A Critique of Why the "Are You Pouring on the Pounds?" Campaign Will Not Prevent Weight Gain -Kate Sullivan

Introduction

Soda, Gatorade, lemonade and ice tea. Refreshing drinks or dangerous drinks? What do these drinks have in common? Tons of sugar. These non-nutritive beverages are wreaking havoc on the weight of millions of Americans. What used to be an occasional treat has turned into a basic food group.
“Gross”, “disgusting”, “I can’t look at it” were comments made by passengers on the New York City subway system late last year (3). What these people were commenting on was a new public health campaign organized by the New York City Department of Health and Mental Hygiene (NYCDHMH), called “Are You Pouring on the Pounds?” The posters placed in the subway system show a soda or other beverage being poured out of a can or bottle into a cup and as the liquid reaches the cup, it turns into yellow globs of fat riddled with blood vessels. The department wanted a shocking campaign to catch people’s attention by focusing on the hazards of sugar-sweetened beverage consumption and to increase people’s awareness of how soft drinks contribute to weight gain and eventually to obesity (1). The campaign was short and focused. It ran for three months at the end of 2009. The message accompanying this image exclaims “Don’t drink yourself fat.” (1) NYCDHMH spent three years and $277,000 researching and developing this campaign.
The New York City Department of Health and Mental Hygiene was stirred to action because of studies showing connection between health problems and sugar-sweetened beverage consumption. To understand the SSBs consumption habits of its citizens, the health department conducted a survey. The 2007 Community Health Survey found that among adult New Yorkers, two million adults drink at least one SSB each day for a caloric intake of 250 calories (1). Serving sizes have increased and with that, increased consumption of empty calories. The department is looking to raise awareness of its citizens through the “Are You Pouring on the Pounds?” campaign about the hazards of SSBs. They are recommending substituting water, seltzer or low fat milk as alternatives (1).
It may be common knowledge that too many calories consumed leads to weight gain. SSBs have played a special role in the rising obesity rates is adults and children. From 1977 to 2001 the consumption of SSBs increased by 135% (7). Besides the infiltration of sodas into the American diet, SSBs also take the form of teas, sports drinks and fruit-based juices. SSBs all contain large amount of sugar. The calories contained in SSBs are empty calories and provide little nutritional value. When people drink SSBs, rarely do they take into account the extra calories. A randomized, double-blind study was conducted by Raben et al to compare the effect of calorically sweetened beverages with that of diet beverages (8). The study showed that the calories from SSBs did not replace food calories, but were additional calories to the diet (8). Those participants who were given the caloric sweetened beverages gained weight during the study and those who drank diet beverages did not (8). This is why the New York City Department of Health and Mental Hygiene is trying to decrease SSBs consumption.
Articles about the campaign are plentiful. Journalists from The New York Times, The Daily News and the British Broadcasting Corporation discussed the effectiveness of the “shock” campaign and interviewed various people. Opinions were mixed. Some people interviewed felt that this kind of campaign would work, others thought it wouldn’t. Many websites and blogs discussed the merits of the campaign (4). Claire Prentice, writing for the BBC News, interviewed a mother and daughter who were riding on the subway. The daughter was quoted as saying “gross” and the mother claimed that she never realized the amount of sugar in SSBs (3). Prentice spoke with a NY psychologist, Jonathan Alpert. He supports the shocking advertising and claims that in makes people think about what they are putting in their bodies. On the flip side, an advertising expert, George Parker, was critical of the campaign. He warned that it might backfire because the image is so gruesome people will turn away before the whole message is absorbed (3). The New York Times interviewed Cathy Nonas, director of Physical Activity and Nutrition programs. She said that the campaign was definitely going for shock value. She also said that the campaign was tested on focus groups and the “graphic in-your-face” approach would work (2). In the Daily News, Adam Lisberg spoke with Associate Commissioner Geoff Cowley. Cowley claimed that “being ‘positive and encouraging’ is not always useful in getting people to change behavior, sometimes you have to get into people’s faces to get attention (4).”
The New York City Department of Health and Mental Hygiene is not the first health department to raise awareness of the link between SSB consumption and obesity. During the summer of 2008, the Bay Area Nutrition and Physical Activity Collaboration in the San Francisco area conducted a campaign called “Soda Free Summer.” The idea behind this campaign was to get people to pledge not to drink soda over the course of a summer. The tools of this campaign included log books, pledge cards and wrist bands which were designed to keep the participants engaged through out the summer (5). Another campaign, called the global “Dump Soft Drinks” campaign is an international effort to improve children’s health and diet around the world. The campaign has succeeded in persuading Coke and Pepsi to provide more healthy alternatives at school vending machines is the Unites States and European Union (6).
There are three flaws in the “Are You Pouring on the Pounds?” campaign. The first flaw is that the campaign relies on the Health Belief model. This traditional model puts the onus on the individual to make a change. It relies on rational thought processes and planned behavior. The second flaw is that the campaign used fear to get the message across to the target audience. The third flaw is that the campaign targeted the proximal causes of SSB consumption.

Critique 1
“Are You Pouring on the Pounds?” is a campaign geared towards the individual. The NYCDHMH is asking each citizen of New York City to reconsider his/her SSB habit and substitute water, seltzer, or low-fat milk. This campaign is modeled on the Health Belief Model which is a traditional health behavior model. It is based on the motivation of the individual to adopt healthy behaviors and is comprised of several factors: perceived susceptibility, perceived severity, perceived benefits of an action and perceived barriers to taking that action (9).
