Challenging Dogma - Spring 2011

Sunday, May 15, 2011

Critique of the Childhood Obesity Intervention Public Awareness Campaign – Paula Diaque Ballesteros


The MetroWest Community Health Care Foundation (MCHCF) launched in 2006 a Childhood Obesity Initiative to combat youth obesity in the region of MetroWest in Framingham, MA. The original goal statement was to create local collaborations among schools, community organizations, public health and recreation departments that would provide leadership in the development and implementation of effective policies and practices to promote and support healthy nutrition and exercise choices among children. In January 2007, the MCHCF instigated the public awareness campaign: Obesity: it’s robbing our kids of their future. The campaign described the health risks associated with childhood obesity and served as a call to action for the region of MetroWest. The goal was to bring attention to parents to the issue of childhood obesity and the associated risks as a way to change individual and family behavior. The key message used was: “It’s about kids, their health and their future”.

According to the Report from the MetroWest Community Health Care Foundation in 2007 in developing the campaign, the Foundation considered the region’s demographic makeup, studied the most efficient ways to reach the public and enlisted the help and input of area physicians, psychologist, educators, and nutrition and exercise specialists.

The media components of the campaign included a series of billboards, television commercials, newspaper advertising, informational posters and booklets and a website.

Negative message: stereotypes and labeling

One of the media components of the public awareness campaign was the use of billboards. One particular billboard showed the legs of an obese child on a scale with the statement: FAT CHANCE Obese children are a good bet for type 2 diabetes. Heart disease. Stroke. Cancer. Sleep apnea. Depression. This approach is based on the idea that a negative message will promote behavioral change, that people behave rationally. The billboard is creating negative stereotypes and labels. Based on the irrationality of human behavior, people are influenced by stereotypes and labels; people are programmed to behave differently based on stereotypes and labels. This is supported by the Labeling Theory developed by Becker in 1950, which began to focus on the way in which negative labels get applied and the consequences of the labeling process. The theory states that “social groups create deviance and that deviant behavior is that which is so labeled. The deviant is one to whom that label has been successfully been applied; deviant behavior is behavior that people so label” (1).

Labeling theory states that behavior of individuals may be determined or influenced by terms used to describe or classify them. Edwin Lemert made a distinction between primary deviance and secondary deviance. Primary deviance “is rule-braking behavior that is carried out by people who see themselves and are seen by others as conformist. But when a negative label gets applied so publicly and so powerfully that is it becomes part of that individual’s identity” (2), that is secondary deviance. These dramatic negative labelings become turning points in that individual’s identity; and is apt “to employ his or her deviant behavior or a role based upon it as a means of defense, attack or adjustment to the problems created the subsequent societal reaction” (2). The use of the negative label (FAT CHANCE) will make children live up to it, and not change their behavior.

Research on stereotypes shows not only that we react differently when we have a stereotype of a certain group of people, but also that stereotyped people themselves react differently when they are aware of the label that they are forced to wear (3). Steele and Arsonson (1995) (4) described a phenomenon called stereotype threat, a situational predicament in which individuals suspect their behaviors could be judged on the basis of negative stereotypes about their group instead of personal merit. Good et al (2008) (5) conducted a study on stereotype threat and women’s achievement in high-level math courses. The study examined the relevance of a stereotype threat, an environmental impediment to women’s math performance, to the test-score gap between men and women in advanced mathematics courses at a major university. The results showed that the effect of stereotype threat is not limited to the typical woman’s performance on a general mathematics tests. Rather, even among women in the most difficult math courses in college, can be vulnerable to the effects of negative stereotypes. However, ensuring women that the same diagnostic test was free of gender-bias reduced stereotype threat and unleashed their mathematics potential. The study suggests that even among the most highly qualified and persistent women, stereotype threat suppresses test performance. Our own behavior can be influenced by our stereotypes and that activation of stereotypes can depend on our current state of mind and how we view ourselves at the moment (3).

