Why Calling a Fat Kid a Fat Kid Doesn’t Solve Childhood Obesity -Jessica Ochalek

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

Defeating Self-Efficacy

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

SCAREMONGERING

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

POSITIVITY-MONGERING

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages; physical activity is fun; obese children are also entitled to fun; obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small; anxiety and withdrawal occur when a challenge is too great; curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

CONCLUSION

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

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A Critique of the New York City Department of Health and Mental Hygiene Pouring on the Pounds Campaign - Lauren DeBerry

Obesity
During the past 20 years there has been a dramatic increase in obesity in the United States (1). More than one third of U.S. adults, more than 72 million, people and 17% of U.S. children are obese. From 1980 through 2008, obesity rates for adults have doubled and rates for children have tripled (2). If current trends continue, it is estimated that 75% of Americans will be overweight or obese by 2015 (3). The prevalence of obesity is a serious public health concern because of its health and economic consequences (4,5). Obesity is a major risk factor for cardiovascular disease, certain types of cancer, type 2 diabetes, and lifetime morbidity (4). The medical care costs of obesity in the United States are increasing with the increase rate of obesity. In 2008 dollars, these costs totaled about $147 billion a large share of which is being paid for by Medicare and Medicaid (5). The Center for Disease Control and Prevention (CDC) states that obesity results from an energy imbalance. This involves consuming too many calories and not getting enough physical activity (6). According to government surveys, the number one source of calories in the American diet is sugar-sweetened beverages, representing 7 percent of the average person’s caloric intake and up to 10 percent for children and teenagers. These calories are worse than useless because they are empty, and contribute to a daily total that is already too high (7,8,9). In 2009, the New York City Department of Health and Mental Hygiene implemented the Pouring on the Pounds campaign in order to highlight the health impact of sweetened drinks (10).

Pouring on the Pounds
New York City is comprised of five counties, Bronx, Kings, New York, Queens, and Richmond (11). The 2008 age adjusted estimates of the percentage of adults who ware obese in these counties were 28.3%, 24.2%, 16.1%, 23.5% and 24.6% (3). In an effort to highlight the health impact of sweetened drinks and address this increasing rates of obesity, the New York City Department of Health and Mental Hygiene asked New Yorkers “Are you pouring on the pounds?” The agency’s public-awareness campaign was comprised of posters in the subway system and a multilingual Health Bulletins and public service announcements. 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 campaign attempted to disgust and shock people into changing their consumption of sugar-sweetened beverages to water, seltzer, unsweetened tea or low-fat milk instead (11).
The pouring on the pounds campaign is deeply rooted in the health belief model. The health belief model stipulates that a person's health-related behavior depends on the person's perception of four critical areas: the severity of a potential illness, the person's susceptibility to that illness, the benefits of taking a preventive action, and the barriers to taking that action (12). The New York City Department of Health and Mental Hygiene expected to change New Yorker’s drinking habits by simply educating the public on their susceptibility to obesity and the severity of obesity. Although this was a good starting point in developing the campaign they missed the mark on a few important issues; the campaign did not fully express the benefits and barriers/cost of removing the benefits of removing sugar sweetened beverages from your diet, the campaign ignores advertising theory, and the campaign does not account for behavior influenced by context.

