A Look at Be Informed, Be Healthy: A Critique on the Campaign and Ways it Can Improve – Elaine Shu

Introduction

Obesity and overweight concerns have continued to be a major public health issue in the United States. Obesity rates have continued to increase from the 1976-1980 survey period up to the current millennia (19). While obesity rates showed no significant increase from 2003 to 2006, the people of the United States have continued to lead the world in obesity rates at 30.6% compared to the 14.1% average of the world’s 30 most obese countries (18).

The U.S. does have a number of public health campaigns that addresses this problem; however, considering the fact that obesity and overweight rates have remained unchanged in the past decade or so, many of these campaigns targeted at obesity problems have failed to address this health problem efficiently. An example of one of these campaigns is the Be Informed, Be Healthy campaign initiated by the Seattle and King county government.

Although the underlying intent of this campaign was to promote healthier eating, there are some striking flaws of this intervention. Three main faults of the Be Informed, Be Healthy campaign is that it is based on incorrect assumptions of the human nature, it addresses the wrong issue by focusing on calories and targeting individual behavior, and lastly, the campaign is a passive intervention that does not call for any action or involve any community.

This campaign was launched in early 2009, and if the public health officials of Seattle and King county want to see a future reduction in the 54% of adults who are either obese or overweight in those areas (29), they will need to implement some alternative methods in their campaign. This campaign can be improved by addressing the issues mentioned above to become a more effective intervention. This can be done by switching to social science models that cater to correct assumptions of human nature, creating a campaign which encourages healthy eating, and apply principles of psychology and business to create a movement that people can participate in.

Critiques of Be Informed, Be Healthy

Critique #1: Intervention based on incorrect assumptions of human behavior

Like many existing public health interventions, the Be Informed, Be Healthy campaign is based on individual level models of behavior, more specifically the Theory of Reasoned action and the Health Belief Model.

The theory of reasoned action predicts an individual’s behavior based on his or her attitude and the subjective norms (26). The individual’s attitude refers to his or her belief of the consequences of a certain action and the evaluation of the resulting consequences. The subjective norms are the expectations of the people most important to the individual (26). This theory assumes that people will reason and that intention will lead to behavior. In Be Informed, Be Healthy, the campaign assumes that the reason people are choosing fast food meals with non-diet soda and large fries instead of lower-calorie meals is because they do not know the calorie differences between the two meals, and that if they consume fewer calories, they will be healthy. The campaign assumes that if people are informed about the caloric content of non-diet fast food meals, they will then be able to reason that they want to be healthy, and therefore should choose meals with diet sodas and smaller fries.

Be Informed, Be Healthy is also based on the health belief model. This model is based on four conditions which explain and predict behavior:

1. Perceived susceptibility – the individual believes that he or she may become overweight from consuming fast food.

2. Perceived severity – the individual believes that being overweight may lead to serious diseases such as diabetes or heart disease.

3. Perceived benefits – the individual believes that the benefits of the recommended behavior (eat fast food meals with fewer calories) outweigh the costs and barriers.

4. “Cue to action” – the individual receives a force that leads to intention of eating fast food meals with fewer calories (13).

However, a problem arises because similar to the Theory of Reasoned Action, this model assumes that people make rational decisions based on these four conditions and that intention to be healthy will always lead to behaviors that correspond. There are a number of issues concerning these assumptions; people may be very well informed of the health consequences of consuming fatty foods, nevertheless, they may choose the fattier meal even if they intend to be healthy in the long run. This is a result of failing to take into account the concept of fundamental attribution error. This is the idea in which we tend to think that the internal traits of a person account largely for behaviors (12). As stated earlier, in Be Informed, Be Healthy, it is assumed that the reason people eat unhealthy food must be because they don’t know any better, or don’t want to lead a healthy lifestyle. In fact, there are lots of external/environmental factors that play a role in this decision-making process.

Be Informed, Be Healthy does not take into account the fact that people go to fast food restaurants when they are in “hot states.” When people are hungry or in a hurry, their immediate self-control is reduced causing them to act on visceral impulses (24). The campaign initiated by the Seattle and King county government sets up Be Informed, Be Healthy poster ads across the city in schools and public transportation to get the information out; however people are likely to get these messages while they are in the cold state. When people are not hungry or in a rush, they may be subject to an illusion of control, which is the idea that people overestimate their control over events (14). This implies that when people are advertised to in the cold state (hanging out at school or sitting calmly on the bus), they may think they have more control over cravings for fast food than they actually do when they are hungry or in a hurry.