The campaign is geared towards the individual: “Don’t drink yourself fat” (1); it is based on rational thought: “I will stop drinking SSBs now”; and it is planned behavior: “Next time I choose a beverage, I will drink water or milk.” The perceived benefits are less chance of obesity. The perceived susceptibility and severity is whether or not the individual believes that drinking any amount of SSBs will cause them to gain weight and to what extent will they become over weight and suffer health consequences if they don’t follow the health advice of the campaign. The perceived barriers to reducing SSBs consumption may be price of other beverages (fruit drink and soda are cheaper than milk); convenience (most SSBs do not need to be refrigerated while milk requires refrigeration) and water may not be appealing (SSBs are tasty and enjoyable, and therefore hard to give up). People may not be willing to spend money on bottled water but also may feel that tap water in their home is not good for them. Water fountains are not well maintained, many are broken, in disrepair or they look unhygienic so people are unwilling to drink from them.
Because this campaign is based on rational and planned behavior of the individual, it fails to take into account the irrationality of the individual. The campaign has created an expectation that if a person continues to drinking SSBs, he/she will become obese and have health problems. This campaign tries to educate individuals on the hazards of drinking SSBs and gives healthy alternatives, but it does not acknowledge that individuals really like SSBs and do not want to give them up; people “own” their SSB consumption.
The campaign is asking the individual to make a decision regarding beverage choice. If the individual does not follow the recommendation, something bad will happen: the individual will gain weight. The campaign is over estimating the ability of any one person, on their own, to make a change and gives no long term support to the individual.
Self-control is also an issue in this campaign. Whenever one wants to give up something, there are always others around who are doing the behavior. It’s hard to say no to soda when your best friend is drinking it. The individual faces added pressure about beverage choice because not only is drinking SSBs socially acceptable, people have been lead to believe through incessant advertising, that SSBs will make you socially acceptable.
The developers of this campaign used the Health Belief Model when they developed this campaign but fell into the “EZ program structure illusion.”(9). The message it provides “SSBs turns to fat” and people should stop drinking it for the sake of their health seems simple enough but the campaign fails to take into account expectation, ownership, framing of core values, context and self-control.

Intervention 1
Juxtaposed to the Health Belief Model with its emphasis on the individual is the Ecological Model for Health Promotion which recognizes that behavior is complex and there are many “factors” involved. The factors involved in this model are intrapersonal factors, interpersonal factors, institutional factors, community factors and public policy (10). The Ecological Model for Health Promotion recognizes that a range of strategies are necessary in health promotion activities (10).
One can understand the desire of the New York City Department of Health and Mental Hygiene to want to reach as many people as possible throughout the city. Putting the ads in the subway system would logically reach a lot of people in a short amount of time. Although their intentions were good, they wasted their money. The ads are catchy, and have a good tag line but are soon forgotten once the individual leaves the subway.
New York City Department of Health and Mental Hygiene would have been wise to target a community in which SSBs consumption is the highest. According to a survey conducted by the NYCDHMH, the Bronx had the highest consumption rates of all the boroughs surveyed (11). The ecological model says that intervening at the individual level is not enough. The community should be part of the intervention: “the purpose of an ecological model is to focus attention on the environmental causes of behavior and to identify environmental interventions” (10).
The Soda Free Summer campaign would have been a good model for New York City to use in the Bronx. The Bay Area Nutrition and Physical Activity Collaborative used an inter-disciplinary approach to reduce SSB consumption. “The soda free summer campaign consisted of a variety of activities to reach residents in the six San Francisco Bay area counties.” (5) The campaign involved the individual by distributing pledge card and logs to track progress through out the summer. The completed pledge cards could be turned in and entered into a raffle to win a prize. Promotional material was distributed to remind people of the program. Wrist bands were distributed to the participants that helped maintain a sense of community: “you are not alone in your endeavor”. Workshops were offered to educate participants on the sugar content of beverages and the health risks associated with sugar consumption. Community factors were applied to the program: school districts, public health departments, community groups, clinics and hospitals assisted in the campaign through a variety of outreach channels. Public policy factors were employed. Political leadership was engaged in the campaign (5). By using aspects of the ecological model, the campaign was a success: 47% of the participants reported a decrease in their soda consumption as a result of the campaign (5).
Money may have been a factor but if the New York City Department of Health and Mental Hygiene had used this model to target a particular community such as the Bronx, they might have made an impact by reducing this type of beverage consumption on the community with the highest consumption level of SSBs. This could then have been used as a model for other communities throughout New York.

Critique 2
The New York City Department of Health and Mental Hygiene framed their campaign with fear. The fear in this campaign is weight gain from drinking SSBs. “Fear appeals are persuasive messages designed to scare people by describing the terrible thing that will happen to them if they do not do what the message recommends” (12). Whether a message is rejected or not depends on the level of threat as well as the level of efficacy, i.e. the ability to do something about it. (12).
Many public health campaigns have used fear to motivate individuals to change their behavior. For example, the drug-resistance campaign that used a frying egg to simulate how a person’s brain looks on drugs used fear to change people’s behavior (12). Fear models such as the Extended Parallel Process Model (EPPM) use the elements of fear appeal as the basis of their model (12). There are four important components to the fear appeal process: fear, threat, efficacy and outcome variables (12).