Benefits and Barriers
As previously discussed, The New York City Department of Health and Mental Hygiene Pouring on the Pounds campaign focused on one’s susceptibility to and the severity of obesity. The campaign’s signature image was a bottle of soda, “sports”drink or sweetened iced tea turns to a blob of fat as it reaches the glass. They also showed images of the amount of sugar in sugar sweetened beverages, an obese person in a wheelchair, a man in cardiac arrest, and a foot mangled by diabetes (10, 13). If the NYCDHMH was following The Health Belief Model these images were necessary, however, images of the perceived costs/barriers and benefits should have been included as well (12).
The most important barriers to address when attempting to switch someone from sugar sweetened beverages to healthier alternatives are the ability of the alternative choices and the social and finical cost of the switch. The campaign never shows a person making the healthy choice and therefore never highlights the ease to making said choice. If a person does not regularly consume water, seltzer unsweetened tea or milk they may be unaware of its wide availability. Most stores, restaurants and vending machines that sell sugar sweetened beverages also sell the alternatives suggest although the option my not be as clearly advertised (example vending machines that list water as the lowest option).
The campaign dose not address the financial cost of switching from sugar sweetened beverages to healthier options. Since the beginning of the recession the media is constantly discussing the increased cost of living. One of the many way they express this is with stories about the increase cost of milk, one of the suggested healthy drinks in the campaign (14,15,16,17). If the campaign want to succeed in switching New Yorker to healthy drinks they must express its effect on the on the consumers wallet.
Another flaw in the campaign is it does not the social cost of removing sugar sweetened beverages from one’s diet. Sugar sweetened beverages are embedded traditions In the United States. Manufacturers of sugar sweetened beverages have associated themselves with everything from sporting events to Christmas (18,19). This makes the perceived cost breaking life long habits and violating social norms. Although the campaign aims at changing life-long habits, if fails to connect healthy habits to the activities usually associated with sugar sweetened beverages in order to display the new habit will not conflict with social norms.
Pouring on the pounds never expresses the benefits of switching sugar sweetened beverages for healthier options. The campaign mention the avoidance of weight gain obesity and diabetes but never mentions how switching can change one’s life (10,11,13). The campaign never mentions that removing one can of soda a day can result in losing 10 pounds a year (19). The ads also fail to mention the many health and beauty benefits of drinking water and milk. By omitting these benefits The New York City Department of Health and Mental Hygiene misses out on providing an enticing promise to their audience.

Advertising Theory
The manufactures of sugar sweetened beverages have used advertising and marketing theory to sell their products for years. The New York City Department of Health and Mental Hygiene wants its campaign to compete with them therefore they should use advertising and marketing theory as well. The Pouring on the Pounds campaign does a good job with branding. The campaign used its catchphrase “Are you pouring on the pounds?” and its signature image on most of their materials making the campaign recognizable to the viewer. The campaign also used the diffusion of innovations theory well by having their videos on the Internet enabling them to go viral, but it can be found lacking many other important elements of advertising theory (10,20). The campaign fails to use core values to create universal appeal and lacks a promise.
The core values that work for persuading the American public are: family, love, success, hard work, freedom, fairness, belonging, attractiveness, sex, youth, rebelliousness, and power. Companies like Coca Cola and Pepsi have used theses values time and again to sell their sell their product (21-26). Some of the common core values used in sugar sweetened beverages advertisements are belonging, attractiveness, sex, and youth. The Pouring on the Pounds campaign does not use one of these values in fact they show images of young attractive people drinking the very drinks they are trying to discourage people from drinking (13). If the campaign utilized the core values they would have a more convincing argument and would likely reach more people.
According to David Ogilvy, a prominent copy writer from the 1960s, the key to a successful advertising campaign is its promise (20). The promise is made by the messenger about the idea they are selling. The audience is driven by the promise. Strong promises usually include one or more of the core values of the audience. The stronger the promise the more effective the effective the campaign (20,27). Considering the Pouring on the Pounds campaign was trying to compete with sugar sweetened beverages advertising campaigns it is a surprise they choose to not include a promise in their posters and video. NYCDHMH could have promised New Yorkers happiness, belonging, attractiveness, sex, youth or love among many other things to encourage people to drink healthier beverages. The pouring on the pounds campaign has an advantage over the sugar sweetened beverages makers in that their promise can be backed up with real proof, another key part of advertising theory. The NYCDHMH already has scientific studies at their disposable showing the health and beauty benefits of increased water consumption and decreased sugary drink consumption.

