formidable political power through lobbies and fundraising bases. Policies with significant impact will be difficult to pass into law.

Far from the spirit of cooperating with the goals in the WHO report, there is evidence that the fast food industry actually consciously targets low income minority customers. In one study, geographic information system (GIS) software was used to map fast food restaurants in the city of New Orleans and correlate this with neighborhood sociodemographics using census data. Neighborhoods that were predominately black and low income had a 60% higher density of fast food restaurants than neighborhoods that were predominately white and higher income.

This evidence suggests that private industry cannot be relied upon to assist in advancing the goals of public health when this will negatively affect their business prosperity.

Up to this point, some of the potential flaws of the WHO Global Strategy on Diet, Physical Activity and Health have been critically examined. Based on social behavioral theory, this paper will now turn toward potential solutions for the flaws that were identified.

Behavioral Change through Group Level Intervention

Whereas the WHO report relies on the individual model HBM, a successful campaign to change behavior should integrate models that act on the group level. There are a few important premises to consider. Groups are more than just collections of individuals, and behavior at this level is different than one might expect if only individuals were modeled. In addition, behavior can be changed at the group level, rather than the individual level (22).

With these premises in mind, one intervention to be considered to attempt to affect diet and physical activity would include use of the Social Expectations Theory. This theory describes the fact that people conform to social norms of society in which they live. If you want to change behavior, then you must change the social norms. This can be accomplished in several ways, including legislation, public information campaigns, and through mass media (23). In the example of the issue of smoking in bars, regulations were passed prohibiting the behavior in question. This then led to a change in the social norm, and the behavior was curtailed. Other examples include implementation of seatbelt and car seat laws. By passage of these laws, the thought process at the individual level about these behaviors was removed. People changed their behaviors because society changed.

This theory can be applied to the campaign to improve physical activity and diet. Regulations should be drafted, disseminated, and supported internationally which specifically ban certain food products. The movement to ban trans-fat in the U.S. is an excellent example (24). When left to individuals to make the decision, consumers tend to choose based on ease of access, price, and taste. By imposing regulations banning the use of trans-fat in restaurants, the decision making process at the individual level was removed. A new social norm has been established and behavior has been affected at the group level.

There are several specific recommendations which could be included in the WHO report. The most important of these could be targeted at our children. Adults, especially in the U.S., often baulk at regulations on their choices which are seen as paternalistic. If these measures are targeted at children, however, they tend to be more socially acceptable. In addition, they may have greater impact for potentially altering habits on a life-long basis. Bans on full calorie beverages such as sodas, bans on fast food franchises on school and college campuses, and age limits in convenience/grocery stores for buying high sugar/fat products could be instituted.

Within the realm of promoting physical activity, governments have the opportunity through planning and construction to alter the “built environment.” This includes building recreational parks and bike paths, expanding mass transportation, integration of stairs into building structures instead of escalators and moving walkways, and supporting recreational sports leagues (24). Again, integration of these measures into the social norms will alter group behavior over time.

Targeting Barriers to Change in At-Risk Populations

In the sections above, specific at-risk populations were identified who have been shown to have lower self-efficacy for ability to change their behaviors. These primarily include racial minorities, people with low socioeconomic status, women, and the elderly. Unfortunately, not only are these populations not protected, but as described earlier, they are sometimes intentionally targeted by industry as consumers of specific products.

Goals of any public health campaign should include targeting these at-risk populations with specific interventions that will assist them in behavioral modification. There are specific social behavioral models which can provide guidance in this area.

The Social Network Theory is a traditional group level model that describes behavior as being influenced by an individual’s social network (25). It states that an individual’s behavior is strongly associated with the behavior of other members of the same social network. In order to change the behavior of an individual, the behavior of the social network must change. This can be accomplished by influencing key members of the social network, whom the other members hold in high esteem. Once behavior changes in a small influential segment of the network, the new behavior can spread throughout. This has been demonstrated in both of the behaviors of smoking and obesity (26, 27).

Since the specific populations at risk for our behaviors of concern have already been identified (and plotted on a map, in some cases) interventions should be able to be fairly easily targeted toward their social networks. By targeting influential members of these communities such as business leaders, government officials, athletes and religious leaders to become models for the community, behavioral change can be affected.

Another behavioral model which could be employed in this situation is the Psychological Reactance Theory (28). This model suggests that people experience reactance, or a negative reaction, when their behavioral freedom is threatened. People react by rejecting the intervention they are being told to adopt.

In order to decrease reactance to a public health campaign, specific techniques need to be used to craft the message correctly (29). The message should be explicit, thereby making the intent of the message clear. In this case, campaigns should state that the goal of increasing physical activity and improving diet is to decrease the burden of chronic disease, improve quality of life, and extend life expectancy. The message should minimize the appearance of dominance. This can be accomplished by using an individual from the target group to convey the public message. Support for the message should be presented in powerful images set to inspiring music, such as healthy athletic individuals from that specific community enjoying a recreational activity. The traditional public health method of support through facts and figures tends to increase reactance and should be avoided (30).

Utilize Key Tricks of the Trade

As discussed earlier, it is unlikely that the public health community can truly count on the genuine wholehearted support of private industry to promote physical activity and healthy diet. For this reason, the public health community must take the marketing of these campaigns into its own hands. In order to do this effectively, the same behavioral modification techniques that private industry has been using successfully for years should be employed.

Advertising Theory is a group level model that packages the product in question as a core value, and then makes a promise to the consumer that the product will help him obtain this core value (31). This is supported through powerful imagery and music to convey the promise to the consumer. Marketing Theory is similar, in that it targets strong core values (such as happiness, self-esteem, freedom, etc.) and then creates a brand image to which the consumer aspires. The product is associated with the core value, and the consumer is compelled to purchase the product to obtain the core value (32-34).

These theories have been used with unequivocal success by private industry for decades. Companies like McDonald’s, Nike and Ford have made hundreds of billions of dollars by branding their products as a way to fulfill core values such as love/happiness, freedom/autonomy, and strength/toughness. The public health community has begun to catch on, and campaigns such as the “Truth” have embraced these theories. The Truth was so successful, that the campaign became a serious threat to the tobacco industry and its funding was pulled due to political pressure (35, 36).

With regards to the campaign to promote physical activity and healthy diets, some appropriate and powerful core values could be used in campaigns including freedom, self-esteem, independence, autonomy, youth, and virility. Even the classic teen core value of rebelliousness could be used to encourage teenagers rebelling against the establishment of the fast food industry. By incorporating youths into the development process through focus groups and interviews, the final product would be more appealing to them. In the end, a fresh and exciting new brand could be created that helps promote the specified goals.

Final Thoughts

The “World Health Organization Global Strategy on Diet, Physical Activity and Health” sets important goals for improving global public health through a renewed focus on noncommunicable diseases. These new leading killers comprised of heart disease, cancer, and stroke have common precipitants rooted in a lack of physical activity and poor diet. While the goals are noble, the methods proposed to attain them fall short. An outdated dependence on individual level social behavioral models, a lack of focus on specific social barriers to behavioral change, and an over-reliance on the good will of private industry represent significant shortcomings to the strategy.

By shifting the focus to group level social behavioral models, analyzing and targeting specific barriers to change, and implementing advertising theories to create a marketable brand to the public, the common goal of improving the public health can be attained.


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