A fear appeal can be explained by examining the content of the fear appeal, (gory pictures of crash victims) or fear appeals can be explained by the reaction of the target audience. The target audience can give self-reported levels of fear or instruments can be used to measure the physiological state of the target audience. The fear appeal targeted to the audience in this campaign is that if you drink soda, you will gain weight and have health problems (12). Fear is a negative emotion and has been described by various researchers as anxiety, concern, worry or physiological arousal (12). In this campaign, the fear of weight gain may cause anxiety. Since the campaign does display a glob of fat riddled with blood vessels, negative emotions are aroused and the images in the campaign are labeled as ‘gross” (3). Threat is an external stimulus variable that exists whether a person knows it or not (12). Threats are categorized based on severity of threat (12). In this campaign, the threat can be categorized as the severity of the weight gain and extent of health problems. A person may gain a couple of pounds or hundreds of pounds; have few health problems or many. Efficacy is the targeted audience’s ability to perform the recommended response (12). In this campaign, efficacy is the ability of the target audience to reduce the amount of SSBs in their diet. In the fear appeal, the researcher is looking for message acceptance as an outcome. The outcome does not always lead to message acceptance. Sometimes avoidance and reactance are the outcome (12). The outcome of the campaign is the actual response of the target audience to the message. The target audience may reduce consumption of SSBs, therefore the message was accepted. There may be no change in consumption habits in which case the message was avoided. The worst outcome would be an increase of consumption in defiance of the message, indicating the message had the opposite effect.
Although the campaign fits into the EPPM and this model can explain how the target audience will react to the fear appeal, researchers don’t know how effective fear campaigns are. “Beck and Frankel (1981) noted that the parallel process model is the most broad of the fear appeal theories and although virtually untestable, offers a nice frame work in which to further theorize (12).”
If the EMMP provides a framework, other researchers have explored reinforcement in relation to fear appeal. The effective use of fear is when fear is coupled with reinforcement; this is called “response- fear offset pairing (13).” An example of the type of situation that uses “response-fear offset pairing” is the pairing of seatbelt use with an outcome. Seatbelt-use campaigns have tried to get the target audience to use seatbelts. The underlying message of wearing seatbelts is that if you don’t wear seatbelts, you could die. Even though this could happen, the likelihood of it happening is very small, so the target audience rejects the message. When seatbelt-use messages are reinforced with laws that allow police to ticket and fine non-seatbelt users, the target audience embraces the message and wears seatbelts (13).
This campaign did not use fear successfully. “The use of fear is only likely to work under particular circumstances involving the identification of specific behaviors which successfully reduce the fear aroused (13).” Although the images of fat in a glass are unsettling, the threat of weight gain and the risk of poor health are not strong enough to trigger a change in the target audience because there is no appropriate reinforcement i.e. response-fear offset pairing. A reasonable reinforcement could be a tax added to sugar-sweetened beverages. Increasing the price of SSB would impact the “wallet” of the target audience.
When changing a behavior it is also helpful to see immediate results of the change (13). The target audience may feel that they have been drinking soda for a long time and it has not caused them any harm. Even if the target audience did give up drinking soda, it may be along time before they saw any positive results (weight loss). In addition, it would be impossible to judge if in fact the target audience was able to avoid poor health outcomes from reducing SSB consumption. Researchers recognize that health promotion should not be the removal of unhealthy behaviors but of the reinforcing of healthy behaviors (13). The overall message of “Are You Pouring on the Pound?” is a fear-invoking message dictating the decrease of SSB consumption instead of a positive message encouraging consumption of water or milk.

Intervention 2
The New York City Department of Health and Mental Hygiene should take some cues on promoting healthy beverage choices from the “got milk?” campaign. The campaign used humor and what the advertisers called a milk deprivation strategy (14).
For years drinking milk was promoted as “the key to good health”. Dairy advertising, public relations efforts and the government worked together to encourage milk consumption. For a while the idea of good health from drinking milk worked. But in the 1990s due to other beverage choices made available to consumers, milk consumption declined. SSBs were fun to drink; their packaging was colorful and had innovative designs. This was in contrast to milk which was packaged in boring cardboard cartons and plastic jugs (14). In order to increase sales of milk, the California Milk Processor Board hired a San Francisco ad agency to create a new campaign. “Got milk?” campaign became one of the 1990s most popular and critically acclaimed advertising campaigns (14).”
Money aside (the advertising agency had a $23 million per year budget) the advertisements were effective because they appealed to a core value that was something other than health. Although many people surveyed thought of milk as a compliment to certain foods, the advertising team decided not to sell milk as a complement to those foods (14). Instead, the ad agency used a milk deprivation strategy mixed with humor. The television ads showed people put in silly situations where milk was not available. For example, one commercial showed a man going to heaven and there were chocolate chip cookies everywhere. As he ate the cookies, he grabbed carton after carton of milk, and they were all empty. He began to wonder if he was in heaven after all. This helped to sell milk because the commercials were humorous and people could relate to that feeling of being without milk when it was needed it most (14).
What the New York City Department of Health and Mental Hygiene could have done to “sell” water was use a deprivation strategy. The campaign could reach the target audience by portraying people performing strenuous activities and then not having the most thirst quenching beverage available: water. Posters with an image of someone in the dessert seeing a mirage of water, but not being able to reach it might have portrayed a water deprivation scenario. Making the image enjoyable and positive would have a greater impact than showing an image that is disturbing and negative.

