A World With(out) Polio: A Critique of the Polio Eradication Campaign in Nigeria – Alix M. Wilson

For much of the western world the crippling effects of polio remain only as a mere memory from the lives of our ancestors. We categorize poliomyelitis as a disease of the past, yet polio remains a serious concern in other areas of the world. The virus remains active in four endemic countries including India, Afghanistan, Pakistan, and Nigeria (3). As of 2010 these countries accounted for 85% of all new polio cases worldwide (7). Although significant progress has been made, there is still much work to be done in areas where poliovirus still infects populations. As the World Health Assembly turned their attention and energy to eradicating polio, they were committed to global eradication by the year 2000 (6). Today, exactly one decade later polio has not disappeared from the global agenda. However, more than any other endemic area, Nigeria’s eradication movement has demonstrated the dangerous effects and setbacks that can come of a failed campaign. The lessons learned in Nigeria are of grave importance for future efforts towards polio eradication. Without careful examination and remediation of Nigeria’s campaign, a world without polio will remain out of reach.

Although the effects of poliomyelitis had been known throughout the 20th century, the virus gained worldwide attention in 1955 with the announcement of the first vaccine against polio by Dr. Jonas Salk (6). During the early 1900’s polio was being referred to as the most serious and most frightening public health problem of the postwar era. (14). By 1952, polio was responsible for killing more children than any other disease at the time worldwide (15). The symptoms of the disease are often not fatal, however polio is an acute viral disease that is highly contagious and frequently passed through the fecal-oral route (7). Most commonly, people acquire the infection from ingesting contaminated food or water. Infection with poliovirus may result in different outcomes. In most cases, polio infections are asymptomatic. However, in 1% of cases, the virus enters the central nervous system and selectively destroys motor neurons resulting in paralysis, permanent loss of limb function, and often death (7). Furthermore, once paralytic damage has occurred there is no treatment to reverse the polio paralysis (6). This muscle paralysis can sometimes result in permanent skeletal deformities, joint tightness, clubfoot, and severe movement disability (14).

As Salk’s announcement to the world brought hope and optimism into the picture of despair created by polio, nations were in dire need of vaccination campaigns. With polio spreading among populations in developing nations where sanitation was lacking, the devastation was even more evident. Finally, in 1988 as the World Health Organization (WHO) launched the global eradication program, Nigeria became one of many countries flooded with health care workers bringing Salk’s vaccine to stop the spread of a disease that had claimed thousand of innocent lives (9). The eradication endeavor around most of the world was achieved, but by the year 2000 Nigeria remained one of four countries still endemic with poliovirus. With success having been achieved in a multitude of different cultures and among all sects of governments around the world one has to ask – why did the campaign falter in Nigeria?

The failure of the public health intervention to eradicate polio in Nigeria can be attributed to three distinct factors. First and most importantly, health workers were not prepared on how to effectively address resistance to vaccination stemming from a lack of perceived susceptibility and unfounded beliefs surrounding the treatment. Second, the campaign efforts failed to fully take into account the viewpoints and core values of Nigerian citizens. Lastly, in conjunction with sociopolitical context, the approach to vaccinate children was too reliant on a top down, vertical strategy with little to no community involvement. Each of these setbacks presented unique challenges and extended the initial deadline past its goal set for the year 2000.

Propelled by the incredible success of smallpox eradication, the case for polio eradication seemed the next feasible step in a global effort to limit infectious disease. The donor world gave billions of dollars to scale up polio eradication efforts, just as it had done previously for smallpox (20). As health workers were sent to Nigeria to scale up vaccination efforts as a part of the global polio eradication campaign, they had one goal in mind: to eradicate polio through vaccination by the year 2000. However they were quickly met with increasing resistance that they were not prepared to resolve. As vaccination campaigns spread throughout Nigeria there was an increasing resistance encountered to accepting the vaccination (21). Without adequate knowledge or any perceived susceptibility, parents were unwilling to allow health care workers to administer the vaccine to their children. As the Health Belief Model indicates, people who have a low perceived susceptibility to a disease or fail to understand the consequences of being infected with a particular disease will be highly unlikely to adopt any behavior targeted to prevent infection (5). Unlike smallpox, the majority of those infected with poliovirus were unaware they had the infection. In fact, polio only results in paralysis in 1 in every 200 of the people who are infected (8). Consequently, if one person is discovered to have polio after displaying signs of paralysis, they have likely already passed along the infection to others who can remain asymptomatic (10). These victims are the most dangerous in the realm of public health. They pass along the disease unknowingly and simultaneously increase the notion of low perceived severity.

The detrimental impacts of perceived susceptibility and perceived severity as defined by the Health Belief Model were extremely underestimated in the vaccine campaigns designed to eradicate polio in Nigeria. In a study conducted in Gombe State, Nigeria, a total of 216 parents out of 422 of those interviewed believed that their children were not susceptible to poliovirus (15). In other words, less than half of these parents had any degree of perceived susceptibility. Moreover, 55.7% of these respondents did not know the route of transmission for poliomyelitis (15). Furthermore, misconceptions about the vaccine’s safety were rampant throughout much of Nigeria (15). In Between 2003 and 2004, the oral polio vaccine was withdrawn from use in the State of Kano due to strong beliefs that the polio vaccine was more harmful than beneficial (16). These barriers are defined in the Health Belief Model as perceived benefits of taking action (5). If parents do not believe there are any perceived benefits to taking action, or worse yet, those results will be harmful, they will be highly unlikely to take up the behavior (5). Without proper evaluation of the low levels of perceived susceptibility, severity, and or benefits to taking action that existed in Nigeria, health care workers were fighting a loosing battle from the very beginning of the campaign. Regardless of the access to and availability of the vaccine for children in this area, immunization days were unsuccessful in vaccinating a large percentage of children (11). Research that led to the development of the Health Belief Model in the 1950’s was based around findings similar to these. At the time free tuberculosis screenings were being offered, but despite easy access turnout was extremely low. Investigation by Hochbaum and his collegues led them to the conclusion that people are more likely to engage in a preventive behavior if they thought they were at risk and believed they would benefit from that behavior (5). These findings are congruent with those in Nigeria. Regardless of whether the other components of the Health Belief Model were addressed, without any perceived susceptibility or need to change their behaviors, parents in Nigeria were not motivated to adopt the behavior being promoted by the vaccine campaigns. Although the Health Belief Model may not be the entire story behind the breakdown of the eradication campaign, it certainly points out the failure in addressing the populations’ attitudes and beliefs regarding vaccination.

However, not all parents were unaware of the serious consequences polio infection or of the intended benefits vaccination could bring to their child and thousands of others. In fact, despite those who were not motivated to participate and remained passive to the campaign, there was a large outcry against the vaccine campaign as well (11). As the polio vaccine eradication went into full swing in Nigeria, people began to question Westerner’s intentions. With a country still suffering from a multitude of preventable diseases, such as diphtheria, pertussis, typhoid fever, and hepatitis B, polio is just one of the many challenges remaining in the battle of childhood survival (8). Consequently, when free polio vaccines began pouring into the country, Nigerian citizens began to question the Westerner’s approach of focusing all their efforts on one problem. They were well aware of the ongoing threat of other treatable diseases that were killing even more children than polio. From their perspective, fighting the battle against polio was important, but was only a small piece to improving childhood survival rates (11). As a result, frustrations arose and Nigerians began to actively resist vaccination efforts (17).

As this active resistance increased throughout the country it became clear that the approach being taken by Westerner’s, although good intentioned, was faltering. In 2004, Nigeria’s head of primary health care, Dr. Muhammad Ali Pate expressed concerns that the gains made by polio eradication will never hold without a broader health-care system (8). He shared common beliefs held by many Nigerians that vertical attacks on single diseases are ineffective and ultimately ignore the larger problem of stopping infectious diseases. In public health promotion in developing nations, donors tend to ignore the wants and needs of the population they will be serving (8). The polio eradication campaign in Nigeria did exactly this, falling into the dangerous pattern of formulating public health interventions based around intuition rather than research. Too often in public health, practitioners base their campaigns or interventions on what they feel people should want (18). As marketing theory has demonstrated, public health practitioners can be much more effective in achieving their goals by first identifying what it is the people actually desire before designing their intervention (18). The key to establishing an effective campaign is creating a program that addresses the core values of the target population (18). The polio eradication campaign in Nigeria did not address the main concern of the audience it was trying to serve. Nigerians wanted a broader approach. They wanted to eradicated polio, but not at the expense of allowing other diseases to continue to ravage their population. The eradication campaign failed to address the core values of the audience they were serving. Nigerians shared the same concern of controlling the spread of polio, but what they really wanted was control and autonomy over where efforts were being focused. They watched donor money being poured entirely into the polio fight while their sons, daughters, and grandchildren died of a multitude of other diseases that were entirely preventable. As time went on and polio continued to be a problem, Nigerians became frustrated with the narrow approach underway and became resistant to, what they felt, was a loosing battle.