Stereotype is a source of stress and could result in a number of physiological, emotional, cognitive and behavioral reactions that are distinguished along the lines of voluntary and involuntary responses (6). Stress can also contribute to self-control failure, usually because of attempts to cope. The use of negative labels and stereotypes in the public awareness campaign will not only hinder any change in behavior but it will also affect self-control; an important characteristics for healthy eating and increased physical activity.

Psychological reactance to newspaper advertising

Another media component used by the public awareness campaign was a newspaper advertisement. The add showed a “pointing finger” aimed straight at the reader; similar to the old Uncle Sam poster “I WANT YOU” for the US Army Recruitment. The newspaper advertisement was followed by “THIS IS NOT A BLAME GAME. IT’S A CALL TO ACTION”, however the advertisement’s effect is exactly the opposite: people or parents when they see the advertisement they feel they are being blamed. Overall the advertisement is threatening.

When delivering messages or when interventions are trying to get people to do something it is important to consider psychological reactance.

“Freedom of behavior is a pervasive and important aspect of human life. People continually survey their internal and external states of affairs and making decisions about what they will do, how they will do it and when they will do it. They consider their wants and needs, the dangers and benefits available in their surroundings” (7). The theory of psychological reactance developed by Brehm in 1966 states that if a “person’s behavioral freedom is reduced or threatened with reduction, the person will become motivationally aroused. This arousal would presumably be directed against any further loss of freedom, and it would also be directed toward the reestablishment of whatever freedom had already been lost or threatened” (7). Freedom can be threatened by forces that mitigate free choice, such as commands and persuasion.

The newspaper advertisement may be considered as a threat and people will experience reactance and react in various ways. In a study by Erceg-Hurn (2011) (8) psychological reactance was evaluated to cigarette health warnings in smokers. The results suggest that it is possible for cigarette warning to elicit state reactance. 80% of smokers who were exposed to graphic warnings experienced reactance. Smokers who were exposed to graphic warnings were much more likely to experience elevated and extreme levels of reactance than were smokers who were exposed to text-only warnings.

Some of the ways the study suggested reactant smokers could restore their freedom was to smoke more than they previously did or become less motivated to quit. Similarly results can be expected from the newspaper advertisement, parent may become less motivated to take action and children may want to engage in unhealthy behaviors.

Another study in Australia by Ricciardelli et al (2008) (9) examined student’s understanding and perceived effectiveness of an alcohol campaign designed to increase student’s awareness of excessive and harmful drinking. The tagline used was “Is Getting Pissed Getting Pathetic? (Just ask your friends)”. Students were asked to comment on the messages that the campaign was communicating; some students described the message as “truth and realistic”, however, other views were more negative and indicative of psychological reactance. These included comments such as “they don’t want to be told what to do”.

The findings highlight how media campaigns can help an audience contemplate behavioral change, however, they can also alienate individuals and promote counterproductive attitudes. The newspaper advertisement did not consider psychological reactance, their message sounds authoritarian. It has been seen that dominant and controlling messages elicit reactance; the more dominance the more reactance the individual will experience.

Optimistic bias

Some of the billboards and newspaper advertisements included the following information: “Obese children are a good bet for type 2 diabetes, heart disease, stroke, cancer, sleep apnea, depression”. The aim was to increase awareness of the seriousness of the problems of childhood obesity, by stating the consequences of being overweight.

According to Weinstein (1980) in the optimistic bias theory people tend to believe that negative events are less likely to happen to them than others, and they believe that positive events are more likely to happen to them than others (9,10). People tend to think they are invulnerable; they expect others to be victims of misfortune, not themselves. “Such ideas imply not merely a hopeful outlook on life, but an error in judgment that can be labeled unrealistic optimism” (9).

People may understand the general risk of obesity; but when it comes to people’s own perception of risk, the majority thinks they are less likely to experience a negative event or any adverse consequence. Using facts and showing the consequences in the public awareness campaign is not going to make parents do something about their child’s weight; they already know the adverse effects of obesity, but because of optimistic bias theory, they think it will not happen to their children.