Other positive illusions people may have is optimistic bias and distorted risk perception. In this case, people may be well informed of the negative health implications of consuming calorie-packed fast food meals, but because serious diseases such as heart disease or diabetes does not happen overnight, these consumers may be optimistically biased and have a distorted risk perception; people perceive themselves to be less likely to experience negative events compared to others (3). Therefore, people may be informed of what “healthy” means as defined by the campaign ad, but still may not see their unhealthy eating behavior as a threat to themselves, but only for others. The Be Informed, Be Healthy campaign does not take into account any of these correct assumptions of human nature.

Tying back to the intervention’s supposition that as long as people are informed of the facts, they will follow to make healthy diet choices, this assumption actually triggers psychological reactants. This is an opposed reaction when an individual’s freedom is threatened, often in cases where one is told what to do or what not to do (22). The campaign ad includes two lines of words which read “Be Informed, Be Healthy” and “Read menu labels and make healthier choices” (29). The ad’s visible message may be “you make your own choices,” however, the underlying message is actually “you make your own choices, but based on what we tell you to choose.” This inadvertently tells people who read the ad what they should and should not eat; the dominance sets off psychological reactants which prompt people to not heed the suggestion.

Because the Be Informed, Be Healthy campaign is based on the incorrect assumptions that people behave rationally and that intention will always lead to behavior, it fails to take into account many other factors that actually determine whether or not an individual chooses to consume healthier meal options.

Critique #2: The campaign focuses on the wrong issues: a.) incorrectly defines “healthy” as consuming fewer calories and b.) Targets individual behavior

The underlying intent of the Be Informed, Be Healthy campaign is to promote awareness of nutritional labels in order to be healthy. Pictures of fast foods, along with each of their caloric content, make up a large portion of almost every poster, flyer, and interactive game created by the campaign. This sends a clear message to people that the focus is on the amount of calories consumed, and that being healthy is merely not consuming more than the recommended amount of daily calorie intake. The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (30), and reports from the USDA and the Wall Street Journal have shown that it is essential to maintain a nutritious diet in order to achieve physical and mental well-being (8, 28). While being aware of calories could definitely be a first step to leading a healthy lifestyle, being healthy is not simply eating no more than the 2000 calories adults are allotted per day; it includes the intake of foods that will provide for our nutritional needs. All of the messages in Be Informed, Be Healthy centers around fast food meals, and this conveys to both adults and children that it is fine to eat fast food. However, the campaign will actually unintentionally allow people to consume more fast food; studies have shown that eating foods high in fat and sugar leads to rapid satiation, but followed by a drop in blood sugar, resulting in a desire for more food (16). This defeats the campaign itself because people will find it hard to limit their calorie intake. Furthermore, these fast food cravings will have people going back each day, resulting in a diet poor in nutrition in the long run.

Another flaw in the focus of Be Informed Be Healthy is that it targets individual behavior. The social science models mentioned earlier are all based at the individual level. In one of the chapters of Critical Perspectives on Racial and Ethnic Differences in Health in Late Life from the National Academies Press, author David Cutler brings to attention that individual interventions neglect the significance of environmental factors; “Individuals are products of their environment…and thus one cannot change the individual without changing the community in which he or she lives” (6). An example of an unsuccessful intervention Cutler mentions is the Multiple Risk Factor Intervention Trial, which sought to decrease behaviors that lead to heart disease (6). By the same token, Be Healthy, Be Informed fails to touch on any aspect of community behavior, but rather sends a message to each individual who reads the poster.

Critique #3: An unattractive campaign that does not call for any action

As a method to encourage parents and children to participate, the officials behind the intervention created what they thought would be an interactive game – the “Fast Food Challenge” – for children to learn about their calorie needs and calories in fast food. In this game, children choose a fast food meal they like by picking different food cards showing the caloric content. They then tally up the total calories in their meal and compare it to the meal calorie guide provided; if the numbers come close, the player wins. While kids may want to play this a couple times, younger children may quickly lose interest and older children may find it boring. Furthermore, there is no direct link between picking the right foods in the game and actually choosing those same foods at a fast food restaurant. Not only is this game minimally interactive, it also contains a problem mentioned earlier: communicating to kids that being healthy is based on meeting caloric needs. The Fast Food Challenge brochure also lists statistics showing how many children and adolescents in the U.S. are obese, how much of a child’s total calories were from fast food consumption, and the fact that people who eat fast food consume more calories than those who do not (29). However, statistics on how many people are overweight have not been proved to successfully persuade people to make healthy meal choices, and it does not help people in taking action. On the other hand, a successful intervention that addresses healthy eating in adolescents – Choosing Healthy and Rewarding Meals (CHARM) – provides a different kind of statistics that promotes action. The DC Assembly on School Health Care, which created CHARM, provides a “Data and Facts” section on their website containing fact sheets that demonstrates statistics on poverty in D.C., how the health needs of students are addressed, the relationship between adolescents’ visit to school health centers (SHC) and presence at school and suicide reduction (7). In addition, the fact sheets address childhood obesity by stating ways SHC’s are tackling the problem (7). Nowhere on the website are there any statistics on calories or how many overweight children there are; this intervention offered data and facts that shows the concrete actions CHARM is taking to help adolescents be healthy. Unlike CHARM, Be Informed, Be Healthy provides no guidance to what it really means to “be healthy.”