In addition to the failure of the polio campaign to address the core values and desires of those it was meant to serve, the campaign also lacked community involvement. As a result, Nigerians felt no sense of ownership to the campaign efforts or impacts and thus were not invested in the programs. As the World Health Organization (WHO) developed the implementation strategy for polio eradication efforts in Nigeria they stressed the inclusion of political, community, and religious leaders, but evidence demonstrates that none of these players were involved effectively (11). When WHO was ready to role out the eradication campaign, they met with the Minister of Health, but did not include political or religious leaders in gaining support for immunization programs (11). Consequently, the polio eradication campaign in Nigeria transformed into a top-down approach with little to no involvement of community leaders and influential citizens.

This lack of community involvement likely weekend the campaign efforts. Specific theories address the importance of community involvement and are applicable to public health approaches. As Rothman and Tropman stated in their theory of community organization developed in 1987, community change is most effectively accomplished through the involvement of a broad cross-section of members in the community (1). They expand upon this definition by stating that community change is most likely to occur through consensus building, cooperation, and a coordinated effort by the community to address its own concerns (1). Without a sense of involvement in the campaign efforts, Nigerians became subjects of the intervention rather than agents of change. They were simply being vaccinated to fulfill the eradication goal, rather than participating in making this goal a reality. Moreover, there was no involvement on the part of their influential superiors, both religious and community members, to incite motivation. Lastly, the intervention lacked a key component of community organization theory, which was empowerment. According to the theory, empowerment is defined as a process by which communities gain mastery over their lives by being enabled to effectively transform or change their environments (12). Essentially, individuals gain self-efficacy on the community level and these gained confidences and skills are essential to bring about behavior change on a large scale. However, the lack of empowerment in conjunction with few influential and respected leaders at the helm, Nigerians felt no sense of ownership to the cause. With a top-down approach in full scale, the polio eradication in Nigeria continued to suffer further setbacks.

As the campaign was continuing to face further challenges, it became clear that the original goal set for the year 2000 would have to be pushed back. Many people questioned how smallpox eradication could have been so quick and so effective, while polio was proving to be more challenging as each day of the campaign went on. Although smallpox had encountered challenges along the way, the vertical campaign approach along with compulsory vaccination ultimately proved to be successful when the last case of smallpox was reported in 1979 (20). However, the eradication of polio has proved to be more complicated. With increasing opposition and lack of motivation on the part of Nigerians to comply with polio vaccinations, it will be necessary for the campaign to adopt a new strategy. In order to overcome the variety of obstacles encountered in the Nigerian polio eradication campaign, the intervention approach must be altered. Namely, several health behavior models in combination with marketing theory must be understood and applied to meet the resistance being faced to create a solution, rather than a mandate for compulsory vaccination or a continuation of strict vertical strategies.

First, the campaign must address the issues of perceived susceptibility and severity. By increasing the awareness and knowledge about poliomyelitis, parents will understand the importance of getting their children vaccinated. Furthermore, they will appreciate the potential consequences of this infectious disease for their own child as well as other children. In order to accomplish this goal, the campaign workers should collaborate with community leaders to develop information cards. Information cards have been utilized successfully in childhood nutrition programs through South America, where a lack of knowledge about breastfeeding and complimentary feeding have left thousands of children malnourished (22). These cards contain pictures on the front side depicting the message being relayed, while the backside of the cards contain simple words, guidelines, or messages about the public health intervention. These cards can be carried by health workers and posted throughout the community. In the case for polio, the cards could display a picture of a child suffering from polio on one side with information and pictures on the back indicating how the disease is transmitted, what health effects it causes, and how vaccination prevents transmission and infection. These cards will serve to accomplish barriers identified by the Health Belief Model. Many parents do not know how crippling the effects of polio can be. The picture and listed health effects will serve to increase the parent’s perceived severity. Also, the information on the mode of transmission will influence parents’ perceived susceptibility as they learn how infectious poliovirus is among the population. Lastly, the utilization of pictures in combination with words to display messages about the health effects and transmission of polio makes these cards a quick and easily viewable device that transmits a powerful message. Moreover, even though Nigeria has a 72% literacy rate (13) and most citizens will be able to read the accompanying messages, those who are illiterate will not miss out on the message. As the cards a distributed by health care workers and spread throughout communities, the messages can transform the views concerning perceived susceptibility and severity and break down these harmful barriers to vaccination.

With this first step underway, the Nigerian community can begin to see the benefits of taking action. However, in order to motivate people to act, it will be necessary to address the needs and desires of community members. Many people in Nigeria feel that polio eradication efforts ignore the larger issues concerning health care and childhood diseases rampant in the country (8). In order to better quantify and qualify these concerns, campaign workers should be deployed to hold focus groups in collaboration with influential community members throughout Nigerian states. At these focus groups, citizens can have their voices heard about what issues they feel need to be addressed immediately, where they believe resources should be allocated, and in addition to polio, which diseases they feel are of most importance for donors to address. Once these focus groups have been conducted, community leaders and campaign workers can combine their findings for submission to the donor agencies. Given that polio is the mission of this eradication campaign, citizen feedback will serve to increase multiple vaccination efforts or other sanitation projects that will directly address the desires of the people as an extended portion of the eradication campaign. By recognizing the core values of the Nigerian people, mainly their desire to surmount the multitude of diseases currently affecting them, the campaign can redefine and repackage its goals towards these desires. As marketing theory predicts, if public health practitioners offer programs that the target population values and demands, they can more effectively face the challenges of inciting behavior change (18). Instead of working against the Nigerians to incite change, they will be able to work with them. If donor agencies can adopt this strategy, their implementation of polio eradication will be more well rounded and successful.

To bring the campaign full circle, another component for a successful strategy is to incorporate community members as well as influential political, and religious leaders. The polio eradication campaign is too focused on a top-down strategy that disregarded the importance of involvement and community leadership throughout Nigeria. It has become evident throughout the global campaign that wherever community involvement has been low, vaccination coverage has also remained low, directly resulting in the failure to eradicate polio (9). There is no question as to whether community involvement will be beneficial; the only question remaining is how to implement these strategies.

To incite and propagate community involvement health care workers should seek out influential leaders in the political and religious sectors. Health care workers should seek out many of these leaders in every state to ensure all parts of Nigeria are initiating community leadership and involvement. Moreover, once these relationships are established, responsibilities must be defined and shared between the health care worker and the community advocate. They should not simply serve as a voice, but also an agent of change. Research has indicated that active community leadership and community involvement in planning and implementing your own health care is vital to successful health projects (1). If Nigerians can be incorporated into the eradication campaign strategy, they will have the leverage to encourage their counterparts to do the same. In addition, it is generally accepted that people are more willing to follow the advice of those they feel a connection or similarity with (2). Furthermore, religious leaders can be utilized to dispel misconceptions surrounding the dangers of the polio vaccine that surfaced among religious groups in 2003. Again, those who were influenced by these misconceptions are more likely to listen to their own leaders who share common morals and values, than they are to Westerner’s attempts at dispelling these delusions (2). The involvement at the community level is expected to have drastic implications in inciting behavior change by encouraging Nigerians to take an active part in creating a polio-free world. With the increased awareness being created through cards and media to address perceived susceptibility, they will have the tools and a reason to join the cause. Finally, with attention paid to their own needs in the realm of global health initiatives, they will have a more genuine commitment to the cause.

The set backs that have been encountered in the Nigeria are not by any means entirely avoidable. However, with the proper planning and evaluation through known public health strategies such as the Health Belief Model, Marketing Theory, and Community Organization Theory, these set backs can be overcome in a systematic way. Today the world is a decade past its original goal set for polio eradication. Polio has dodged a 20-year effort to eliminate it along with the disbursement of $8.2 billion dollars supplementing the ongoing human effort worldwide (8). Cleary, a new approach is in order. It is expected that the major leaders in polio eradication including WHO, UNICEF, and the CDC will announce a reorganized plan and strategy to address the failures of campaigns like those in Nigeria this week (8). The world can only hope that these strategies address the roots of the problem, taking into consideration the beliefs and viewpoints of those on the ground and the involvement of community and religious leaders in creating new, effective strategies. If these strategies are implemented effectively the world may finally be free of polio once and for all.


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(5) Edberg, M. Social and Behavioral Theory in Public Health. Essentials of Health Behavior. Washington D.C. 2007.

(6) Global Polio Eradication Initiative. The History. WHO, CDC, UNICEF. http://www.polioeradication.org/history.asp.

(7) Global Polio Eradication Initiative. The Disease and the Virus. http://www.polioeradication.org/disease.asp.

(8) Guth R.A. “Gates Rethinks His War on Polio”. Wall Street Journal 23 April 2010.

(9) Lahariya C. Global Eradication of Polio: The Case for “Finishing the Job”. Bulletin of the World Health Organization 2007; 6:421-500.

(10) Miyamura T. Global polio eradication program: fundamental lessons for the control of infectious diseases. National Institute of Infectious Diseases 2009; 2:277-286.

(11) Mohamed A.J., Ndumbe P., Hall A., Tangcharoensathien V., Toole M., Wright P. Independent evaluation of major barriers to interrupting poliovirus transmission. Wild Poliovirus 2008 – 2009 Executive Summary 2009;

(12) Ndiaye S.M., Quick L., Sanda O., Niandou S. The value of community participation in disease surveillance: a case study from Niger. Health Promotion International 2003; 2:89-98.

