Challenging Dogma - Spring 2011

Monday, May 16, 2011

Mitigating Climate Change: How Can Public Health Change Behavior When the Public Health Approach Refuses to Change? – Shanta Shepherd

A. Introduction
Evidence clearly illustrates that within the past 5 decades, global climate change has been due to human activity (1). Since industrialization began to take off in the late 18th century and early 19th century, there has been a 29% increase in atmospheric carbon dioxide (CO2), for which developed countries are largely responsible (2). However, even among developed nations, the levels of Co2 emission vary greatly. The average American puts out five tons CO2/year compared to the average Swedish counterpart, who puts out only 1.5 (3). These numbers therefore reflect waste and over usage, not wealth or standards of living. However, with the exception of the successful deleading of gasoline beginning in the 1970s (4), the public health community has yet to influence the public to make any of the widespread modifications necessary to mitigate the potentially impending crisis we are collectively inducing (1, 3). The fact is that many people still, despite the recent disastrous effects that climate change is starting to have on local communities (e.g. Hurricane Katrina, exponential increase in flooding in Norfolk, VA, recent tornadoes in the Midwest), do not believe in the existence of climate change, or are simply apathetic and just do not care (5, 6).
A recent climate change advertisement for the UK’s Climate Challenge intervention aptly stated, “If we could see the gases, the causes of the problem would be obvious to everyone…and if you could see the effects we are having on our planet, you’d do something about it (2).” Unfortunately, we cannot see the gases being produced, and the effects are gradual and far removed, such as in the ocean, or in distant communities. This makes the issue of climate change particularly important and the delivery of public health messages extremely difficult. While many public health interventions have addressed climate change, several components of the current public health approach to climate change serve as major barriers to adaptation, resulting in few successful interventions (7-9).
The United Nations Framework Convention on Climate Change (UNFCCC), a global summit of countries that works to curtail the effects of climate change, has attempted to create plans of action, such as the Kyoto Protocol, in order to control and reduce greenhouse gas emission (1, 4, 8). While this treaty was a step in the right direction, the fact that the US did not ratify it sent two strong messages to the world. First, the Kyoto Protocol put the economic burden of reducing emissions on developed nations, while allowing developing countries, particularly large ones like China and India, to continue to heavily pollute (4). Secondly, the steps required to mitigate climate change were rejected as economically unviable and unsustainable due to heavy dependence on fossil fuels (4). Unfortunately, the US’s stance also set the tone for public response to climate change: people have difficulty making small, yet seemingly expensive, changes in their daily lives, particularly when they will not see benefits from the changes, economic or otherwise, over a long period of time (5, 6, 10). Present savings is a stronger driver than potential gain in the future (5).
Unfortunately, many interventions currently use reducing greenhouse gas emissions as the basis for mitigating climate change and promoting behavior change (1, 3, 4). However, if much of the public has already rejected the idea that green house gases cause climate change, dismissed the relevance of this argument, any intervention with greenhouse gas emissions as a focus will likely be ineffective (1, 5). Moreover, conflict between theories concerning climate change amongst the expert scientists in the field has caused the public to grow skeptical of assertions made by the public health community as a whole (3, 11, 12). As a result, climate change campaigns have been dismissed as erroneous, and the public has continued to use the controversies as a way of rationalizing and validating their current behavior (5, 11). This paper will attempt to explain the reasons why the public health community has been largely unable to effectively influence the public, by presents a brief background of the current state of climate change interventions, three common barriers to the successful delivery of climate change messages within the current public health approach, and an alternative framework consisting of three key components.
B. Background
Models of Human Behavior and Current Interventions
Current public health interventions are generally based on classical theories of human behavior (7, 13). Theories such as the Health Belief Model, Theory of Reasoned Action, and Social Cognitive Theory have long been the archetype for public health interventions (5, 7, 13). These theories fundamentally assume that a person is rational, and that knowledge followed by intention must always precede behavior (5, 7, 13). However, the literature has shown that these theories are largely ineffective in promoting and accurately predicting patterns of behavior and behavior changes in the general population (1, 5, 7, 8, 13).This is due to the fact that these theories are inappropriately applied (1) – promoting behavior change among the population requires a different approach than promoting it among individuals (7, 13).
An example of the inappropriate use of behavioral theories is in the difficulty the public health community has had getting people to stop smoking. The vast majority of smokers are aware of the health risks associated with smoking tobacco, and yet many still do (14). This is largely due to classic cognitive dissonance, in which there is a conflict between beliefs about tobacco and their actions (smoking) (7, 13). As a result of this conflict, they then rationalize their behavior by changing their attitude toward tobacco use – they either focus on the immediate positive results of smoking, change their perception of self risk, or both (7, 13). Thus, interventions that depend on the human mind to make rational decisions will almost always be ineffective, because the very act of rationalizing is irrational (1, 7, 13).