Critique 3
“Are You Pouring on the Pounds?” addresses the proximal causes of weight gain. It maintains that if you drink soda and other soft drinks you, the individual, will gain weight. Telling the individual to cut back on SSB consumption is futile in light of marketing tactics, availability, social norms and policies. Beverage companies target children and teens in their advertising campaigns. For example, the Sprite “Obey Your Thirst” campaign featured rap artists and basketball players combined with “playful cynicism” to create a brand that became popular with urban youth (14). The availability of alternatives such as water fountains is not taken into consideration. The campaign doesn’t take into account the wide availability of SSBs. Everything is geared towards making drinking beverages easy. There are reminders every where that you too can be carrying a beverage. SSB are available everywhere: in corner stores, vending machines, grocery stores, and street vendors. The fact that people bring their drinks where ever they go is not addressed. There are very few places where it is not acceptable to carry around a beverage. Schools allow students to have drinks in class. Cars have beverage cadies as do strollers and shopping carts. SSBs are portable, inexpensive and do not spoil if not refrigerated.
SSBs are served to the youngest members of society, usually in the form of fruit juices. At an early age, children are given juice during the day are snack or meal time. They are conditioned at an early age that sweetened beverages are normal. The Federal Government endorses the consumption of sweet beverages (juices) because there is concern that young children are not getting an adequate amount of fruit in their diet. The Dietary Guidelines for Americans recommends fruit juice consumption by children (15). Since SSBs are a normal part of every day life from early on, asking people to give up SSBs is not practical.
People are taught from early on that sugar-sweetened beverages are a normal part of their diet. This is further reinforced by the wide-spread availability and social acceptance of SSBs. SSBs are ingrained in the American diet. It is unrealistic to expect people to change their behavior when even the government is encouraging people to drink SSBs.

Intervention 3
Efforts to reduce SSB might be better addressed at the distal level. From a rational point of view, the individual has control to a certain extent but people are not rational. Putting policies in place such as requiring beverage manufacturers to make some labeling changes and even levying a tax on sugar-sweetened beverages would go along way in changing people’s relationship to SSBs.
Sugar-sweetened beverages are packaged and bottled in various configurations. Some juices are packages in colorful cartoon featuring favorite cartoon characters. Each juice box represents one serving. The box is around 6-8 ounces and may have a calorie content of 100 calories. This is a reasonably sized portion and represents the small end of the scale for size. Many SSBs are available in 2 liter or ½ gallon-sized bottles. These SSBs contain numerous servings. Most people would agree that this size is not a single serving size and would adequately serve a number of people. This represents the large end of the scale. In between the juice box and the 2 liter bottle is a landscape of bottles of various sizes and shapes. Are the bottles in between single serving containers or are they multiple serving bottles? Even though the 20 ounce soda bottle claims that it contains 2.5 servings, how many people are really going to share that bottle? In actuality, the 20 ounce bottle is one serving. Even if a smaller size beverage is available, it is not priced as favorably as the larger size so one may feel a little “ripped off” buying it. Larger sizes are considered a “value” because they are cheaper per unit measure. Buying in bulk is cheaper on the wallet but drinking in bulk carries the hidden cost of weight gain.
Bottlers have been getting better about labeling their bottles. They may still consider that the 20 oz bottle provides 2.5 serving, but some bottlers are also putting the calorie content of the entire bottle on the nutrition label as well as the calories “per serving”. This type of labeling was recommended by the FDA’s Obesity Working Group “encourage manufacturers immediately to take advantage of the flexibility in current regulations on serving sizes and label as a single-serving those food packages where the entire content of the package can reasonably be consumed at a single-eating occasion. For example, a 20 oz bottle of soda that currently states 110 calories per serving and 2.5 servings per bottle could be labeled as containing 275 calories per bottle.”(16) Not all bottlers are doing this but consistent labeling of the calorie content of the bottle will help consumers make better choices.
Another way to reduce SSB consumption from a distal vantage point that has caused a lot of controversy is taxing SSBs. Public health groups advise taxing SSBs would lead to decreased consumption and subsequently reduced health problems. Many consumer groups see taxes as regressive, affecting poorer people disproportionately (17). On the other hand, poorer people have greater health problems related to a nutrient-poor diet and would benefit from reducing the consumption of sugar-sweetened beverages (17). According to Brownell and Frieden, the best way to implement the tax is to use an excise tax (17). This type of tax structure taxes a fixed cost per ounce at the manufacturing level. This cost would be passed on to the consumer and it would be seen as the true purchase price of the beverage (17). The sales tax, on the other hand, is added on to the beverage at time of purchase. At this point the consumer has already made their choice or feels obligated to pay since they are already at the cash register (17).
According to Brownell et al, taxing SSBs would reduce the amount of consumption because of “price elasticity” which is described as consumption shift caused by price (18). The price elasticity for all soft drinks is the range of -0.8 to -1.0 (18). This means a decrease in consumption from 8-10% if there was an 8-10% increase in price of the beverage. Consumers would switch to diet beverages (which would not be taxed) if their favorite SSB becomes too expensive, or perhaps to a smaller size container if available (18).
Reducing consumption of SSBs through taxation would in turn lower risks of obesity, diabetes and other diseases. The tax money raised could go to obesity prevention programs geared towards children and teens.