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(22) Linkages Projects. Ghana. 1998-2004. http://www.linkagesproject.org/country/ghana.php

Drinking Life Away in New York City: A Critique of the Pouring on the Pounds Campaign

In the past 20 years the incidence of obesity has been continuously rising in the U.S. and most recently around the world (1). The prevalence of obesity is a serious public health concern because it is a major risk factor for cardiovascular disease, certain types of cancer, type 2 diabetes, and lifetime morbidity (2). According to the Centers for Disease Control and Prevention (CDC), in 2007-2008 around 33% of Americans were obese and nearly 68% were overweight, ranking the U.S. as the number one country in the world with the highest rate of obesity (1). If current trends continue, it is estimated that 75% of Americans will be overweight or obese by 2015 (3). Research has stated that the rising trend of obesity in the U.S. has been consequent to the suboptimal eating habits and sedentary lifestyles of Americans (2). This unfavorable lifestyle leads to the lack of energy balance, which is the precise cause of overweight and obesity (4). Consequently, obesity and overweight occur over time when you take in more energy or calories than you use.


To combat this trend, many intervention programs have been designed to encourage consumption of healthier foods along with heightened physical activity. In 2009, the New York City Department of Health and Mental Hygiene implemented the Pouring on the Pounds public communications campaign in order to highlight the health impact of sweetened drinks (5). The campaign was designed in lieu of the proposed, but highly debated, 18% “obesity tax” on sugary sodas and juice drinks (6). Instead, the Health Department decided to target drinking habits to combat obesity by designing a public awareness campaign. Sugary drink consumption was chosen as the area of focus for this campaign because research has shown that more than 2 million New Yorkers drink at least one sugar-sweetened beverage a day, adding as many as 250 empty calories to their diets, which puts the human body at increased risk for a multitude of diseases (5). The campaign urges people to drink lower-calorie alternatives or limit their portions.

The message of the campaign is disseminated through public ads in city subways, educational brochures, the campaign website and most recently through a viral Internet video. The main component of the ad is a poster of disgusting, unadulterated, gelatinous fat substituting for soda as it pours into a cup. The video, titled Man Drinking Fat, shows a man pouring fat out of a soda can and drinking it as it drips out of his mouth. It ends by exhorting the audience to choose healthier alternatives like water, seltzer or low-fat milk. The ads work to demonstrate that we are literally pouring on the pounds and drinking ourselves fat by consuming soda and other sugary beverages. According to the Health Department, the video was produced to playfully send out the message that sugar-sweetened beverages are fueling the obesity epidemic and disabling millions of New Yorkers (5). The goal of the campaign is to shift drinking habits even slightly by gruesomely depicting the health impact of sweetened drinks.

Although the campaign was recently launched, it has had successful exposure due to the mediums of communication used. Not only has the Health Department chosen to place their ads in highly trafficked city subways, but also set up and placed ads in social media networks such as youtube.com/drinkingfat and facebook.com/DrinkingFat. Together, these networks have had over half a million hits in the past few months and word-of-mouth exposure is becoming viral. However, aspects of the campaign are flawed and susceptible to scrutiny.


The Campaign Does Not Account for Behavior Influenced by Context
The goal of the Pouring on the Pounds campaign is to change human behavior by embedding nauseating images of the health impact of sugary drinks. The first assumption of the campaign is that behavior is planned and rational. It is assumed that by viewing the gruesome ads, people will be disgusted and decide to eliminate or reduce sugary drinks from their diet. This concept is partly correct. In a hot state, during exposure, people might discard their beverages or avoid drinking for a few hours (7). However, the objective of the campaign disregards the concept that human behavior is dynamic and that it is influenced by context (7). It is visceral drives, or instinctive unreasoning, that control people’s behavior (7,8). Visceral factors refers to a wide range of drive states, including hunger, thirst, and sexual desire. According to a research studying the effects of emotions on economics, visceral factors can alter desires rapidly because they are affected by changing internal bodily states and external stimuli (7). The emergence of a new situation generally alters the present course of action and alters behavior (7). For example, a person purchasing a drink at Starbucks will transition to an alternative hot state to accommodate their environmental context. Exposure to images and menu options at the store or restaurant will now influence their purchasing behavior. Their decision is based on situational awareness defined by the context of their environment. This concept further suggests that the environmental context has a greater impact on unfavorable eating habits. This could be demonstrated by the considerable gap in the prevalence of obesity found among neighborhoods or cities with differing socioeconomic levels.

East Harlem, a low-income minority community, has the highest rates of obesity in New York City (9). According to a report by the Health Department published in 2006, one third of East Harlem adults are overweight or obese (9). The demographic profile of the neighborhood consists of predominantly African-American and Hispanic residents. Over 38% of the population in the community is below the national poverty level, which is nearly twice as high as in Manhattan and NYC overall (9). Similar to other low socioeconomic communities, the built environment of the neighborhood is comprised of fast food restaurants, bodegas and affordable energy-dense food grocers (10). The area also has 18 schools with fast-food restaurants within one-tenth of a mile (10). This is not surprising since researchers in New Orleans recently discovered that fast-food restaurants are geographically associated with low income, and in particular African-American, neighborhoods (11). These neighborhoods average twice as many fast-food restaurants per capita as white neighborhoods, making fast food a more likely choice for their residents (11).

High rates of obesity in low-income neighborhoods demonstrate that a stronger correlation exists between eating habits and the neighborhood residential context (12). A recent report stated that studies have not been able to link a uniform change in perceived control of health, but instead suggest that environmental and social factors can affect one’s sense of control over one’s own health (12). Therefore, public service announcements that seek to modify human behavior will only work if risk factors are modified or reduced within the context of the built environment.


The Perceived Cost Undermines the Perceived Benefit
Motivating people to modify behavior remains a critical and unmet challenge in the U.S.(13). This is especially true with modifying eating habits and physical activity. Research suggests that there are four motivational factors that are modifiable and may be influenced by education, experience and coaching: 1) Perceived chances of success, 2) Perceived benefit of the goal, 3) Perceived cost, and 4) Inclination to keep old habit (13). The most pertinent factors for this campaign are perceived costs and perceived benefits of giving up sugary beverages. This is so because people ultimately decide whether to adopt or reject behavior based on the balance of the appraisal of these factors.

Applicable to the Pouring on the Pounds campaign, the perceived benefit of modifying behavior is losing 10 pounds a year by not drinking one can of soda a day. Although it is not mentioned in the ads, it is implied that this change will ultimately reduce the risk of obesity as well. Conversely, the perceived cost of the campaign is eliminating or reducing sugary drinks from their diets. Instead of deciding to drink sugary drinks, the ad encourages consumer to drink water, seltzer or low-fat milk. The perceived cost in this equation, however, has a high significance in the U.S. due to the embedded traditions of sugary, not healthy drink, consumption (14). Events such as happy hours, bar-b-ques, sports outings, etc., have accustomed Americans to a drinking habit that often promotes sugary drinks. These habits have given significant social value to the context around sugary drink consumption. Although the campaign aims at changing life-long habits, if fails to connect healthy habits to the rhythm of life. Stating alternative drinks as bland and boring options does not strengthen the proposal to change drinking habits. Expecting people to change lifelong sugary beverage consumption needs to be supported by a strong promise to the consumer (15). Instead, stating that only a 10 pound weight gain could be prevented weakens the perceived benefit of giving up sugary beverages and associated social norms. To a portion of the population, especially those who are overweight, a 10 pound difference might not be worth the cost of giving up their drink of choice. To these people, the perceived chance of successfully modifying habits involves more than just giving up sugary drinks. This is especially true when linking behavioral risk factors, aside from social norms, to drinking habits. Instead, perceived capability and confidence has a stronger influence on initiation and self-efficacy (16). To this effect, the campaign fails to frame the issue in a way that gives strength to a change in social norms and ultimately a rippling effect on individual behavior. The intention to modify behavior is focal and crucial, yet the content of the campaign dominates the message instead of the outcome. Moreover, the campaign also uses the unadjusted approach that one sugary beverage is consumed every day. Therefore, those who consume less sugary beverages will consider the ad irrelevant instead of incorporating the overall message.

To overcome the common obstacles of modifying behavior, framing the issue in a way that gives people control and a broad sense of choices must be used (17). If the goal of the intervention is to get a high level of reactance, a program that implies a change in social norms will be more influential than targeting individual behavior (18).


The Campaign Reinforces Negative Social Stigma Towards Unhealthy Weight
Obesity has had in increasing trend for the past two decades. Yet as Americans are becoming more overweight, the standard for attractiveness remains thin and fit while overweight people are widely stereotyped as lazy, unattractive, and lacking self-discipline (19). The constant exposure to the idea of beauty as slim and proportioned has created a negative and stigmatized perception towards the overweight and obese. Not only has this created a pool of isolation, but numerous studies have examined a variety of social stressors, including discrimination, stigma and low socioeconomic status, all of which have been linked to poor health outcomes (20).