Few public health professionals have ventured from the classical models to innovative alternatives, but with each passing year, more and more do (5-7, 9, 13). Alternative models such as Advertising and Marketing theories, Diffusion of Innovations Theory, and Theory of Hierarchy of Needs, are being used with increased frequency, but still make up the minority of current interventions (7). Evidence has shown these models to be more effective in understanding collective human behavior, thus promoting sustained behavior change amongst populations (5-7, 13). This is because these models work at the group level; they are based on the understanding that human behavior is not always rational, and in fact, it is chiefly irrational – knowledge and intent rarely precede behavior (5, 7, 13).These notions allow the interventions to take advantage of cognitive dissonance by changing behavior first, which forces people to subsequently change their attitude about the behavior, making the intervention a sustained one (7, 13).
Climate Change and the Public’s Mindset
There are many reasons why climate change interventions have been ineffective in mitigating widespread changes amongst the world’s population (1, 4, 15). Some include the feasibility and affordability of their solutions, but for the most part, the limiting factors are in the communication between the public health community and the public (1, 8, 15).The public’s perception of climate change and the way public health messages are framed to the public are major obstacles to the success of interventions (5, 6, 10).
The public’s lack of motivation regarding climate change can be explained in part by the Theory of Hierarchy of Needs, in which there are several levels of need required for personal growth and survival (7, 9, 16). These needs range from physiological basics such as food and shelter, to security and social status, to the highest level, which is self actualization (9, 16). Therefore, people who are concerned with putting the next meal on the table or paying their rent or mortgage do not have the luxury to worry about the effect of human behavior on the planet (16). It simply is remiss for public health practitioners to not take this into consideration.
The fact that the effects of climate change are far removed from the public’s everyday lives further exacerbates people’s lack of motivation to change their behavior (1, 3, 8). The Theory of the Tragedy of the Commons, in which “common spaces” deteriorate as a result of no one wanting to take responsibility for them (5, 7, 13), exemplifies the current stance people have taken today with regard to issues such as rising sea levels resulting from glacial melts. Even people who care about environmental issues use cognitive dissonance to rationalize their lack of response, with the notion that there is nothing they alone can do to mitigate the problems (1, 3, 10).
C. Barriers to Successful Delivery
The public’s skepticism of climate change, and its resistance to behavioral changes, is only potentiated by public health community’s inability to effectively communicate with the public (1). Despite consistent evidence of the ineffectiveness of classical behavioral theories in population-based interventions, the public health community has been largely resistant to changing its own methods and behavior (7). While there are various flaws in the current public health approach to climate change, this paper will focus on three: the concept of climate change is a man-made consequence, the use of fear or alarmism, and the mixed messages being sent out to the public by experts regarding the specific causes and effects of climate change.
The Concept of Man-Made Climate Change
Core values are the ideas or beliefs that people hold dear; they are the basis of all that we do and how we experience, and understand our realities (13). They are how we give meaning to life. These values range from family to freedom and autonomy, love and belonging to fairness and justice, power and youth to rebelliousness (5, 6, 13). While there may be slight differences amongst people in different parts of the world, overall these values transcend cultures fabricating the essence of what it means to live (13).
The belief in man-made climate change is complex. It requires first the belief that climate change exists, and then that human beings are responsible for it. Current public health interventions require audiences to buy into this two-fold belief system in order to be effective (10). This is crucial because there may be, and probably is, a cohort that believes in climate change, but not in the man-made component of the argument, and thus dismiss the message altogether (10). As a result, the only people the message reaches, and for whom the message is effective, are people who already share the common belief in man-made climate change (10, 13). These are the same people who are most likely to be already engaging in environmentally friendly behavior. Because the message may interfere with their core values – their beliefs – many people who could benefit from changing their behavior may outright dismiss the intervention (6, 7, 13).
Public health professionals today often miss this key idea of addressing core values when creating and implementing interventions (13). This is evidenced by the “Above the Influence” campaign, particularly in the early years of the intervention, in which data showed that not only was the campaign ineffective in mitigating attitudes toward marijuana and usage, but that it may have had a boomerang effect, and caused an increase in usage (14, 17). The ineffectiveness of the campaign can be explained by the fact that people who value freedom, a value particularly important during adolescence, will reject messages that take away their freedom to make their own decisions (6, 7, 10). Psychological reactance, which occurs when their freedom is threatened to a larger degree (7), causes them to actively pursue the activity they were urged against as a result of their freedom being so threatened.