Conclusion
The New York City Department of Health and Mental Hygiene sponsored a campaign that was geared towards getting people to change their sugar-sweetened beverage habit. The campaign focused on the individual instead of looking at the larger community, it used fear instead of positive reinforcement and it targeted the proximal causes of weight gain instead of looking at distal causes. One New Yorker said it well, “They look kind of lame (the posters). We’re bombarded with so many messages and these don’t stand out (3).” Unfortunately, the message may not be heeded and New York City will likely have wasted taxpayer money.


References
1 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Health Bulletin, 2009.
2 Chan, Sewell. “New Targets in the Fat Fight: Soda and Juice.” New York Times. 01 September 2009. Web. 02 April 2010.
3 Prentice, Claire. “Anti-obesity as shocks New Yorkers.” BBC News. 07 October 2009. Web. 31 March 2010. http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/8281203.stm.
4 Lisberg, Adam. “Controversial new subway billboards show human fat being poured out of soft drink bottles.” Daily News. 21 August 2009. Web. 02 April 2010.
5 Bay Area Nutrition and Physical Activity Collaborative. Getting the Soda Free Message. San Francisco, CA: Bay Area Nutrition and Physical Activity Collaborative. 2009. www.banpac.org.
6 Center for Science in the Public Interest, International Association of Consumer Food Organizations. Global Dump Soft Drinks campaign. Web. 02 April 2010. http://dumpsoftdrinks.org/index.html.
7 Malik, Vasanti S, Schulze, Matthias B., Hu, Frank B. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition 2006; 84: 274-88.
8 Bray, George A., Nielsen, Samara Joy, Popkin, Barry M. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. American Journal of Clinical Nutrition 2004; 79: 537-43.
9 Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
10 McLeroy, Kenneth R., Bibeau, Daniel, Steckler, Allan, Glanz, Karen. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly. 1988; 15(4): 351-377.
11 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Press Release # 057-09. http://www.nyc.gov/html/pr057-09.shtml. 31 August 2009. Web. 09 April 2010.
12 Witte, Kim. Putting the fear back into fear appeals: the extended parallel process model. Communication Monographs, 1992; 59: 329-349.
13 Job, R.F. Soames. Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health, 1988; 78(2): 163-167.
14 Holt, Douglas B. Got milk? Advertising Educational Foundation. 2002. Web. 08 April 2010. http://www.aef.com.
15 United Stated Department of Agriculture. Is Fruit Juice Dangerous for Children? Washington, DC: Center for Nutrition Policy and Promotion. March 1997.
16 Food and Drug Administration. Calories Count: Report of the Working Group on Obesity. Obesity Working Group. 2004. Web. 15 April 2010. http://www.fda.gov/food/labelingnutrition/reportsresearch/ucm081696.htm.
17 Brownell, Kelly D., Frieden, Thomas R. Ounces of Prevention-The Public Case for Taxes on Sugared Beverages. New England Journal of Medicine 2009; 360(18): 1805-1808.
18 Brownell, Kelly D. et al. The Public Health and Economic Benefits of Taxing Sugar-sweetened Beverages. New England Journal of Medicine 2009; 361(16): 1599-1605.

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.

References

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New York City’s, “Are You Pouring On The Pounds?” Campaign: A Critique based On Psychological Reactance Theory- Tricia Pellizzi

Obesity is a growing concern in the United States. In the United States 68 percent of adults age 20 and older are overweight or obese (BMI greater than 25) (2). In response to the growing rate of obesity in the United States, the New York Department of Health and Mental Hygiene launched an ad in the summer of 2009 targeted at the source of many of the extra calories we consumed on a daily basis: sugary beverages. The department claims that, “On average, Americans now consume 200 to 300 more calories each day than we did 30 years ago. Nearly half of these extra calories come from sugar-sweetened drinks.” (3). The ad recognizes the link between the consumption of sugary beverages and the increased risk of obesity, diabetes, heart disease, stroke, arthritis and cancer (2,3) and warns New Yorkers to cut back, using the tag line; “ Don’t drink yourself fat, cut back on the sugary drinking and go with water, seltzer or low fat milk instead” (3 ). Although the ad has a legitimate source and objective, the ad’s graphic may divert viewer’s eyes before they read the health message. The graphic depicts a hand emptying a soda bottle into a glass; however, it is not soda pouring out of the bottle, it’s fat. Many New Yorkers are opposed to this message, rejecting the “unpleasant image” and “nanny state” the ad represents (8). These powerful emotional reactions can lead to the ultimate backfiring of the Health Departments campaign. Although sugary beverages are a source of many empty calories and are consumed in greater quantities than ever before and therefore are a contributing factor to the growing rates of obesity in the United States (3), the ad’s use of negative, highly directive, overtly persuasive language and improper use of social marketing techniques creates a potential for negative labeling of soda drinkers, and produces high psychological reactance, which can lead to a ‘Boomerang effect’.