Weight-based stigmatization is defined as “negative weight-related attitudes and beliefs that are manifested through stereotypes, bias, rejection, and prejudice towards people because they are overweight or obese” (20). Acknowledging this perception, it is assumed that most obese people would like to become more fit. However, for so many leading a healthy lifestyle is a very difficult undertaking. They may give much energy towards trying to change their personal behaviors to acquire attractiveness, but their attempts continually fail.

The message of the Pouring on the Pounds Campaign reinforces this social stigma by producing a disgusting reaction of fat, which reflects a negative view of unhealthy weight. This is opposed to a good or proactive view of healthy weight. The message only serves to further internalize negative association of unhealthy eating habits. Studies that have examined the relationship between weight-based stigmatization and psychosocial functioning, state that in addition to affecting emotional well-being and social functioning in obese people, stigmatization can also negatively impact health behaviors (20). Stigmatization or the perceived threat, as the campaign message indirectly implies, has been associated with increased weight concerns, dieting, binge eating and unhealthy weight control and bulimic behaviors (21-23). This suggests that the objective of the message could be counterproductive and ineffective to prevalent cases of obesity.


Addressing and Implementing an Obesity Intervention in New York City: A Cultural Approach
The demographic profile of New York City is unique in its level of diversity. According to the U.S. Census Bureau, in 2006 over 3 million or 36.7% of the population in New York City was foreign-born (24). A recent report by the Department of City Planning states that the Newest New Yorkers, or immigrants, tend to live in enclaves of highly dense low-income neighborhoods (25). Intertwined with socio-economic disadvantage, obesity is also largely prevalent in these neighborhoods of the city (11). These neighborhoods are mostly comprised of minority or immigrant families who have assimilated to some degree to U.S. eating habits. This is evident by contrast of the Latino Paradox which refers to the epidemiological finding that Latinos in the U.S. tend to paradoxically have substantially better health than the average population in spite of what their aggregate socio-economic indicators would predict (26). Instead, the high prevalence of obesity, especially among Black and Hispanic children, supports the concept that the health status of immigrants deteriorates after acculturation to U.S. norms (26). Although obesity is widespread, a behavior modifying intervention should be targeted towards those at higher risk. Hence, due to the demographic profile of those at risk in NYC, changing the current campaign material to a culturally appropriate awareness campaign is proposed.

In order to combat obesity, we need to recover the traditional values of immigrant people. Similar to the Pouring on the Pounds campaign, the proposed campaign This is my Neighborhood, This is my Food aims to create awareness through community mediums of eating habits among immigrant families. The proposed campaign aims to emphasize traditional customs for maintenance of protective behaviors. The program is based on the concept that prevention begins in the home and embedded as tradition to future generations. Three major components will be the focal point of the campaign:
(1) Create awareness of the built environment by informing the community about their vulnerability as target consumers of fast and energy-dense processed foods,
(2) Empower perceived benefits by encouraging traditional eating habits, and
(3) Focusing on a proactive view of healthy weight.

These methods will serve as motivators to empower the community to integrate traditional customs in food consumption and preparation.


The components of the campaign will be disseminated through prominent mediums of communication in the community. Similar to the Pouring on the Pounds campaign, the material will be posted in city subways, near bus stops and near supermarkets in low-income communities around the city. Language specific material will be designed and posted in corresponding neighborhoods. However, knowing and adjusting to the most effective mediums of communication for immigrant families will be a major component of the campaign.


Create Awareness of Behavior Induced by the Built Environment
Although obesity can have many causes, most studies agree that environmental
influences are the primary factor in the current epidemic(11). The proposed campaign is based on the fact that modifying urban development is much more challenging that modifying human behavior (27). Therefore, the campaign serves to inform residents of their risk factors and susceptibility to fast food consumption. This is based on the idea that disseminating awareness of the environmental context transfers empowerment to the communities’ purchasing power of healthier foods. In low-income communities, the built environment is usually comprised of fast food restaurants, small shop bodegas and energy-dense foods (11). Unapparent to many local residents, this urban planning makes them highly susceptible to purchasing high-fat foods instead of healthy option. Therefore, informing the community about their controlled behavior by the built environment will hopefully produce a rebellion against this force. Consequently, a plan of action will be implied in the campaign ads. Encouragement to revert to traditional methods of food consumption and preparation will lead to an overt action of healthier eating habits. This plan of action however, must imply that unfavorable health outcomes were not as prevalent when practicing traditional eating habits. Therefore, proposing an awareness campaign that implies power, freedom and the perceived benefit of reverting back to traditional protective customs will be hopefully overcome the risk factors induced by the built environment.


Empowering Perceived Benefits of Traditional Values
In contrast to the traditional lifestyle in households, immigrants have been increasingly adapting to U.S. eating habits and forgoing the rice, vegetables, and fresh fruit drinks their grandparents ate and drank (26). Dietary standards in a traditional immigrant household consist mostly of home-made food with locally grown and purchased produce. Most recently, however, assimilation to U.S. eating habits has led people to flock to U.S.-style fast food and calorie-laden dishes once reserved for special occasions. Adaptation of food tailored for the mainstream American market usually is also very different than food typically served in other countries as well. This leads to the production of convenient, frozen, packaged foods and soft drinks that are widely available in local markets. To combat this trend, the campaign will serve to remind the target population that the unfavorable health outcome has occurred because of the adaptation to U.S. eating habits further induced by the built environment.

Contrary to the Pouring on the Pounds, the perceived costs of the proposed campaign are undermined because it does not discourage habits embedded in lifelong traditions. Instead, it incorporates them back into diets. By discreetly informing women that traditional values in eating habits have changed and their children’s health is at risk, women will realize that they have the power to change the outcome. This concept of the campaign strengthens perceived benefits by promoting healthy habits through tradition sustainability. It aims at changing culturally adaptive social norms, thereby allowing less perceived threat of freedom. Ultimately, the content in the material will be framed in a way that gives people control of their purchasing and eating behavior.


Focusing on a Proactive View of Healthy Weight
The focus of the This is My Neighborhood, This is My Food campaign is to modify the perception of social norms in eating habits. This is done by pointing out and targeting the risk factors, such as the context of the built environment and assimilation, of unhealthy eating habits. The campaign avoids placing blame on individuals for their eating habits, but instead implies power and freedom of taking charge of their communities and eating habits. To some extent the campaign shifts the problem from individual responsibility to corporate responsibility. In a way, the campaign skips eating habits and links obesity to the risk factors. Similar to the concept of the causation of lung cancer, the blame should be placed on tobacco manufacturers instead of smoking (28).

Transferring the association of obesity to external factors eliminates the threat of stigmatization on individuals. Instead the campaign will induce a comparison between traditional and current norms and the change in the prevalence of obesity. To this end, disseminating risk factors, encouraging modified behavior that provides empowerment and promoting proactive methods of healthy weight will prove more effective in reducing and preventing obesity in New York City communities.


References
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(6) Chan S. New York Times. New Salvo in City’s War on Sugary Drinks. August 31, 2009. http://cityroom.blogs.nytimes.com/2009/08/31/new-salvo-in-citys-war-on-sugary-drinks/?hp. Accessed 4/19/10.
(7) Loewenstein G. Emotions in Economic Theory and Economic Behavior. Preferences, Behavior and Welfare. May 2000;90(2):426-432.
(8) Loewenstein G. Out of control: Visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996;65(3):272-296.
(9) New York City Department of Health and Mental Hygiene. Community Health Profile: East Harlem. 2006.
(10) Dwyer JC. Hunger and obesity in East Harlem: Environmental Influences on Urban Food Access. 2005.
(11) Block J, Scribner R, DeSalvo K. Fast food, race/ethnicity, and income: A geographic analysis. American Journal of Preventive Medicine. 2004;27(3): 211-217.
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(13) Phillip EM. Schneider JC, Mercer GR. Motivating elders to initiate and maintain exercise. Arch Phys Med Rehabil. 2004;85(3):S52-7.
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(21) Hayden-Wade HA, Stein RI, Ghaderi A, Saelens BE, Zabinski MF, Wilfley DE. Prevalence, characteristics, and correlates of teasing experiences among obese vs. non-obese peers. Obesity Research. 2005;13:1381–1392.
(22) Thompson JK, Shroff H, Herbozo S, Cafri G, Rodriguez J, Rodriguez M. (2007). Relations among multiple peer influences, body dissatisfaction, eating disturbance, and self-esteem: A comparison of average weight, at risk of obese,
and obese adolescent girls. Journal of Pediatric Psychology. 2007;32:24– 29.
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(25) New York City Department of City Planning. The Newest New Yorkers. 2000.
(26) Abraído-Lanza AF. Chao MT. Flórez KR. Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox. Social Science and Medicine. September 2005;61(6):1243-1255.
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(28) Boos J. Cigarette Smoking-Who is to Blame? University of Maryland. 2009.