Behavior in Context
NYCDHMH assumes with its Pouring on the Pounds campaign that behavior is planned and rational. The campaign expects that by viewing their ads, people will be disgusted or shocked and decide to eliminate or reduce sugar sweetened beverages from their diet. This idea may work for people in who are consuming beverages when they are not thirsty or hungry but will not be as effective for those who are. During exposure to the ad, people might discard their beverages or avoid drinking sugar sweetened beverages for a few hours but what happens when that person develops the desire to quench their thirst (28,29)? The campaign disregards the concept that human behavior is dynamic and that it is influenced by context (28,29). Many things including hunger, thirst, and sexual desire can induce a hot state. In a hot state people’s behavior is instinctive unreasoning and irrational (28,29).
Research has shown, instinctive factors can change desires rapidly as they are affected by changing internal and external stimuli (28). For example, a person can see the Pouring on the Pounds ad in the subway on their way to work and decide to stop drinking sugar sweetened beverages. Later on their lunch break when they are hungry and thirsty, the person goes to a deli to get lunch. Seeing the vast variety of drinks offered as well as enticing images, they may forget their desire to remove sugar sweetened beverages from their diet. Exposure to images and menu options at the store or restaurant will now influence their purchasing behavior. This concept suggests that the environmental context has a greater impact on eating and drinking habits. The Pouring on the Pounds campaign would have a greater impact on viewers if they sought to intervene when the viewer is in the hot state.

Improving Pouring in the Pounds
Although the pouring on the pounds campaign had a few flaws it would be advantageous for the New York City Department of Health and Mental Hygiene to address those flaws rather than develop a new campaign. Because the brand messaging was well developed, it would be helpful to consumers to identify the campaign to keep the tag line.
In addition to the posters and videos the campaign already used, the campaign should develop a new series of videos that the highlight the benefits of reducing consumption of sugar sweeten beverages . The first video show a man in the convenience store reaching for a water or other unsweetened drink in slow motion. As the man gets closer to the water, you see him becoming slimmer illustrating the weight loss achievable if you do not drink sugar sweetened beverages. As the video is running a voice will be heard saying “Removing sugary drinks can result in 10 pounds weight loss.”Then the tag line will appear as well as a prompt to friend the campaign on Facebook. The second video will be set in an office. It can show three co-workers in the break room getting ready for lunch. Two of them, a thin and attractive man and women, will have reusable bottles of water one filling his up with the cooler. The third work, chubby, will be digging around in his pockets for money before asking the others for a dollar to buy a soda. As the women reaches into her purse she will smile say “It’s a good thing I’m saving so much money bring my own water to work. You should try it. ”and laughs. The soda drinker takes the money and says “Thanks boss” The next screen will show the average savings you can make by switching from sugary beverages to unsweetened beverages. Then the tag line will appear as well as a prompt to friend the campaign on Facebook. The next video could show a groups of happy fit young adults wearing matching team uniforms carrying a large trophy grabbing water and milk from the cooler pushing aside the sports drinks and sodas. As the camera pans out, you see the losing team drinking sports drinks. The announcer will say another benefit of drinking unsweetened beverages “Drinking low fat milk can help you build strong bones and keep you lean.” Then the tag line will appear as well as a prompt to friend the campaign on Facebook. The final video will show a young women walking along the refrigerated aisle in a bodega. She continual walks past cooler after cooler of soda and fruit punch. Finally she reaches the cooler with the water and as she reaches for a bottle her hand brushes against another had. She looks up for find a handsome man holding a bottle of water. He smiles a knowing smile at her and they begin to talk. The announce will say “Replacing soda with water can help you stay hydrated and you complexion looking young.” Then the tag line will appear as well as a prompt to friend the campaign on Facebook.
In conjunction to the new videos there will be a Facebook campaign. Facebook is important to the campaign because of it make the messenger seem more like the viewer and allows for grater access. Using Facebook allows the campaign to provide a community for people to discuss ideas and information about the campaign and its ideas. The campaign can use Facebook send out facts and reminders about sugar sweetened beverages and advertise events relating to the campaign. Facebook is unique in that it can provide an online community setting even for those who do not have regular access to computers. African-Americans and English-speaking Latinos are among the most active users of the mobile web (30). These ethnic backgrounds also have disproportionate rates of obesity. By utilizing Facebook the campaign can reach more people than by using the government run website as Facebook had applications for most mobile phones.
One of the events that will be advertised on facebook will the the trade in your sugar events. The campaign will go to both busy tourist locations and areas populated by office workers. Here they will have young happy attractive people in Pouring on the Pounds t-shirts asking people to trade in their sugar sweetened beverages for recommended drinks or reusable water bottles labeled with the Pouring on the Pounds tag line on one side and a fact about sugar sweetened beverages on the other. Some of these can be done as flash mob style surprising unsuspecting workers during their lunch break while others will be advertised on the facebook page. If they events are successful they could be filmed and aired in the vein of the truth campaign advertisements (31) .
The final improvement to the campaign would be the placement and content of the print advertisements. The NYCDHMH chose to run the ads in the subway system where people are not allowed to eat. They should place the in locations where people would be likely to see them as they were one their way to eat such as billboards close to fast food restaurants or posters in delis. The Pouring on the Pounds campaign should also run its commercials during eating hours so people at home can be reached in the hot state as well.