Another reason that contributes to the flaw of passivity in Be Informed, Be Healthy is that it lacks major components of communication, which is one of the principles of psychology. Communication is the essential bridge between the public health message and any behavior that might result. In his book Influence: The Psychology of Persuasion Robert Cialdini discusses attractiveness, familiarity, and the use of the “luncheon technique” as keys to successful and persuasive communication (15). Be Informed, Be Healthy is a flawed intervention that fails to call for any action because it does a poor job of incorporating each of the three aspects of communication. The campaign posters contains pictures of fast food meals along with the calorie content and messages that tell people to read menu labels and choose the right meal because adults should eat no more than 2000 calories per day; it is not an attractive poster because people are not drawn to things that tell them what they should or should not do (22). This intervention also excludes familiarity. The proposed way of being healthy is the method of calorie counting, however, it was reported in Consumer Reports Health that 85% of Americans rarely, if ever, count calories (9). This suggests that the proposed method of maintaining health is not a familiar habit for a large majority of the people. Lastly, Be Informed, Be Healthy does not use the “luncheon technique,” which may increase the people’s responsiveness and appeal to the campaign (15). Not being able to motivate people to respond, the campaign proves to be a passive intervention.

Alternate Interventions for Be Informed, Be Healthy

Proposal #1: Base the campaign on group level models

The first flaw of Be Informed, Be Healthy was that the campaign was based on individual level models. To address this flaw, I would base this campaign on group level models or theories, as there have been a number of successful health interventions based on group level models (27). An example of such a model is the Social Marketing theory, which has been fundamental in business sales. Likewise, if the marketing theory is applied to health issues, we can “sell” healthy behavior successfully. This theory utilizes ideas from commercial marketing to design and apply programs that hope to bring about social change (25). The key behind the efficiency of the marketing theory is that it starts by finding out what is it that people want in life; creators of Be Informed, Be Healthy might find it beneficial to think about ideas such as people like to be identified as someone who a.) is confident, b.) loves his/her family and friends or c.) takes control of his/her life and health. Instead of focusing health on the calories, the intervention should shift the focus on relating health to building confidence and success in life, loving family and friends, or finding a sense of empowerment. If healthy eating behavior is packaged and associated with these outcomes that satisfy the core needs, people will be more willing to adjust their eating behavior to meet these needs. The social marketing theory works because it addresses the fundamental idea of “who we are” and the core values that are universal to all people.

Advertising theory is another group level model that is often the basis of successful commercial sales. This theory is grounded by the notion of causal persuasive arguments. This is the idea that a statement is made claiming a relationship between an object or event to another; furthermore, it does not have to come with an explanation of how one end of the claim relates to the other as long as a reason “because” is given (31). This theory can be applied to Be Informed, Be Healthy in creating claims public health officials want people to believe. Some examples could be “eating fruits will bring you love because everyone loves healthy people” or “eating vegetables will give you control of your life because it gives you strength.” These claims may sound funny or slightly far-fetched, but it can be used since it provides a reason. Be Informed, Be Healthy can use similar claims to base their slogan on. These group level models will be more effective than the individual models that the intervention currently uses for the reason that the underlying principle touches on the correct assumptions that humans are attuned to a set of universal core values and that people are more likely to follow causal statements as long as a reason (any reason) is provided.