Social Behavioral Theory and Marketing Fundamentals Missing from GE’s healthymagination Campaign – Cristina Cruz

This paper will analyze the fundamental components of a public health campaign that are missing within GE’s healthymagination initiative, specifically a tailored message, target audience and relatable messenger. Through an analysis of socio-behavioral theories utilized to formulate public health initiatives and referencing studies on successful public health interventions, this paper will pinpoint where GE went wrong. By highlighting the benefits of a social ecological approach and market research as exemplified in the SISTA and truth campaign, this paper will show how these three fundamentals can improve GE’s health initiative.
Healthymagination’s Mission and Implementation

General Electric’s (GE’s) recent, web-based public health initiative, healthymagination, was released in conjunction with the 2010 Winter Olympics in Vancouver (1). In the initiative’s mission statement, GE hopes to help people “become healthier through the sharing of imaginative ideas and proven solutions” (1). This involves making health information more comprehensive, accessible and approachable for site visitors. Healthymagination’s site is composed of multiple projects. The “Better Health Study,” conducted with the Cleveland Clinic and Oschner Health System, reveals the way people perceive their health and how they relate to their doctors. The “Better Healthy Conversations” project, formed in partnership with WebMD, allows patients to prepare a customized list of questions for their next doctor visit. The “Howcast” page is composed of “Healthy-How-to” informational youtube videos geared toward adolescents and college-aged students, presenting pseudo-health information guised in a comical skit. The site also acts as a forum for health discussion by posting the latest in health news through the “Sharing Healthy Ideas” portion of the site. Visualizing Data uses colorful graphs and interactive charts to take complicated health statistics and make them more comprehensive for the general public.
A Lack of Theoretical Application: No Target Audience, No Message

When browsing through the site, it becomes evident that GE has some of the best marketing and communications experts designing and facilitating the site. With a closer look, one can see that healthymagination is a public health campaign that focuses more on presentation than substance. Fundamental elements of social behavioral theory and marketing theory are absent in the initiative’s execution. The root flaw is the lack of a defined audience. With no audience, the minds behind healthymagination cannot tailor their message to their audience’s “core values” (5). To properly “frame” the message of the desired behavior and make the initiative successful, campaigners must appeal to core values in the community (5). These values can include rebellion against authority (an ideal often appealed to in campaigns designed for adolescents (3)) or “fairness” and “justice” (5).

Without a properly framed message, healthymagination isn’t showing why having access to better health is important. This framed message will not only “fulfill important core values,” but it will also show how “maintaining the [targeted] behavior is actually conflicting with these values” (11). Thus, GE isn’t showing that there’s any consequence to not being healthy. Without the proper “packaging and positioning [of] the product-” health- there is nothing special about the information GE provides. Despite its high-quality graphics and videos, the healthymagination site does not effectively promote healthy behavior purely by providing health information.


Health Education: GE’s Implementation of the Health Belief Model
In the healthymagination mission statement, GE claims that “almost everyone wants to make healthier choices, but they don’t know how.” (1)
GE’s belief that better knowledge can lead to better health behaviors is rooted in the Health Belief Model (HBM). This model assumes that a person will change their health behaviors once he/she realizes that he/she is susceptible to a severe disease after weighing the pros and cons of changing his/her health behavior with a new health behavior. Once this person decides the best course of action, he/she will then adopt a new, better health behavior into his/her lifestyle (2).

The first problem in utilizing this model as the foundation for the healthymagination initiative is assuming that people always decisions in a systematic manner. One critique of the HBM is that it “assumes an internal, rational process” that should lead to one conclusion and that all persons have “equal access to, and an equivalent level of, information from which to make the rational calculation” (2). Therefore, the minds behind this project presented health facts and statistics through several forms of multi-media to supplement these rational thought processes. However, much of this information is referenced from other websites in a feedback, user-based platform. Essentially, this is common health information people could easily access elsewhere. In a study on the effects of national anti-drug campaigns, researchers found that the “My Anti-Drug” campaign was ineffective because adolescents had been saturated with information from previous advertisements that repeatedly alerted them to the dangers of smoking (3). In this case, more information did not lead to target behavior deterrence because the campaign’s “implicit message” was not novel and “incremental exposure was small.” Healthymagination’s delivery has a similar issue in that it is not presenting a unique message about health and through so much information, there is little direct impact.

The issue with using the Health Belief Model as the basis for this campaign is that the HBM ignores the effects of social and environmental circumstances on a person’s decisions and assumes that everyone has equal access to the same, pertinent information (2). GE’s concerted efforts in providing instantaneous information through videos, blogs, iPhone applications and online news articles show that they assume all people viewing this information will understand these statistics through multi-media. However, this assumption neglects a very critical population. The nearly 56 million people on Medicaid not only have limited funds for health care, but they also “face serious communication barriers related to limited literacy, language, culture and disability” (10). GE’s utilization of the HBM and presentation does not really take into account the low-income groups who need more tailored information to learn how to make healthy decisions in their daily lives.


Healthymagination’s Non-existent Messenger
The premise of healthymagination’s “Sharing Healthy Ideas” project is “when one person inspires a healthy idea, good health catches on…Let’s make Healthy decisions together” (1).

The “Sharing Healthy Ideas” project is a forum of continuously updated health topics prevalent in the media, healthcare industry and among medical specialists. Popular topics include autism, Alzheimer’s, nutrition, physical fitness and cancer risks. Users are provided multiple social networking sites to peruse these topics. Some are news media outlets, such as the New York Times. Others are trendier, facilitated through users’ contributions, such as iVillage. And, naturally, the minds behind healthymagination maintain their own blog.

The issue with this presentation is that there is no face to the voice providing this information. Studies have shown that audiences respond better to information from someone who is similar to themselves (4). This hearkens to the idea of Albert Bandura’s Social Learning Theory, whereby “individuals observe other people’s actions and. . . adopt those patters of action as personal modes of response to problems, conditions, or events in their own lives” (12). Having a person similar to the audience deliver a message about health is more compelling because that messenger lives by similar norms that exist in the audience’s community. This is how socialization occurs, by learning from others in the community (12). These similarities could be exhibited through a person’s race or ethnicity, level of education, housing situation and family life or simply similar tastes.

In a study on compliance, researchers found that “similarity increases the positive force toward compliance by increasing liking” and it “also increases the communicator’s credibility” (4). Healthymagination’s advisory board is comprised of high-profile politicians and other leaders within the medical industry. They compose a demographic that is not highly affected by the nation’s most pressing health issues. These are the consistent faces of the initiative that don’t appear to have much in common with the female African-American population that suffers from high HIV infection rates (8) or the adolescents that rebel through smoking (13). Utilizing similar messengers is particularly important when targeting adolescent populations who often feel threatened by authoritative figures who are trying to tell them what to do (13). When the truth campaign used young actors to promote their message, they were able to deliver a message that effectively reduced youth smoking by appealing to adolescents’ core value of rebellion with a tone that was not authoritative and helped them see how the smoking industry was controlling their lives through an addiction to smoking (13).

The absence of a relatable messenger is best exemplified by the “Visualizing Data” portion of the site. This project is solely comprised of graphics that condense statistical data into a more colorful, engaging chart. Some issues discussed include: stress at the workplace, the cost of medical treatment for different age groups, and the main causes of death in the nation per ethnic group. The “Causes of Death info-graphic” is summed up as “a reminder to make choices that will keep you healthy” (1). The nation’s various ethnicities and races are boiled down to percentages in relation to age and health problems. According to the social learning theory, these charts are not utilizing a “model” with whom site visitors can identify and learn “functional” behaviors, that “will bring about some desired result if [they are] imitated” (12).

The secondary problem with not using a person to relay this information is that GE assumes anyone can interpret these graphs. A study that addressed patients with limited health literacy (LHL) noted that clinicians often “overwhelm the patient with too much information, using jargon and technical terminology, relying on words alone, and failing to assess patient understanding” (9.) These graphs are taking a similar approach to relaying health information: facts and figures, but little verification of comprehension. This is problematic when “approximately half of the U.S. adult population has LHL” (9). Presenting data in a more interactive manner would allow patients to better absorb the information, particularly those with LHL who “often rely solely on verbal communication” (9).

A Reconstruction of Healthymagination using the Social Ecological Model
A New Approach: Creating Multiple Messages for the Nation’s Audience
By lacking a message, GE is lacking an audience to be receptive to its better health goal. One of the first rules of marketing for public health involves identifying the audience’s core values (5). With these core values, one can then develop a campaign that delivers a compelling message about health that coincides with these values. Healthymagination appears to have identified better access to health information as its audience’s core values. Since the site itself has merit in its design and use of graphics, GE could build upon the healthymagination mission by showing site visitors what current health issues look like by focusing on different topics through a variety of communities in the nation. Using real stories to show a health intervention applied to a community would create a “model” for the visitor to relate to and, subsequently, create an audience by profiling different demographics with whom visitors can relate. Ultimately, by focusing on specific health issues in certain communities, GE’s healthymagination campaigners can create framed messages that will apply to those populations, giving their health information more pertinence in the site visitors’ daily lives.