Negative Framing and the Potential for Negative Labeling
Labeling is a social process; the label is often not inherent in the behavior that receives it (24). Labeling Theory suggests identity and behavior of certain individuals, usually those seen as deviating from perceived social norms, may be determined or influenced by terms used to describe these individuals. This leads to stereotyping and self-filling prophecy (1). Due to the fact that the ad states that an increasing number of New Yorkers, 2 million according to Health Department researchers, drink sugary beverages daily (3), this ad has the potential to create a stereotype that people who drink soda, or sweetened beverages regularly are ‘fat’, creating a stigma for this group of the population. Research has found that weight related stigmas occur on a variety of levels, including, but not limited to, family, friends, and even health professions, (22) this has great potential to negatively affect emotional functioning as well as provoke negative coping behaviors, which may include overeating or indulging. By negatively effecting emotional functioning, the targeting individual may decrease levels of self-esteem and other psychological stressors that may decrease confidence in their ability to make healthy decisions. This can perpetuate the cycle and create a self-fulfilling prophecy among these individuals (22). There are positive associations between psychological stress and excess body fat accumulations and experiences of unfair treatments lead to increases in abdominal obesity. (24). Clearly an advertisement that intends to positively influence health behaviors should avoid labeling and discrimination of groups to decrease the psychological stress of stigmas that may reinforce negative health behaviors.
Psychological Reactance: Potential for Adverse Reactions/Boomerang Effects
According to the Psychological Reactants Theory, emotions are reactions to threats of personal freedom, which in this case, is the freedom to drink sugary beverages. These emotional reactions often lead to behaviors that restore the freedom perceived to be threatened. Prior to the display of negative reactance the individual must feel the freedom to hold an attitude or belief, or engage in a behavior; in this case sugar sweetened beverages (in moderation or otherwise) is an example of exercising such a freedom. Determinants of the ability to exercise a freedom include; physical ability, wealth, or political regulations that may restrict the exercises of this activity (18,19,20). In this case, anyone can engage in this behavior; however, not everyone who engages in the activity is overweight; many people can enjoy these drinks in moderation without experiencing weight gain. Due to this attempt to manipulate personal freedom by advising against this behavior “individuals may engage in a threatened behavior simply to demonstrate their prerogative to do so” (20).
The attempt of the individual to restore the threatened freedom often results in acting out against recommendations. An example of this can be found in a study investigating the consequences of warnings by Stewart and Martin in 1994, which found that, “[although] empirical research suggests that warning messages increase consumer awareness of potential product hazards…Warnings may produce behavior that is exactly the opposite of that intended by the placement of the warning.” (12) The reaction to threats and acting out in attempts to restore to freedom can also be referred to as ‘The Boomerang Effect,’ which ultimately causes the opposite of the Health Departments intended effect. Not all warnings produce such negative effects; “…effective warnings result in improved awareness of warning information, more accurate perceptions of risk, and enhanced understanding of risk avoidance mechanisms….effective warnings [also] result in the measurable reduction of hazardous behavior.” (11).
According to the Psychological Reactance Theory, “People will react against attempts to control their behavior and eliminate their freedom of choice” (9). The freedom of choice deals with specific, discrete behavioral and attitudinal freedoms that people act upon in everyday life (9). The freedom to choose which beverages you consume on a day-to-day basis definitely fits the mold for exercise of daily behavioral freedom. This attempt to control New Yorkers behavior and thus their freedom, by warning that consuming these beverages will cause you to gain weight is a threat to their freedom; ads that attempt to persuade people to act in a certain way may in fact act in direct opposition in order to exercise their autonomy (9, 26). This theory supports the view that trying to influence peoples’ behaviors by advising against certain choices in this manner may not produce the desired effect of having New Yorkers decrease their consumption of sugary drinks and substitute those beverages with water, seltzer or low fat milk. In a study regarding consumer behavior and psychological reactance, researchers found that, “…the degree that an advertisement …is seen as intending to persuade, there should be reactance arousal and accompanying decrease influence”(9). People don’t like to receive unwanted advice about how they should behave. Warning against unhealthy products may only make them want the product more (15,26).
Adolescents seem to be a population that have an increased sensitivity to psychological reactants (13) and because the NYC Department of Health and Mental Hygiene ad is warning against soda and other sweetened beverages, which of course is popular among adolescents, the message may not be well received and even cause and increase in soda consumption as a result. DeTurck and Goldhaber conducted an experiment in 1991 with a “NO DIVING” warning sign to adolescents. Not only did the researchers find that, “controlling messages such as warning signs with increasing levels of psychological reactance, and as a result, warning signs are less effective with high school students than with middle school students;” is very clearly demonstrated by adolescence in response to warning messages. But also that “…[it] seemed to have a ‘boomerang effect’-caused the opposite than the intended effect” (13).
Due to the profound effect that psychological reactance can have on a variety of populations, Janis Hovland et al., in an article on communication and persuasion, accounted for six possible reasons for high psychological reactance or boomerang effect to a particular message; three of which apply to New York’s ad. The first being when the sender of the message uses counter norm communication the public may react against it; by describing the norm in order to argue against it the sender adds to the receivers knowledge of the norm and heighten conformity. This may be of particular significance with the “Are you pouring on the pounds?” advertisement because the campaign recognizes the daily high consumption of soda and sugar sweetened beverages in New York, and due to this increase the health department needs to intervene. But what the ad could be reinforcing to the public is that everyone drinks soda daily, but we want you to go against societal norms and stop. The second being when, after being influenced by the sender, the receiver becomes sharply aware that he is deviating from the norm, the audience my act in direct opposition to the desired effect. The third being that the boomerang effect may occur when the message produces feelings of aggression or unalleviated emotional arousal (17). This last point may play a significant role in the public reactions to this ad campaign. Viewing the ad or the video may produce many emotions; first and foremost it produces a strong feeling of disgust, which only elevates as the commercial continues, it also may produce anger or frustration in reaction in reaction to being told not to drink soda, or sugar sweetened beverages.