Defense of the improved Pouring on the Pounds
Each of these improvements address the what was missing in the campaign. The new commercials clearly discuss the benefits of the behavior change and each video can address the many different benefits both health the beauty of switching from drinking sugar sweetened beverages to unsweetened beverages. The advertisements also subtly show and dispel the perceived barriers to the switching from drinking sugar sweetened to unsweetened drinks. By showing people saving by money by not drinking sugar sweetened beverages and by showing that in stores filled with sugar sweetened beverages you can still find healthy options as in the second and fourth videos, The barriers are proven wrong with out specifically calling the barriers to the mind of the viewer and turning them off to the message.
Each commercial uses advertising theory. The commercial promises the viewer attractiveness. The second commercial promises wealth and belonging while also highlighting the core value of power since the boss is drinking water she brought from home. The commercial with the team uses the core values of happiness youth attractiveness and success. The promise of being a winner should compel the viewer to change their behavior. The final commercial employs the core values of youth, attractiveness, love and sex to show the viewer that replacing sugar sweetened beverages from their diet can be beneficial to their life. As the campaign continues the NYCDHMH can add new commercials to that highlight other key core values keeping the campaign in touch with New Yorkers’values and targeting new demographics.
The use of Facebook, in addition to providing increased access, creates a community. This will tap into the viewers’core value of belonging as well. Using facebook correctly can also keep followers informed on the issue as well as provide reminders of the need for behavior change.
Finally by placing the strategically placing advertisements in and around places of consumption the new campaign can reach viewer in the hot state where they are more less rational and forget previous messages to attempt to enact behavior change. The new Pouring on the Pounds Campaign also reaches people in the hot state by asking them to trade in their beverages during their lunch breaks.
The New Pouring on the Pounds campaign should be successful. If The New York City Department of Health and Mental Hygiene took advantage of its many different resources and employed the use of different behavior change theories they will be successful in any campaign they attempt.

References
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8 Schulze, M. B. (2004). Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women JAMA: The Journal of the American Medical Association, 292(8), 927 934. doi:10.1001/jama.292.8.927

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18 Gómez, L., Jacoby, E. & et all. (2011). Sponsorship of physical activity programs by the sweetened beverages industry: Public health or public relations? Retrieved 4/30/2011, 2011, from http://74.125.155.132/scholar?q=cache:g2NTDsKZ0McJ:scholar.google.com/+pouring+on+the+pounds+new+york+"pouring+on+the+pounds"&hl=en&as_sdt=1,22