People’s tendency to think their risk is less than that of their peers has been investigated with various unhealthy habits. Chapin (2001) (11) evaluated the role of optimistic bias in African American teens engaged in risky sexual behaviors. Results showed that adolescents are aware of the risks associated with reckless sexual behavior, yet they do not change such behaviors despite efforts of mass media campaigns and educational programs. Students perceived they were less likely than their peers to become pregnant or cause a pregnancy.

The explanation for this phenomenon by the authors is optimistic bias, adolescents take risks because they ignore or greatly underestimate the actual risk associated with their risky behavior. About 27% of the variance in the amount of protected sex may be attributed to optimistic bias (11). Weinstein (1980) (9) showed that individuals make comparative risk assessments in an egocentric manner, paying little attention to the risk status of others when asked to determine their own relative risk.

In another study, Waltenbaugh et al (2004) (12) showed that cigarette smokers are generally aware of increased health risks associated with smoking, but smokers tend to underestimate their own susceptibility to disease. Ayanian et al (1999) (13) also demonstrated that among current smokers only 29% and 40% perceived their risk of myocardial infraction or cancer, respectively, as higher than other persons of the same age and sex .

Numerous studies (14) report a positive relationship between perceptions of control and the optimistic bias such that the greater the perceived control over the outcome of an event, the greater the optimistic bias for that event. Perceptions of control are associated with perceptions of personal risk estimates rather than target risk estimates. The greater one’s perception of control the lower one’s personal risk estimates.

Taking into account the implications of optimistic bias theory, facts and statistics about the consequences of childhood obesity will not prompt parents to do something about it. They already know the risks associated with certain behaviors but they think it will not happen to them or their children.

New approach

The Childhood Obesity Initiative’s objective is to increase emphasis on leading proactive community health initiatives, in partnership with local organizations and through grants and value-added non-grantmaking activities. The initiative is addressing an urgent issue and targeting various areas of impact: individual behavior, school and organization behavior and community behavior. Although this is good for the intervention there are several different approaches that could be implemented in the public awareness campaign for greater impact and changes in behavior.

As stated previously, negative labels and stereotypes influence people’s behavior, people are programmed to behave differently based on stereotypes. When people use labels, individuals live up to them; so instead of labeling with negative messages, labels should be positive. By using positive messages and labels that encourage people to engage in healthy behaviors, it will influence individuals to do the right thing by following that label and stereotype. People generally respond to positive messages. As a replacement of the negative labeling billboard “FAT CHANCE”, the campaign should use positive labels such as: “Happy kids”, “Being part of those who care about themselves”, “Being aware about what you eat and do”.

Positive labeling has been associated with healthy behaviors, an example would be “the 8ighty 4our” movement “It’s not just a number, it’s who you are”. A youth-led movement fighting for a tobacco-free generation in Massachusetts. The movement is using the positive label “non-smoker”, 84 represent the 84% of youth in Massachusetts who do not smoke; this has had a self-fulfilling effect on youth. If they want to be a part of the 84, they have to be a non-smoker. The use of a positive message encourages youth to be part of the movement and be a non-smoker.

Advertising theory can also be used in the public awareness campaign. Advertising theory can promote to take up or maintain a healthy behavior; it usually works without drawing attention to itself. It takes into account three basic concepts: promise, support and core values.

Making a promise is the main concept. The larger the promise the more effective and stronger the advertisement. The promise must be presented in a way that it is appealing to the audience.

The promise must be supported, but not with the use of statistics and facts but through visual proof. For example showing how a child will feel by following healthy behaviors or telling a story.

The promise and support are surrounded by core values. Universal core values that appeal to everyone and get people do what you want them to do. Examples for core values for the public awareness campaign could be youth, independence, freedom and love; not health.

Advertising theory can help the public awareness campaign to develop positive messages and stereotypes and labels that influence people to engage in or be part of a specific healthy behavior or change their current risky conduct for a healthier one.