Using a Broader Approach: The Social Ecological Model
The first thing that could be done to make Healthymagination a more effective public health intervention would be to break away from the simplistic approach of the HBM and create an intervention for the nation’s health from a holistic approach. Implementing change that will stay has to occur on all levels and not through a program that is “oriented solely toward modifying individuals’ behavior” (6.) This means turning away from the individualistic approach touted by the Health Belief Model to put more emphasis on the environmental, social and cultural circumstances that influence a person’s health behaviors. Thus, healthymagination should adopt the Social Ecological Model, which places an emphasis on “creating an environment conducive to change...to facilitate adoption of healthy behaviors.” (6) Providing information to separate individuals does not create the kind of change within the community to see that those health behaviors last.

As more public health campaigns have turned to adopting a marketing approach, multiple studies have shown that targeting a health issue from a group-level has been most effective (8). Healthymagination can use a group-level approach with the social ecological model by placing multiple interventions within different communities across the nation. With a specific demographic represented through each project, the proper marketing research can be performed to determine an effective “message design” implemented through “channels widely viewed by the target audience” (7). Each project can then address different issue areas in their assigned location (i.e., nutrition in Mississippi; physical activity in New York City’s urban population; preventive care in Montana’s rural communities). This approach would separate the nation into “subgroups based on important characteristics” addressing “demographic variable’s [and] risk characteristics” (7).

Utilizing a social behavioral theory that emphasizes the use of models and the role of social factors is essential to developing an effective public health campaign. A 1996 study by Wingood and DiClemente showed that in order to develop the most effective HIV prevention program for African American women the initiative would need: to be driven by a public health theory, target a specific group (in their study, women were the target audience), be “peer led,” focus on the external, everyday factors that influence women’s sexual health practices, and “require multiple sessions” to establish follow-up (8). Wingood and DiClemente’s HIV intervention, SISTA (Sisters Informing Sisters About Topics on AIDS), targeted toward African American women was based on these tenets and showed remarkable success for its “social skills intervention” when compared to the “control condition” it tested against (8).
While still using its current tools of video, engaging graphics and user feedback, GE will have a stronger impact on viewers once they see the anecdotes of people similar to them dealing with prevalent health issues in their community. Giving the messenger (each project’s target community) a sense of place (thereby identifying environmental factors and social norms) appeals to the social skills and needs as exemplified in the SISTA project (8). Multiple sessions of the intervention could be recorded in a video series for each community. By utilizing discussion boards and hosting podcasts with intervention participants, healthymagination could re-enforce its message through follow-up to see how the interventions’ behaviors were incorporated to the community’s daily lifestyle.

By using a person’s life story to convey what it’s like to live with AIDS or to battle with weight loss in the “Better Health Study” project, site visitors can develop an understanding of how to apply the advice from the “Sharing Healthy Ideas” articles. Each location investigated in the “Better Health Study” could have a central topic covered by a video. This video’s web page could have links to the related articles already posted on healthymagination’s site in the “Sharing Healthy Ideas” portion of the site.


Addressing Limited Health Literacy: A Multi-lingual Site
To make their health information most accessible, Healthymagination needs to address the English-language barriers among immigrant populations who frequently have limited health literacy (9). The site’s designers could best explore this avenue by implementing a drop-down menu that could change the language preference of the entire site that pops up when initially connecting to the home page. This could include placing subtitles on all of the videos in the desired language (when specified) and links to verbal translations of podcast scripts in multiple languages. If implemented properly, this could bridge the gap between Western physicians and their non-native patients.

When teaching a new health behavior, especially to patients with LHL, it is best to follow through with a “confirmation of understanding” (9). This could best be done in a web-based format through summary points presented at the end of each video to re-affirm the main message (healthy eating habits, reasons for getting a breast cancer screening, etc.). These final points would automatically be formatted in the selected language the site visitor chose when he or she first entered the site.


Branding the Healthymagination Initiative
After covering the bases of creating an audience through regional health stories and addressing the community’s core values by teaching these communities how to apply healthy behaviors to their everyday life, healthymagination can brand itself. A brand is used to convey the “personality of a program or policy” (5). For Healthymagination, this could involve creating a logo that symbolizes the act of sharing to coincide with its mission of people coming together to make “better health for more people” (1). This symbol could be placed on t-shirts, bumper stickers, pins or any other paraphernalia to give a look to healthymagination’s purpose. This brand would be placed throughout the Healthymagination site, giving new visitors something to identify with when returning to the site.

Both the truth and SISTA campaigns capitalized on the branding technique. When deciding to make a brand for the truth campaign, Jeffrey Hicks and his colleagues recognized that brands “serve as a shorthand way for youth to identify themselves to the world” (14). By visiting the truth website, one can see how the truth campaign (in its apparel, games and videos) identifies itself with rebelling against the tobacco companies, emphasizing the autonomy adolescents crave (14, 3). The SISTA campaign utilized the acronym SISTA in its “project motto” in a “culturally appropriate” way that appealed to young African America women’s values (8). “SISTA love is strong. SISTA love is safe. SISTA love is surviving” speaks to the intervention’s goal of promoting safer sex, re-affirms the women’s ability to be a decision-maker in their relationships by emphasizing strength, and appeals to the African American history of overcoming oppression by ending the motto with the note of survival (8). By making these interventions a part of the target audience’s daily lives, through clothing or by appealing to the audience’s culture, these brands make the intervention more accessible and relatable (5).


A Tailored Approach to a Broad Mission
By properly applying social behavioral theory to its healthymagination initiative, GE can create more compelling messages to which multiple site visitors can relate through a variety of messengers with similar social and environmental circumstances. Research has shown that health interventions have been most successful with a message tailored to the defined audience’s needs and core values that is delivered by a messenger similar to the audience. Since GE’s healthymagination’s site utilizes engaging graphics and popular social media tools, applying these standards to their current broad-based mission would allow greater impact on multiple, diverse communities.




REFERENCES
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MyPyramid – MyFriend or MyFoe? – Alison Krajewski

Introduction
Since its inception, the Food Guide Pyramid has used the same nutritional standards for everyone, regardless of age, height, or weight. To address the inadequacies in these nutritional standards, the United States Department of Agriculture (USDA) restructured its design and introduced MyPyramid. The new MyPyramid campaign has began to implement a personalized plan of action; however, there are still many revisions that still must be completed. Some of the modifications to consider are the following: enhance education on how to use MyPyramid, understanding the dietary guidelines, and the importance of healthy eating; incorporate societal input to gain an understanding of how to effectively market their campaign, as well as the public’s knowledge of MyPyramid; and increase accessibility not only to information about MyPyramid, but also to healthy foods, such as fruits and vegetables.

The Food Guide Pyramid was created in 1992 by the USDA. The pyramid provided suggested daily nutritional guidelines for carbohydrates, vegetables, fruits, proteins, and oils through a illustrative diagram of a pyramid (Figure 1). This graphical representation was used a general guide for individuals to choose healthy foods that were right for them. The Food Guide Pyramid was created with three key concepts at its core: variety, proportionality, and moderation (1). Variety was considered to be a balanced mixture of all food groups; proportionality was based on the recommended serving sizes; and moderation referred to the means to control one’s eating from being excessive (1). The Food Guide Pyramid became the basis for nutrition and healthy eating in America, taught in schools, appeared in countless media articles and plastered on cereal boxes and food labels. Every five years, the USDA reassesses the current guidelines for necessary revisions and updating when emerging nutritional issues arise. Such was the case in 2005 when the Food Guide Pyramid was up for review. Consideration of its effectiveness, in addition to how to incorporate new trends in eating, such as vegetarianism and veganism were focal points. Hence, the USDA retired the old Food Guide Pyramid and replaced it with MyPyramid, a new symbol and “interactive food guidance system” (2). Additionally, MyPyramid was supposed to help stop the increase of obesity rates; however, obesity rates in adults and children continue to rise and obesity-related diseases, such as cardiovascular diseases, are also increasing. Thus, MyPyramid has come under scrutiny over its effectiveness. Currently, the United States is once again working to re-evaluate its dietary recommendations for the general population.

MyPyramid was designed to be a simplistic representation for dietary standards. The new design is color coded and depicts a stick figure ascending stairs on the pyramid to represent the importance of physical activity, which the previous pyramid neglected to represent (Figure 2). The core concepts that were previously used for the Food Guide Pyramid were expanded upon to incorporate the necessary changes in nutrition and maintenance of healthy lifestyles. Now, the anatomy of the pyramid consists of proportionality, variety, moderation, activity, personalization, and gradual improvement. Proportionality is represented by the widths of the food bands; variety is symbolized by the six colored bands; moderation is represented by the narrowing of each food group from the bottom to top; activity is represented by the steps and the person climbing them as a reminder of the importance of daily physical activity; personalization is represented by the person on the steps and the word “My” in MyPyramid; and gradual improvement is encouraged by the slogan “Steps to a healthier you” (3). Although this new pyramid is an improvement from the previous design, it still lacks information for people to make informed choices about their diet. With rates of obesity and obesity-related diseases, such as type 2 diabetes and cardiovascular disease, soaring, the pyramid has once again come under intense scrutiny (4). Currently, the USDA is assessing the dietary guidelines, and it is predicted that revisions will be made to MyPyramid in 2010 (3). The question remains whether there needs to be change in how nutritional information is conveyed to the public or if the problem lies elsewhere.