19 Hill, J. O. (2003). Obesity and the environment: Where do we go from here? Science, 299(5608), 853 855. doi:10.1126/science.1079857

20 Ogilvy, D. (1964). How to build great campaigns (chapter 5). 
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24 Kiley, D. (2009). New pepsi ads hit and miss as they try and ride obama's ascension - BusinessWeek., 2011, from http://www.businessweek.com/the_thread/brandnewday/archives/2009/01/new_pepsi_ads_hit_and_miss_as_they_try_and_ride_obamas_ascension.html

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Fear as a tool to promote healthy driving habits - Stephanie Reynolds-Bigby

Scope of the Problem
With nearly 260 million motor vehicles on U.S. streets, it is to be expected that there would be a number of deaths due to motor vehicle accidents in this country each year. (5) However, statistics show that the number of deaths due to this preventable situation is staggering. According to the CDC’s Web-based Injury Statistics and Query and Reporting System, unintentional injuries, including motor vehicle crashes, are among the leading cause of death for 5-34 year olds in the U.S. (1) The 30,797 fatal automobile crashes reported in the U. S. in 2009, resulted in 33,808 deaths. Of these deaths, about half (17,640) were drivers. The rest were passengers, pedestrians, motorcyclists and others who share the streets and highways. (4) In addition, 2.3 million adult drivers and passengers were treated in emergency rooms for motor vehicle related non-fatal injuries that same year. (2) The economic impact of motor vehicle accidents is also notable. In 2005, the lifetime costs of crash-related deaths and injuries for drivers and passengers amounted to near $70 billion. (3)
This problem remains at the forefront of public health efforts because of its preventability. Statistics show that seat belt use in motor vehicle accidents reduces the risk of fatal injuries by about 45% and the risk of serious injuries by about 50%. (6) Seatbelt use is also considered the most effective current intervention available for prevention of fatalities in motor vehicle accidents. (7) However, other interventions such as the use of air bags and motorcycle helmets and institution of minimum drinking-age laws are still known to save lives. (7) Thus, many current public health campaigns aimed at reducing the number of fatalities and injuries caused by motor vehicle accidents encourage the use of these interventions.

Current Initiatives
Current public health initiatives to reduce fatalities and injuries due to motor vehicle accidents primarily focus on seatbelt use, distracted driving, and impaired driving. Other initiatives involve proper use of child restraints, motorcycle helmets, and certain pedestrian safety habits. However, these initiatives address issues that have a smaller impact when compared to the primary initiatives. (7)
The CDC makes recommendations for governments to prevent impaired driving (driving while under the influence of drugs and alcohol). Such current recommendations include using ignition interlock programs to prevent any drivers above a certain blood alcohol content from starting a vehicle, enforcing minimum drinking law ages to reduce access to influential substances, and implementing sobriety checkpoints to actively identify drivers who are under the influence of alcohol or drugs as well as using public media to discourage driving while under the influence. (8) The CDC makes similar recommendations for addressing seatbelt use and distracted driving.
Social media campaigns are the primary means of informing the public of new efforts and enacting change in their behavior. Programs such as the Put it Down campaign against distracted driving, Buckle Up: Click It or Ticket to encourage seatbelt use, and the innumerable social media campaigns against drunk driving all act to inform the public of the efforts being taken by the government as well as to promote a particular ‘healthy’ behavior on the parts of individuals in the public.