The Theory of Hierarchy of Needs also demonstrates that even if a person finds the issue of climate change to be important, more imminent issues such as everyday survival will take precedence (16). If the message does not convey that the behavior change will help in the fulfillment of immediate needs, the public will likely ignore the message (6). This is why public health professionals have such difficulty getting people of lower socioeconomic status to eat healthier – they are not providing a solution that will allow people to work the required two or three jobs needed to make ends meet while getting dinner on the table quickly enough to feed their families (5- 7, 10, 13, 16).
Fear and Alarmism
Classical theories such as the Health Belief Model, upon which the majority of current public health interventions are built, have numerous flaws when applied to mass audiences (7, 13). The first is the assumption that behavior results from very deliberate and rational processes, which take place within an individual’s mind (7, 13). There are various perceived benefits and perceived barriers of a particular behavior, which are then weighed to create the intention of the person, and ultimately lead to a behavior that reflects the intention (7). Factors that contribute to the perceived benefits of a behavior include ones perceived susceptibility to the harms associated with the behavior, as well as ones perceived severity of the associated harms (7). Public health interventions often use fear to capitalize on and increase perceived susceptibility and severity in order to deter individuals from certain behaviors (6, 7, 10).
A recent, yet classic, example of the use of fear to drive behavior change was the H1N1 influenza outbreak. Normally public health professionals struggle to get the public vaccinated. This issue has become so commonplace that hospitals have had to mandate vaccination among their employees. However, when H1N1 first appeared, it was a new and seemingly deadly virus unlike any influenza virus before it, and the field of public health was able to capitalize on the fears held by the public of the severity and susceptibility of the disease that schools closed; shortages of the vaccine put people into a panic. Months later, when the public realized that H1N1 was not as virulent as projected, the resulting decreased perceived severity caused few people lined up for vaccines the following season, setting the stage for a potentially deadly outbreak of a similar strain in the future.
The blowback, or unforeseen damages, of using fear or alarmism can mean the difference between life and death in public health (10). If there is no compelling evidence to support a message, coupled with conflicting messages being sent to the population in the case of climate change, the public health community may be faced with an enormous task of regaining a desensitized public’s trust in them and in the issue at hand (6, 10). The use of fear tactics also tends to drive psychological reactance amongst the population once the realization that the public health community has lied to them occurs, making the job of public health professionals that much harder (10).
Mixed Messages
Despite the fact that the general public still has many incorrect ideas about the science of climate change and that evidence clearly shows that education does not result in behavior change, the public health community still attempts to use education about climate change as a driver for behavior change (6, 7, 13). Details regarding the science of climate change are insignificant with regard to the public (5). While most scientists agree on that man-made climate change exists, many disagree on the details of climate change (3, 11). Outward discussion of the details amongst scientists is crucial for the development of science and technology (3, 6, 10).
Scientists are at odds about whether the planet is warming or cooling (2, 6, 11). They are unsure whether CO2 is the gas most responsible for climate change or if there are others (2, 6, 11). They also cannot agree on the effects of climate change, when they are going to occur, how fast, and to what magnitude (6, 11). This constant argument and lack of leadership makes the field unreliable, and as a result leaves the public unwilling to take seriously, any of the messages (6, 11). However, when public health professionals use the detailed arguments in their messages, and then their arguments are proved wrong by a new theory, the entire field gets discredited (6). At present, “,” amongst other organizations, make a mockery out of climate change experts, and serve as resources to the public (11). provides extensive information and research on the contradicting ideas and messages the public health community has put out regarding climate change since the advent of industrialization (11).
It may very well be that the public is simply looking for any way to discredit climate change messages due to preconceived notions (6). However, where the field of public health goes wrong, is that we focus our attention on the minutia of the issue, rather than on tangible actions, which can only mitigate the problems, whatever they may be (5, 6). The fact is that we are uncertain about the details regarding climate change. Despite false perceptions and uncertainties, the main focus of the public health interventions needs to be the behavior change (6-8).
D. A Framework for a New Approach
Applying Advertising Theory to Public Health
The current public health approach to climate change neglects people’s core values, relies on ineffective tactics such as alarmism to promote change, and frequently sends the public mixed messages about the causes and effects of climate change (5). Advertising Theory is an alternative behavioral theory that has been proven on countless occasions to be effective in promoting behavioral change (7, 13).
Advertising Theory sells the product or idea to the target audience by promising the audience something, which is of desire (13). This desire can be fulfilled through the product. Unlike traditional public health theories, Advertising Theory does not tell the audience to purchase the product; it does not tell the audience what to do (7, 13). Rather, it makes the product something that the audience wants to do, and the packaging around this promise is the audience’s core values (13).