Critique 1: Usability
The new design of MyPyramid was meant to be substantially simpler than the original version. However, there are issues with the new design. The design is ultimately too simple, MyPyramid is impossible to interpret without the accompanying online tool (5). The colored bands are ambiguous as they do not indicate what food groups are associated with which color (5). For example, orange represents grains, green for vegetables, red for fruits, a teeny band of yellow for oils, blue for milk, and purple for meat and beans (3). There is no logic behind the color coding, making it difficult to interpret. Without visiting the website, one would never know what the colors represent. Furthermore, making MyPyramid solely internet based limits the availability to only those with internet access. Millions of Americans who do not have access to the internet, most often those of low socioeconomic status, are considered to have the least knowledge about nutritional information since most people now get this type of material from the web (5). Consequently, the people in most need of MyPyramid are the ones who cannot obtain the information readily. Although the government has made a valiant effort to keep up with the use of modern technology as a way to convey public health messages, the restricted access to MyPyramid as an interactive online tool puts limitations on its usability.

MyPyramid does not follow the traditional representation of a pyramid. The original Food Guide Pyramid outlined portions American should eat, from the most at the base (grains) to the least at the apex (fats, oils, sugars) (6). With MyPyramid, however, the shape of the pyramid has nothing to do with serving size like the original. Furthermore, without text on the design, it is necessary to visit the website in order to learn what the nutritional recommendations are for each food group. These nutritional recommendations were designed to be personalized, based on age, sex and activity level; however, the online tool makes it optional for the user to include body size (height and weight) – the most important determinant of caloric needs (5). The generated recommended intake can thus be inappropriate for one’s body size or weight, easily recommending hundreds of calories per day too high or too low (5). Additionally, MyPyramid fails to incorporate any other specific dietary needs. Although USDA boasts that the new pyramid is personalizable, the online questionnaire does not take into account adjustments for special dietary needs such as individuals with diabetes, heart disease, high blood pressure, high cholesterol or food allergies.

MyPyramid was designed to be simple. Yet the simplicity of this new design limits its usability. With information about the dietary recommendations only available through interactive online tools, it restricts the accessibility. Furthermore, the dietary recommendations provided by MyPyramid do not take into account the needs of individuals with dietary restrictions due to health-related illnesses, such as diabetes or heart disease.


Critique 2: Dietary Recommendations and Serving Sizes
The Food Guide Pyramid and MyPyramid were created as a way to inform the public about nutritional information through easy-to-read diagrams (3). Dietary guidelines provided individuals with recommended dietary allowance and serving sizes for each food group. USDA defines recommended dietary allowance as the dietary intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in a particular life stage and gender group (7). This term is most commonly known as recommended serving, not to be confused with serving size. Serving size, as defined by USDA, is a standardized amount of a food, such as a cup or an ounce, used in providing dietary guidance or in making comparisons among similar foods (7). Adding to the complexity, serving size is sometimes confused with portion size, which is defined as the amount of a food consumed in one eating occasion (7). The terms as defined above are often undifferentiated amongst the general public, and this confusion can result in over or under eating of the dietary guidelines.

The previous Food Guide Pyramid recommended a range of serving sizes without elaborating on why there was a difference in serving sizes. For instance, the pyramid recommended 6-12 servings of grains every day, but did not specify who was supposed to eat 6 servings and who was supposed to eat 12 servings (6). Instead, MyPyramid uses recommended servings in conjunction with the theory of planned behavior, which states that individuals take personal responsibility and utilize moderation to make healthier choices (6). This technique of personal responsibility and moderation to make the “right” food choices is a major downfall for many people because of lack of self-control, lack of knowledge, or even lack of awareness of the issue. Furthermore, the MyPyramid campaign fails to incorporate the importance of self-efficacy, meaning that an individual believes s/he will be able to perform the behavior of healthy eating. It also neglects to incorporate personal empowerment which allows an individual to overcome the obstacles and perform the behavior of healthy eating. Individuals will not be able to successfully navigate their way through MyPyramid if they do not understand the information provided to them or believe that s/he will be able to follow the guidelines.

After using the online form to enter in one’s age and physical activity level – weight and height are optional – the personalized MyPyramid Plan appears. It is when one enters in this information that s/he is able to see the appropriate serving sizes. Nevertheless, as a population, we still have issues understanding what constitutes as a serving and portion control. Portion size per serving has increased in the last thirty years, which continues to affect the rising obesity rates (8). Larger portions encourage people to eat more (8). With the on-the-go lifestyles that many people live, fast food options are ideal. Fast food corporations pride themselves on their larger sizes, like Supersizing at McDonald’s. The Big Mac Meal at McDonald’s has 1350 calories, nearly 68 percent of the total calories an average adult should consume in an entire day (9). Many would take this meal as one portion, which it is clearly is not. Furthermore, chain restaurants promote large portions on their menus and in marketing campaigns, such as the grand slam breakfast at Denny’s. At minimum, this breakfast meal contains 820 calories and 1270 mg of sodium (10). It is difficult for people to control their portions and follow the dietary recommendations of MyPyramid when they are constantly bombarded with media campaigns suggesting that they abandon those principles.

The dietary recommendations for MyPyramid are supposed to be the most up-to-date and based on scientific evidence (3). There has been speculation that the USDA is influenced by the agricultural and food industry groups such as the National Dairy Council, the National Cattlemen’s Beef Association, and the U.S. Potato Board, to incorporate their products in MyPyramid rather than solely depending upon scientific research to make dietary recommendations (11). The tiniest change to the guidelines or pyramid can swing food companies’ sales by millions of dollars, either way (11). Thus, it is suggested that the guidelines are promoting the sales of certain types of foods rather than promoting healthy eating. For example, the guidelines suggest that it is fine to consume half of our grains as refined starch. However, since refined grains behave like sugar, they act simply as empty calories when incorporated into the diet (2). The U.S. Potato board and baked goods lobby groups are depending on this recommendation to keep sales steady by continuing to have recommendations for refined starches (11). The guidelines continue to lump together red meat, poultry, fish, and beans and ask consumers to judge these proteins by the total fat content to make choices that are lean, low-fat, or fat free (3). This guideline ignores scientific evidence that all these proteins have different types of fat, like the heart healthy omega-3 fats found in fish. Furthermore, this recommendation completely ignores the scientific evidence and research studies which have found that replacing red meats with a combination of fish, poultry and beans provides numerous health benefits, such as a reduction of the risk for coronary heart disease (12). This recommendation could be the result of pressure from the National Cattlemen’s Beef Association on the USDA to keep consumption of red meats in the guidelines to keep their products in demand (11). Although recommending fish as a replacement for red meat has been shown to have a multitude of health benefits, this recommendation does not address the issues of methylmercury found in fish. Methylmercury can have profound adverse side effects of the nervous system, especially in pregnant women (13). The recommendation should include which types of fish contain the least amounts of methylmercury or a caution that fish should be consumed sparingly. Lastly, MyPyramid recommends consuming either three glasses of low-fat milk or other dairy products per day even though such a recommendation adds more than 300 calories to one’s daily intake (3, 2). It is unclear whether the recommendation is based on scientific research that says consuming dairy products has health benefits or if it is based on pressure from the National Dairy Council to keep dairy sales steady. These recommendations need to be reassessed to incorporate the most accurate scientific research studies, instead of integrating the interests from agriculture and food industry lobbyists.

In a recent interview with restaurant chefs, it was found that 60 percent of chefs serve steaks that are 12 ounces or larger, which is four times larger than the recommended three ounce serving according to the MyPyramid dietary guidelines (3, 14). In addition, the survey found that most restaurant chefs dish up one to two cups of pasta with a meal; a serving is half cup (14). When eating at restaurants or fast food establishments, people automatically assume that what they are ordering and eating is one serving. It is difficult to see how people are supposed to make healthy food choices when they are confused about what is a recommended serving versus serving size or how a portion size relates to MyPyramid dietary recommendations. If the USDA hopes to be successful in promoting their campaign of MyPyramid, then they need to simplify what a serving size is versus a portion size and how the recommended dietary allowance fits into everyday life.


Critique 3: The Use of Theory of Planned Behavior
MyPyramid is based on the theory of planned behavior (TPB). TPB focuses on rational, cognitive decision-making processes, meaning that people think about what they are going to do before they actually do it (15). TPB derives from the theory of reasoned action (TRA). TRA is defined as behavioral intention that is influenced by an individual’s attitude toward performing a behavior and by beliefs about whether individuals who are important to the person approve or disapprove of the behavior, the subjective norms (16). TPB includes one additional construct - self-efficacy. Self-efficacy, or perceived behavioral control as applied in context with this intervention, means that a person believes that they can control a particular behavior, in this case, food consumption (16). This decision-making process does not apply here because eating, the defined behavior, is not always planned and rational; sometimes it is based on spontaneous, irrational decisions. A person may believe that they can control their food intake but in reality may not be able to do so.