Flaws of current practice
Each of these public health campaigns has a social media component that is intended to promote a certain behavior. The primary tactic used to encourage safer practices in motor vehicles uses fear of the consequences to spark change in behavior of motorists and their passengers. The use of fear as the primary motivating factor has flaws that reduce the effectiveness of the campaigns that use it. These flaws can ultimately be grouped as three particular issues: 1- lack of relatability, 2- showing statistics, and 3- telling the audience what to do. Yet, numerous campaigns contain these aspects which have been shown as ineffective and sometimes even counter-effective.
Many public health campaigns are ineffective because the intended audience is unable to relate to the message. In order to appeal to the intended audience, a campaign should take advantage of the similarity principle. This principle states that an individual is more accepting of a message from a source to which he can relate. The similarity principle is based on the idea that an individual can more easily trust a source to which he relates. The development of trust by relating visual or bonding over shared interests, morals, or values makes the use of this principle easily applicable to social media campaigns.
Current campaigns generally use adults or individuals in positions of authority to convey a message of fear of consequences. This is true of almost all campaigns aimed at promoting safe driving habits. Campaigns such as Click It or Ticket and You Drink and Drive. You Lose use police authority to threaten the public with fines and incarceration for not abiding by the law. Implementing fear tactics reduces the ability of the target audience to relate to the senders of the message. Since trust does not develop between the public and the police in these campaigns, the potential effectiveness of the campaign is not attained.
Another method that has been used in multiple campaigns to induce fear and enact change is the presentation of health statistics around the behavior of interest. The presentation of statistics relies on the health belief model. The health belief model suggests that if an individual knows the risks involved in a certain behavior, they will weigh the risks against the benefits and make a decision accordingly. It states that an individual’s health decisions are made based on the individual’s perceived seriousness of the danger, susceptibility to the danger, benefits of the behavior change and barriers to behavior change.
Many current public health campaigns still rely on this outdated model which encourages public health practitioners to inform individuals of their risk of disease in order to elicit a particular ‘healthy’ behavior. Studies show however, that when the behavior of interest is linked to the individual’s self esteem, reminders of risk encourage the very behavior it is intended to change. (9) This is due to the fundamental attribution error that generally occurs. In this instance, there is a de-emphasis of the context in which the behavior occurs and overemphasis on the flaws of the individual’s character. In these cases, the Terror Management Health Model is unintentionally used, reinforcing the behavior.
The use of statistics as a means of discouraging a particular behavior is one way in which the terror management model can inadvertently be used. Many of the campaigns used to encourage seatbelt use, or discourage distracted or impaired driving offer statistics of death and injuries related to these behaviors.
The third major flaw of current public health initiatives to encourage safe driving habits is that they take away the individual’s freedom to choose what behavior is best. Although it may seem necessary for a public health campaign to explicitly state the behavior that it intends to encourage, it often results in the opposite behavior. This is due to the Psychological Reactance Theory that results when an individual feels that their freedom to choose is threatened. In the 1981 study Psychological reactance and the attractiveness of unobtainable objects: Sex differences in children's responses to an elimination of freedom Brehm demonstrated this principle with toddlers by showing two toy options but limiting their access to only one of the toys. (12)
Other studies have shown that psychological reactance can be deflected by increasing the credibility of the message and rewording the message to have an open, positive connotation rather than a controlling, negative one. (11) Informing individuals rather than forcing opinions on them, allows them to choose the behavior in which they prefer to engage. By phrasing the message correctly, the campaign can take advantage of psychological reactance and encourage a particular behavior without infringing on the public’s sense of choice.
The similarity principle can also help to deflect psychological reactance by using a messenger that is similar to the target audience. (10) In this way the message is portrayed less as a loss of freedom and more as a positive social pressure. It is still important that the message have the proper framing in order to limit the loss of freedom.