The magnitude of the public’s reaction will vary depending on two important factors. One being how important the consumption of these beverages are to each individual; “ the more important the freedom, the more reactance is generated due to person or impersonal threats” (9), and the other being the mere fact that your freedom to choose these beverages is being threatened, “ the reactance response often entails an overreaction whereby threatened behaviors or attitudes come to be prized more than before.” (9).
Ineffective Use of social marketing techniques
Research has shown that public health practitioners that utilize basic techniques of marketing principles to “sell” their product of health have found much success. Marketing techniques emphasize the importance of selling a product for which there is high demand, “ too often public health practitioners determine the benefits that policy makers and the public ought to want and then attempt to sell these benefits when there is low, or no, demand” (27). New York’s “Are you pouring on the pounds” campaign is attempting to indirectly ‘sell’ weight loss through reducing soda/sugar sweetened beverage consumption. The problem is that the focus of that ad is on the association between soda and ‘fat,’ not the benefits that this reduction can ultimately cause; weight loss, which is an appealing concept for consumers.
Recommendations of the use of marketing techniques in public health campaigns suggest six key objectives to meet when ‘packaging’ a product, New York’s ad violated four of the six objectives. The first violation involved the presentation of evoking visual images that appeal to the target audiences’ core values, rather than appealing to the core values of the population, the image on the New York’s ad evokes strong negative emotions of disgust and aggression (8). The ad also fails to develop a catch phrase that appeals to core values, the catch phrases in this ad a quite negative and potentially stigmatizing. It also does not suggest appropriate metaphors that evoke themes and images that appeal to the core values, Lastly the ad fails to distribute responsibility to society [environment, policy etc], not strictly on the individual. (27)
If we analyze New York’s advertising campaign in terms of the ‘brand’ they are creating for themselves, they identify with the consumer by informing them that their favorite beverage is making them fat. The brand instead should be something the audience can relate and aspire to and should relate back to their core values (27). The problem is that the advertisement is focusing the negative end result of drinking to much soda, rather than the benefits that one receives by cutting down their consumption such as weight control and autonomy, “promise, large promise is the soul of an advertisement (28).
Framing of health issues in a social marketing campaign also influence the outcome of behavior change and overall reaction to health messages; ‘gain-framed’ messages were found to be more effective in promoting prevention than ‘loss-framed’ messages (7). This ad uses a negative frame/ ‘loss-frame,’ insinuating that soda drinkers are ‘fat’, this may both produce a negative or opposite reaction to the desired out come of the campaign as well as create or enforce a stigma that segregates ‘soda drinkers’ from ‘non soda drinkers’ in society (6). In addition, James Price Dillard and Lijiang Shen in their article, On the nature of reactance and its role in persuasive health communication, found that,”…intense, forceful, or dogmatic language may increase the magnitude of reactance (10). The negative angle New York decided to take with this ad, both in terms of language, framing and images clearly increase the psychological reactance of views and therefore increase the potential for a ‘boomerang effect.’
Some theorists believe that campaigns such as this one focus too much attention on targeting individual behavior and not enough on influencing the environment to facilitate the desired behavior change. It is also important for social marketers to anticipate unintended effects of their marketing techniques that would produce adverse reactions (6) The New York City Department of Health & Mental Hygiene did not acknowledge the adverse reactions that having revolting images, targeted at soda and sports drink consumers would have on their ability change their behavior without any help from environmental changes. These changes could include increase availability of non-sweetened beverages, decrease in cost of these alternatives (especially in low income areas), or initiatives on the companies behalf to decrease the amount of sugar in their beverages to facilitate the desired behavior change.
New Intervention: Use Positive Framing and Social Marketing to Reduce Psychological Reactance and Labeling Effects
Due to the flawed design of New York’s “Are you pouring on the pounds?” campaign, alterations can be made to increase the effectiveness of the ad and achieve the desired behavior change of reduce the consumption of sugar sweetened beverages. By addressing the issues of labeling, psychological reactance and social marketing techniques, the ad will produce a more favorable reaction from the public and will be more effective at achieving their goal of reducing the consumption of sugar-sweetened beverages.
Proper use of positive framing techniques and language are useful in decreasing the possibility of negative reactions to health messages and societal stigmas that may be contained within health messages; these alterations will lead to more effective health warnings. A study on the effects of warning and information labels on consumption of full fat reduced fat and no fat products found a similar distinction between reactance and behavior, “people don’t mind being informed about the potentially harmful risk associated with products [but] they don’t like to receive unwanted advice about how they should behave. Warning people about unhealthy products may only make them want the products more” (14). Jensen and Collins explain that offensive, disgusting or fearful advertisements may produce an overreaction of negative reactance in the public due to a phenomenon call “Third Party effect”. This effect is described as the likelihood of people to have an exaggerated complaint or a negative reaction to an advertisement because they believe that other people will be offended (21). This reaction may be due to disgusting images or endorsement of stereotypes in the population. In this case, the disgusting images and stigmatizing negative language presented in both the poster and video presentations of this advertisement, the public may exaggerate their negative reaction because they believe others will be more offended than they are. By removing the stigmatizing language and gruesome images, stigmas can be avoided and messages can be well received.