MyPyramid was designed to be an interactive online tool. As stated above, the details of how to use the pyramid, dietary recommendations, and physical activity advice is only available on the website. Only the most motivated people will take the time to fully explore the website (5). The majority of people will not utilize the tools on the website to find out their specific caloric needs and plan their meals accordingly. One study found that 47 percent of the household food budget is consumed out of the home, which translates to the increased consumption of fast food or take out (5). With the on-the-go lifestyle that many people have, their dietary recommendations as provided by MyPyramid are the least of their worries. Thus, people are more likely to neglect their dietary recommendations and disregard planning their meals based on MyPyramid guidelines for whatever is most convenient.

Although TPB considers the influence of peers, it underestimates how influential peers can be on an individual, ultimately deterring that person away from the desired healthy behavior. Individuals who work in corporate settings are often persuaded into making unhealthy decisions during the work week. Many corporations order fast food on a daily basis and provide light snacks like starchy cookies and sugar-laden sodas. Even if an individual packs a brown bag lunch, these day-to-day temptations lure otherwise healthy people into the fattening and detrimental world of fast food. It is easy for many employees to disregard their healthier meals from home for those with little nutritional value and thus abandon the principles of MyPyramid in order to join their co-workers in an unhealthy lunch time meal. Though they may have been good intention to eat food that is healthy, the need to go along with the majority is stronger than individual choice in this case. Therefore, the TPB did not work for this group of individuals. They planned a behavior and performed a behavior that was based on the subjective norms of their peers. The intended behavior was to eat a nutrient-rich lunch, which was replaced by eating the catered fast food. The planned behavior was neglected, which demonstrates the failure of TPB.

The guidelines of MyPyramid assume that people are eating for the sole purpose of nourishment and does not take into consideration the phenomenon of emotional eating. People use eating as a sort of emotional crutch and will eat out of depression, happiness, or even boredom. When an increase in food intake is in response to negative emotions it is called emotional eating (17). Emotional eating can be considered to be an ‘inapt’ response (17). Emotional eating is a consequence of the inability to distinguish hunger from other aversive internal states, or of using food to reduce emotional distress, probably because of early learning experiences (18). Research studies have found that emotional eating increases the consumption of sweet and high-fat foods in particular (19). Emotional eaters overeat in response to negative affects because they have learned that it alleviates them from aversive mood states (17). When people eat for emotional reasons, it is spontaneous and irrational; they are not going to stop their behavior because it does not fit into their dietary recommendations, thus, abandoning the principle theory for which the intervention was created.

As humans, our actions are not always rational or planned. Using a social behavioral theory like the theory of planned behavior for the MyPyramid campaign, will often result in failure. Norms created by larger society will often influence the behavior of an individual. The previous examples demonstrated that people do not always use logic to make nutritional choices. Sometimes when individuals do plan to make rational decisions, those plans are thwarted by peer pressure. Human behavior is a dynamic process that does not always rely on sensible decision making and thus, using a model that is too rigid to predict health outcomes will be unsuccessful.


Proposed Intervention
While MyPyramid has its faults, there are a few things that are beneficial about it. First, regardless of whether people understand MyPyramid or even the older Food Guide Pyramid, it is widely recognizable. The pyramid shape divided into the six food categories is an iconic symbol in the world of nutrition. Secondly, the new design incorporates the importance of physical activity, which was neglectfully left unincorporated in the last design. Lastly, MyPyramid employs the use of current technologies to try and circulate information about dietary recommendations. Any successful intervention will continue to use these principles and then expand on them to further utilize the MyPyramid campaign to its fullest potential. It is also commendable that USDA did not use statistics and information that is unfamiliar or incomprehensible to the general public in this campaign.


Defense of Intervention: Education
Possibly the simplest but most necessary addition to the MyPyramid campaign is education. Not only because of the simplicity of the design, but in general, people still do not fully understand that the symbol represents dietary recommendations. It is important for people to understand that the balance of nutrition, exercise, and eating healthy does not need to be a difficult process. Education that clarifies definitions like the recommended dietary allowance and serving size will simplify the MyPyramid campaign. The addition of clear and straightforward explanations to the MyPyramid campaign will encourage members of the general public to look into MyPyramid.

Using the online tools for MyPyramid is beneficial, but first, people have to know the website exists, have access to the internet, and then understand how to navigate the website. To fix this issue, there first needs to be awareness of the MyPyramid campaign and that there is an accompanying website. Although one may use the website, it does not mean that the individual will understand the information provided. Information on the website, including the recommended dietary allowance and serving size, needs to be stated in way that is understandable to the general public. Information about how healthy eating and physical activity relates to obesity and obesity-related diseases should be made available for all. Furthermore, in addition to the online tools, local community centers need to have copies of MyPyramid and supporting documents so that those without internet access can have the information. In addition, the local community centers should hold classes on nutrition, guiding people on how to properly utilize the resources of MyPyramid.

Education about the MyPyramid campaign in schools would also be beneficial. Children are greatly influenced by what they see their parents or other adults around them doing. If a parent is constantly eating fast food, foods high in fats and sugars, children will also develop those habits. Teaching children the importance of healthy eating at an early age will help them develop and stick with healthy eating habits throughout their lives. In addition to educating children, parents need to be educated as well. They are the ones buying the groceries, packing lunches, and preparing meals. They are the food role models for their children, and they need to understand how important it is for children to develop a healthy relationship with food.


Defense of Intervention: Societal Input
To find the best way to reach the target audience for MyPyramid, there needs to be societal input. While education is an important first step in any successful campaign, societal norms and roles need to be accounted for as well. One of the best ways to do this is to go directly to the source. For example, in 1998, Florida launched its own version of the “truth” campaign. This campaign was a youth anti-tobacco education and marketing program that was extremely successful. From the beginning, this campaign involved youth. The marketing team convened a 500 person youth summit to gain insight into where youth felt the effort should head (19). They provided the team with what they did and did not like and provided positive feedback to help guide the creative process (19). One of the successful strategy techniques that the team used was interviewing youth about the reasons behind their decision to smoke. They then used all this information to brand their “product” (the “truth” campaign). The key strategy to this campaign was the direct involvement of the target audience. By utilizing the resources available to them, the team was able to build a campaign that proved to be a success – teen smoking decreased by 7.4 percent in middle school and 4.8 percent in high school (19).

The strategy that was employed by the Florida “truth” campaign could also be fruitful in branding MyPyramid. The USDA should employ a marketing team to research the reach and awareness of the MyPyramid campaign. This outreach program could be done through surveys. In addition, the team should interview individuals from all different age groups to fully understand what compels them to eat, their awareness of MyPyramid, their knowledge portion sizes and serving sizes, and the feelings towards following the USDA’s dietary recommendations. Conducting interviews, surveying the target audience, and having the direct involvement of that audience will strengthen the power of the campaign.


Defense of Intervention: Accessibility
The main goal of the dietary recommendations set forth by USDA is to promote eating a healthy balanced diet among the six food groups; however, solely promoting this is not enough, there needs to be accessibility too. National data indicates that less than three percent of men and less than six percent of women aged 19 to 50 years consume the daily servings of fruits and vegetables recommended by MyPyramid (20). National surveillance data and numerous other research studies consistently indicate that low-income populations are less likely to meet recommended fruit and vegetable intake levels, compared to high-income populations (20). Whole grains, fruits, and vegetables tend to be higher in price than other groceries; consequently, millions of Americans either cannot afford these items or would prefer to purchase more affordable items. One research study found that low-income neighborhoods had more convenience stores and fast food establishments and fewer supermarkets, fruit and vegetable markets, specialty stores and natural food stores (21). If the MyPyramid campaign is to be used by all people, regardless of socioeconomic status, then all people need to have equal access to healthy foods like fruits and vegetables.

A solution to the disparities in the accessibility to food is community gardening programs. Community gardens are defined by the American Community Gardening Association as any piece of land gardened by a group of people (20). Researchers have found that community gardening readily provides opportunities for community involvement and experiential education about growing, as well as opportunities to strengthen community ties and build social capital (20). Researchers have concluded that community gardening programs increase the intake of fruits and vegetables in low-income communities (19). By involving the community directly in gardening programs, it gives people the opportunity to access fruits and vegetables. Research has illustrated that when people are directly involved in the process of planting and harvesting, they tend to be more willing to increase their intake of fruits and vegetables, which ultimately reinforces the goal and outcome expectancies of the MyPyramid campaign (19, 20).


Conclusion
The Food Guide Pyramid and now MyPyramid were created to promote nutritious, well balanced eating among Americans; however, these tools have been unsuccessful for the most part. In order to increase the successfulness of MyPyramid, there needs to be substantial modifications to the current campaign. Public health officials, nutritionists, and physicians need to better educate people of the importance of maintaining a healthy lifestyle through eating sensibly as well as engaging in daily physical activity. In addition to education, there needs to be access to healthy foods such as fruits and vegetables. Creating community gardening programs gets people directly involved in the process, while providing them with produce they may not have access to otherwise. Lastly, societal input is key in developing a successful campaign. Knowing how to reach the target audience and what is important to them will create a more successful campaign for nutrition and healthy eating.


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