Proposal part 2: Focus on being informed about the benefits of a healthy diet and cater towards more than one person

As mentioned earlier, Be Informed, Be Healthy leaves the faulty impression that being healthy is all about the caloric intake. In order to address this issue, I propose that the campaign focus on providing information about nutritious foods instead. These can be “fun (or weird) facts” such as “A horn worm can eat an entire tomato plant by itself in one day!” (5). Moreover, these “fun facts” can be turned into challenges or dares such as “A horn worm can eat an entire tomato plant by itself in one day! Can you?” Slogans like these may challenge the ability of people to eat as many tomatoes as horn worms, therefore, setting off psychological reactants and prod people to go and try these dares. Another example could be “Chimpanzees eat their bananas whole when given organic bananas (11). Try adding some orange or mango peel to your next smoothie!” Statements like these can take the place of the original slogan of Be Informed, Be Healthy and be made into several different poster ads that can be posted around different parts of Seattle and King county. Another idea could be to develop a set of things related to healthy eating to try each day of the week. An example mentioned earlier could be used this way: “Mango Monday: Try adding some mango peel to your next smoothie!” The foods do not only have to be fruits or vegetables, but also can include any food beneficial to our diet such as lean meat or dairy products. Although creating the slogan in this way does not directly inform people of the nutritional facts of different foods. It can act as a prompt or a quick reminder to make people think about healthy food choices. At the same time, these slogans do not tell people what they can or cannot eat, and do not make any mention of fast foods; once again, this will be able to minimize psychological reactants and people will be prompted to think about nutritious rather than fast foods.

The second wrong focus of the original campaign is that it targets individuals rather than communities. To address this issue, the third alternative proposal will be able to cover this problem.

Proposal #3: Apply the principle of psychology and business to create an active movement.

As Cialdini mentioned in his book, there are three essential elements that are key to efficient communication: attractiveness, familiarity, and the “luncheon technique” (15). Be Informed, Be Healthy can improve this by making aesthetically pleasing flyers that uses photographs of nutritious foods. Fruits and vegetables are often good for this because they are usually brightly colored. Studies have shown that certain colors and color combinations bring out particular emotions in people (1). Precision Intermedia, a multi-advertising agency understands the effects different colors have on people, and health campaigns can also utilize this (21). For example, red, green and yellow grab attention and elicit positive emotions (21), by putting food of these colors on flyers, the campaign can lead people to associate positive feelings with nutritious foods because of the colors. The Seattle and King county officials can also create a separate website for the campaign, and apply the same color principles.

The second important aspect of communication is familiarity. This idea that people respond best to others who share similar experiences can be used through testimonials. The government can ask for people in the community to write testimonials of how they or someone they know might have experienced life threatening health conditions because of a poor diet. Not only will the target audience be able to relate to others in their community, but people will also be able to see tangible examples of how nutrition is important to health. Another way some commercial product companies have been efficiently reaching out to students by using the sense of familiarity is through college brand ambassadors. I recently received an email offering me a job as an ambassador for an event at Boston University; the company uses the same idea that hiring students themselves will increase the chances of marketing successfully to their peers.

The third key element of communication is the “luncheon technique,” in which people “became fonder of the people and things they experienced while they were eating” (15). This can be applied when campaign members pass out flyers along with a healthy snack such as an apple, thereby using two of the key elements of communication at the same time.

Another principle of psychology the campaign can apply is that of reciprocity. When treated positively (or negatively), people respond back positively (negatively) as well (23). The officials of Seattle and King county can work in collaboration with local supermarkets or food companies to pass out coupons for healthy snacks along with the flyers. When people receive the coupons (something positive), they will might respond by supporting the sponsoring companies or supermarkets. The government can further work with local magazine companies to put in ads for nutritious foods, and supermarkets and food companies can include their coupons here. This is known as the agenda setting theory. This theory has been known to be the basis of successful health interventions such as Arizona’s Challenging College Alcohol Abuse (CCAA) campaign, which uses this media-based method (4).

In order to shift Be Informed, Be Healthy from being a passive to active campaign where people will be motivated to make changes, it will be beneficial to the cause if the campaign leaders reach out to popular and influential people of the community. This method is based on the principles of herding behavior, the social norms theory, and the social network theory. These principles follow the overall idea that people will act together and follow after the actions of others in a group (2). Be Informed, Be Healthy can reach out to “leaders” of the community such as pastors; in schools, the campaign can involve student body presidents or other popular students. By involving the figure heads of certain organizations, the campaign will have more success in connecting with the rest of the people of the group.

Although the officials of Seattle and King County created Be Informed, Be Healthy intended to help people increase awareness of their diet, their campaign is flawed in that it is based on incorrect assumptions of human nature, it focuses on the wrong issues of defining health as eating fewer calories and targeting individuals as opposed to a whole community, and it is a campaign marked by passivity. By applying group level theories, bringing to attention nutritious foods and no mention of fast foods, and involving the businesses and leaders of the community to actively participate in the campaign, Be Informed, Be Healthy can be transformed into a successful campaign that will bring down the currently high obesity rate in the region.

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