A positively framed message emphasizes a brands’ advantage or the potential gains to consumers resulting from the purchase or use of the brand or ‘product’, positively framed messages tend to elicit more desirable responses than negatively framed messages (29). Positive messages engage viewers to process the information. (23). Research shows that those who actively process information in an advertisement tend to respond more favorably because active processing involves an acknowledgement of goals or a conscious awareness of the issue or topic (4). Although most social media contains both negative and positive forces within their messages, affecting both simultaneously, increasing positive force and decreasing negative force, should sharply increase compliance, if the if the negative is reduced so much that the positive outweighs it, there is an even greater likelihood the individual will comply with the recommendation (30) This is essential with NY’s ad because the health department is asking the public to reduce or eliminate the consumption of a product that has clearly gained more popularity over the years. “Harvard school of public health recommends that public service messages designed to deter certain behaviors should avoid message executions that evoke negative emotions and rely instead on the upbeat tactics used by advertisers of consumer products (31).
The helpful or interpersonally appealing qualities of the communication will work in the opposite direction of negative reactance. If the freedom (or importance of freedom) were at a low level, the credible and attractive features of the communication would very likely create a net of positive influence (9). Due to the fact that freedom to choose is so crucial in the production of adverse reactance and “Highly explicit, directive language is often viewed as controlling and may contribute to a sense of helpless dependence rather than confident independence” (5), using language which covertly persuasive and ultimately reminds the viewer of their ability to make decisions (5) is an important aspect in decreasing the occurrence of psychological reactance due to overtly persuasive, directive language in many health campaigns. Using language that is concrete tends to be viewed as having expertise and trustworthiness. The new message should also contain “Low-controlling autonomy supportive language appears to be principally associated with positive affective outcomes related to decreased reactance, such as perceptions of fairness, decreased anger, and more favorable judgments of source sociability. (5). An example of a possible headline that fits these new criteria might resemble, “Wanna cut calories? Decreasing soda consumption can save up to 300 calories a day! The choice is yours.”
Another to achieve a type of processing that will engage the attention of our target audience; social marketers have the most success when they identify a solution to a problem the audience is experiencing and offer a solution or a benefit they will value. Appealing to the audience is key and many health professionals struggle with marketing their recommendations in this way (6). One way to make the message more appealing is to increase the attractiveness of the communicator, liking the person delivering the message increases the attention of the audience. Perhaps having a fitness celebrity state the message on the ad, the audience may be more open to receive the message. The elements needed to accomplish this are in place, no one wants to be labeled as ‘fat’ or deal with the co-morbidities of being overweight or obese, and in terms of getting in shape, people tend to want and most results with the least amount of effort. If the lessons learned about the effects of psychological reactance, the elements of positive framing that encourage active processing and avoid stigmatization of groups are applied to New York’s advertisement, the ad will decrease the boomerang effect and overall negative view of the ad which may interfere with the ads effectiveness. Due to the fact that people will react against attempts to control their behavior and eliminate their freedom of choice,”(9) the ad would frame the information to leave the power to choose with the viewer. In addition, appropriate research needs to be done to identify what New Yorkers want, think, feel and do regarding the target behavior (4); drinking sugar-sweetened beverages.
Many argue that too much time is spent attempting to persuade people to change their behaviors and not enough time on developing affordable, accessible products that allow people to solve their problems and realize the aspirations that matter most in their lives and to modify the environment to make it easier and more enticing to adopt the healthy behavior (6). Assuming that weight control is new York is concerned with, and information regarding weight management is what will entice the public, and the health departments wants to attempt change by focusing on decreasing soda consumption, they might want to create regulations or legislation that supports this initiative for example removing soda in school, or making the alternative options (so fat milk, water, and seltzer) more affordable, or easily accessible especially in areas with high soda consumption and low socio-economic status, such as some areas on Brooklyn (3). The health department might want to consider legislative action or at least collaboration with store owners to help with the initiative to help support the effort, perhaps reorganizing their beverage layout to display the preferred beverages and move sweetened beverages to the back or have promotional pricing. Perhaps using the effects of product placement to draw attention to non-sweetened beverages may be another avenue to pursue; although in lower income areas, price will be a more motivating factor to purchase these items.
The incorporation of these techniques will greatly increase the reaction to the New York City Department of Health and Mental Hygiene’s attempt to decrease soda consumption. Their current campaign made use of three techniques that increase the likelihood of adverse reactions rather than behavior change, namely the use of labeling soda/sugar sweetened beverage drinkers as fat, using images and language that produced high reactance, increasing the likelihood of boomerang effects, and finally the improper use of advertising techniques leads to the decrease acceptance for this campaign. By altering the way the information in the ad is presented, the reaction to this ad can be quite positive.
Conclusion
Decreasing consumption of sugar sweetened beverages to remove a large proportion of empty calories from ones diet is beneficial recommendation for the New York City Department Of Health and Mental Hygiene to deliver to its’ residents; however, the advertisements used to send this message may do more harm than good. The negative language and disgusting visuals not only set the stage for labeling and stigmatization but the improper use of social marketing techniques produce such high psychological reactance that the message can actually produce ‘Boomerang effects’. A more successful means of delivering this health message would be to utilize key marketing objectives, which reframe the campaign to appeal to the public core values and motivate the viewer to make healthier beverage choices. The language of the ad should be direct, to maintain credibility of the source, positive, to decrease negative reactance and avoid stigmas and stereotyping, and indirectly persuasive, allowing the viewer to still exercise their own decision-making capabilities. Incorporating these principles into the advertisement will increase the probability of acceptance and behavior change among New Yorkers.
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