Advertising Theory uses the core values of the target audience to lure them into the message, while simultaneously avoiding psychological reactance (13). In this way, Advertising Theory is proactive, instead of reactive like most classical behavioral theories in public health. Therefore, this theory will make up the basis of the proposed framework to a new public health approach. This framework requires public health professionals to take three major actions: to send out a single coherent message rather than multiple conflicting messages, to understand their target audience using core values, and to ensure sustained behavior change through the use of compelling evidence. These components will help to transform the way the public views issues of climate change by using concrete, solution-centered approaches.
A Single Coherent Message
Conflict among public health professionals has rendered the climate change experts discredited in the eyes of the public (6). These inconsistencies, coupled with alarmist notions that are rarely backed by supporting evidence, not only keep people from engaging in environmentally friendly behavior, but can drive them to engage in increasingly detrimental behavior (5, 6, 10).
Public health campaigns often do a good job of letting the public know expressing the gravity of a situation (7, 8). However, they are unable to provide a clear solution to the problem while giving the public any incentive to do something about it (6, 7, 13). Data shows that people care most about family and future generations and the effect climate change will have on them, which is another source of a framing angle (5, 6).
In focusing on positive solutions, the field will no longer further destroy its reputation among the public by constantly reinforcing preconceptions about the controversies surrounding climate change (6). As a result, the effectiveness of the public health message will no longer depend on changing people’s attitudes about climate change. Rather, the message will directly change their behavior, which is the goal of public health interventions. Once people change their behavior, cognitive dissonance will kick in, and they will change their attitude regarding that behavior, and the change will be sustained. The important thing is that the public health field shifts their focus from anything of uncertainty to only things of certainty (6, 10).
Understanding the Target Audience
Messages that emphasize man-made climate change, make predictions in trends and outcomes of climate change, and speculate as to the exact causes of climate change, have for the most part been unsuccessful (1, 3). Further, the people generally responsive to current climate change messages tend to have already bought into the idea of climate change, and are likely to already be engaging in environmentally friendly behavior (5, 8). This counter-intuitive effect is because traditional climate change messages have tried to impose the public health community’s beliefs on the audience, rather than taking the time to understand the beliefs of the audience, and then appealing to it (13).
Many public health professionals may counter the use of advertising theory in public health campaigns, with the idea that public health messages should not have to be packaged, nor should they be framed to appeal to the audience; people should intrinsically want to mitigate climate change (1, 6). However altruistic this assumption, it is not realistic. The fact is that people respond to messages that align with their beliefs (13). If a person does not believe in the notion of man-made climate change, he will not be responsive to a message with requiring belief in man-made climate change as the core value.
In understanding the target audience, public health professionals will be able to use appropriate values to frame their messages in various ways, giving the messages universal appeal (7, 8, 13, 16). Each message can then be framed in multiple ways. For example, public health professionals selling the use of alternative energy sources can frame their message as either being an opportunity to free the US from oil dependence, for those who value patriotism and freedom, or they could emphasize the importance of legacy and longevity, for those who value family (5, 6, 10). Another option is to take advantage of psychological reactance by deliberately inducing it in the target audience (6, 7, 13). In understanding that people do not like feeling deceived, using psychological reactance can serve as a viable way to get the audience to rebel against a harmful industry.
Ensuring Change with Compelling Evidence
Statistical evidence is generally ineffective in interventions not only because knowledge rarely leads to behavior change, but more importantly the supporting statistical evidence of climate change is bleak and negative (5, 6). When the promise of a message is then supported by evidence, not statistical evidence, but visible and tangible proof that the promise is real, behavior change is likely to be sustained (6).
Effective messages make people feel good (13). Supporting evidence will also show the audience that in buying into the message, the audience will be joining a group of people who also have been able to attain the same goals – the audience joins a movement (6). These movements can grow to influence policy and ultimately change social norms (6).
Having tapped into the audiences’ core values, the only supporting evidence that is required is the proof that the intervention will help them attain their core values (6, 13). This can be conveyed in something as simple as a story. One person or one community’s story, with whom the target audience can relate, can be exponentially more powerful than any statistical evidence (6).
E. Concluding Remarks
There are various approaches to behavior change, each with its own strengths and weaknesses (7). The current public health approach to climate change, however, is ineffective. The climate is changing quickly, and we have adapted too slowly and ineffectively (3).
In order to successfully get the public to buy into the public health message, the public health community must stop trying to force people to change their behavior (6). Environmental health experts must understand and tap into the ideas and beliefs of their target audiences – the audiences’ core values (6, 13).
People want to be a part of something larger than them, and using advertising theory is an effective way to do that (6, 13). In combination with other behavioral theories and approaches, the public health community can facilitate the creation of new social norms. Climate change campaigns can have little to do with climate change, yet induce behavior changes that will ultimately address the issues of climate change (6, 9, 13). Conveying messages to the public is a very delicate matter; one that can easily fail if handled incorrectly. The responsibility of mitigating climate change rests on the shoulders of today’s public health professionals.

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