Overcoming the Flaws
Fear is generally not an effective public health tool. Intimidation and control are two means of inducing fear. Each of the flaws of fear as a public health tactic can be addressed in numerous ways. The examples mentioned previously (using the similarity principle and removing the controlling tone of the message) are ones that should be implemented in every public health campaign to maximize the effectiveness of the campaign. However, other methods exist to correct for these flaws.
In order to make the message relateable to the audience, the campaign should contain individuals who are similar to the target audience. They can share a story that conveys the intended message and that individuals who see the message will be touched by and can relate to. This tactic will follow the similarity principle, but can still show the consequences of the undesirable action.
The flaw with showing statistics is that it can cause terror management in some individuals. This can cause the opposite of the desired behavior as a coping mechanism. In order to avoid this, the campaign can use the exchange principle in place of presenting statistics. Offering something in exchange for the desired behavior removes stress caused by labeling the negative behavior as a character imperfection.
The third flaw, psychological reactance, can be addressed by giving ownership to the individuals who hear the message. This can be done through the proper framing of the message to make it a choice. However, creating a community helps to reinforce the ownership of their decision. This method has been successfully implemented in other public health campaigns such as the movement in Massachusetts called The 84 which is a community of Massachusetts teenagers who choose not to smoke.

An Alternative Intervention
One way to implement all of these new interventions and avoid the flaws of inducing fear, is to create a community, like The 84, for people who choose to practice safe driving habits. For example, the organization can be called How I Ride, and have a website where people can maintain a social network, add their friends or make new ones, be informed about exciting How I Ride events, and purchase How I Ride gear, such as clothing, accessories, stickers, and other enticing trinkets.
In order to gain a strong following, the organization can use members of its target audience to create appealing commercials that encourage members of the public to join the movement. The format of the commercials can be a series of scenes in which each of the members of the community says, “this is How I Ride” and drives off while demonstrating the safe practices. But each individual would have to do something unique that is both appealing to the target audience and safe. For example, one scene can show a teenage boy in a car with his seatbelt fastened and a really attractive girl in the passenger seat, while another shows a teenage girl putting away her cell phone before getting in the car after a fun day at the mall. Similar commercials should also be made to target people in all walks of life: children, young professionals, heads of households, etc.
After the following grows to a certain point, recruitment may no longer be necessary if social pressures encourage those who have not yet joined to open up to these practices. This intervention can be particularly successful in the high risk age group (5-34 years) because of the importance of social acceptance to many individuals in that range.

Conclusion
The use of a new intervention to promote safe driving habits such as using a seatbelt and not engaging in impaired or distracted driving is necessary since a large number of preventable deaths still occur each year. The current initiatives employ scare tactics in an attempt to force the public to adopt these behaviors. Creating an open inviting community where these practices are part of the social norm and individuals have the option to join or not can employ different methods to coerce the gradual shift of these practices from being a stigmatized behavior to simply unrepresentative of the social norm.

References
CDC. WISQARS (Web-based Injury Statistics Query and Reporting System). Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available athttp://www.cdc.gov/injury/wisqars.

CDC. Vital Signs: Nonfatal, motor vehicle-occupant injuries (2009) and seat belt use (2008) among adults—United States. MMWR 2011; 59.

Naumann RB, Dellinger AM, Zaloshnja E, Lawrence BA, Miller TR. Incidence and total lifetime costs of motor vehicle-related fatal and nonfatal injury by road user type, United States, 2005. Traffic Inj Prev 2010;11:353-60.

National Highway Traffic Safety Administration. FARS (Fatality Analysis Reporting System) Data Tables. Available at http://www-fars.nhtsa.dot.gov/Main/index/aspx.

Bureau of Transportation Statistics. Research and Innovative Technology Administration. Table 1-11: Number of U.S. Aircraft, Vehicles, Vessels, and Other Conveyances. Available at http://www.bts.gov/publication/national _transportation_statistics/html/table_01_11.html.

National Highway Traffic Safety Administration. Final regulatory impact analysis amendment to Federal Motor Vehicle Safety Standard 208. Passenger car front seat occupant protection. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 1984. Publication no. DOT-HS-806-572. Available at http://www-nrd.nhtsa.dot.gov/pubs/806572.pdf.

National Highway Traffic Safety Administration. Lives saved in 2009 by restraint use and minimum-drinking-age laws. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2010. Publication no. DOT-HS-811-383. Available at http://www-nrd.nhtsa.dot.gov/pubs/811383.pdf.