Another critique of the public awareness campaign was ignoring psychological reactance. To avoid psychological reactance the campaign must take into account several concepts. In order to reduce psychological reactance explicitness of the message must be considered, the more explicit the less reactance. Avoid dominant message such as the newspaper add and give support to the claim to reduce reactance.

In a study by Silvia P (2005) (14), it was shown that interpersonal similarity can reduce reactance by increasing compliance and by reducing resistance. “Similarity increases the positive force towards compliance by increasing liking. Liking another person increases the tendency to like objects that the other person likes” (14). Similarity also enhances the communicator’s credibility. If the campaign is focused on parents, then parents should be promoting the campaign. If change in children’s health is being promoted children should appear in the campaign or someone they can identify with, relate and admire. The public awareness campaign could include celebrities to promote or talk about a specific behavior to increase compliance and credibility.

Another way to avoid psychological reactance is to find out what the audience believes in and reaffirm what they believe. Do not try to go against what they believe; instead frame the importance of being aware of childhood obesity and the need for healthy behavioral changes, so that it is affirming the values the audience believes in.

Finally, the public awareness campaign should take into account the optimistic bias theory, how people’s perception of risk is distorted. The use of statistics will not change people’s perception of risk. Context and familiarity will more likely persuade someone. It is important to shift from talking about statistics and the consequences of obesity to an individual story. People will care more about an individual story than data and facts.

The illusion of control is the tendency for people to overestimate their ability to control events. It explains how important control is over behavior and how it can be used for changes in behavior in a public health intervention. The more control you give to people the more likely they will adopt the behavior. In order to have a greater impact in the public awareness campaign it has to give people a sense of control, and this can be achieved by rituals, a way that people can take control of their life.

In order to have a greater impact through the public awareness campaign it is important to take into account several theories and models. Group level models such as the advertising theory can affect more than one individual; it takes advantage of irrationality and focuses on behavior. Considering the effects related to psychological reactance and optimistic bias theory will help to increase compliance and change behavior.


  1. Becker HS. Outsiders Studies in the Sociology of Deviance. New York, NT: The Free Press of Glencoe, 1963
  2. Lemert EM. Human Deviance, Social Problems and Social Control. Englewood Clifss, NJ: Prentice-Hall, Inc, 1972
  3. Ariely D. Predictablye Irrational. New York, NY: HarperCollins Publishers, 2009
  4. Steele, C. M., & Aronson, J. (1995). Stereotype threat and the intellectual test performance of African Americans. Journal of Personality and Social Psychology, 69, 797–811.
  5. Good C, Aronson J, Harder JA. Problems in the pipeline: Stereotype threat and women's achievement in high-level math courses. Journal of Applied Developmental Psychology 2008 01;29(1):17-28.
  6. Inzlicht M, Kang SK. Stereotype threat spillover: How coping with threats to social identity affects aggression, eating, decision making, and attention. J Pers Soc Psychol 2010 09;99(3):467-481.
  7. Brehm JW. A Theory of Psychological Reactance. New York, NY: Academic Press Inc, 1966
  8. Erceg-Hurn DM, Steed LG. Does exposure to cigarette health warnings elicit psychological reactance in smokers? J Appl Soc Psychol 2011 01;41(1):219-237
  9. Weinstein ND. Unrealistic Optimism About Future Life Events. J Pers Soc Psychol 1980;39(5):806-20
  10. Klein CTF, Helweg-Larsen M. Perceived control and the optimistic bias: A meta-analytic review. Psychol Health 2002 08;17(4):437-446
  11. Chapin J. It won't happen to me: The role of optimistic bias in African American teens' risky sexual practices. Howard Journal of Communications 2001 01;12(1):49-59
  12. Waltenbaugh AW, Zagummy MJ. Optimistic bias and perceived control among cigarette smokers. J Alcohol Drug Educ 2004 03;47(3):20-33
  13. Ayanian JZ, Cleary PD. Perceived risks of Heart Disease and Cancer Among Cigarette Smokers. JAMA 1999;281:1019-1021
  14. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005 09;27(3):277-284

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