CDC. Injury Prevention & Control: Motor Vehicle Safety. Impaired Driving: Research & Activities. Available at http://www.cdc.gov/Motorvehiclesafety/Impaired_Driving/research.html.

Taubman Ben-Ari, O., Florian, V., & Mikulincer, M. (1999). The impact of mortality salience on reckless driving--A test of terror management mechanisms. Journal of Personality and Social Psychology, 76, 35-45.

Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 27, 277–284.

Miller, C. H., Lane, L. T., Deatrick, L. M., Young, A. M., & Potts, K. A. (2007). Psychological reactance and promotional health messages: The effects of controlling language, lexical concreteness, and the restoration of freedom. Human Communication Research, 33, 219-240.

Brehm, Sharon S. (1981). Psychological reactance and the attractiveness of unobtainable objects: Sex differences in children's responses to an elimination of freedom. Sex Roles, Volume 7, Number 9,937-949.

Shortfalls of the In Our Own Voice Educational Campaign and an Alternative Campaign for Reducing Stigma in Mental Illness - Elizabeth Thompson

Mental illness is widespread in the United States. According to data available through the National Institute of Health’s National Institute of Mental Health over 25% of adults ages 18 and over are diagnosable for one or more mental disorders in any given year(1). Of the estimated 25% of American adults living with mental illness, 22% are considered severely mentally ill (1). The definition of serious mental illness includes such life altering situations as a suicide attempt in the preceding 12 months, an inability to work, and an impulse control disorder with repeated serious violence, among other things (2). Though the number of people with mental illness is overwhelming, more daunting is that 59% of those people do not receive any treatment for their illness (3).

A major concern, along with the 59% of diagnosed mentally ill who do not receive treatment, is the very large estimated number of people with an undiagnosed mental illness. The number is difficult to estimate, but a study published in 2001 in the Annals of Emerging Medicine was undertaken, in part, to approximate the number of people with a mental illness who go undiagnosed (4). The study showed that while 42% of participating patients entering an emergency room had a psychiatric diagnosis according to a computer administrated PRIME-MD exam, only 5% received a diagnosis from the physician, even when the physician was given the PRIME-MD result (4). This suggests that there are a large number of people diagnosable for mental illnesses who are not.

From these data, it is clear that there are Americans living with serious mental illnesses without treatment, either as people who were never diagnosed or as people who were diagnosed but didn’t receive treatment. Addressing the issues relating to why these people go untreated is an interesting and important public health issue. One explanation for the number of patients going untreated is the stigma associated with a mental health issue. There are programs which state their goal as reducing stigma about mental health issues and thereby breaking down barriers to seek care for those suffering a mental illness. These programs fall short of their goal, however, as will be exemplified by the In Our Own Voice campaign.

In Our Own Voice

The National Alliance on Mental Illness is a grassroots organization founded in 1979. NAMI’s organizational goal is to improve the lives of individuals and families affected by mental illness (5). The In Our Own Voice is a campaign run by NAMI, introduced in 1996 as Living with Schizophrenia. As time went on, people with a variety of mental illnesses participated and the program’s name was changed. Since that time, approximately 2,000 presenters have been trained to conduct an In Our Own Voice presentation and over 200,000 audience members have been reached (5). IOOV is an educational lecture series given by those with a mental illness to the general public at organized speaking engagements. An IOOV presentation is given at the request of an organization. Each IOOV lecture has 5 parts, Dark Days, Acceptance, Treatment, Coping Skills and Successes, Hopes and Dreams (5). The lecture is given by two people, referred to as consumers, who have a mental illness in recovery. Recovery is defined by NAMI as: “the point in someone's illness in which the illness is no longer the first and foremost part of his or her life, no longer the essence of all his or her existence. Ultimately, recovery is about attitude and making the effort” (5). NAMI defines the goal of IOOV as providing education to the public about mental illness by involving those with mental illness.

In Our Own Voice has several drawbacks. The campaign does a good job with regards to the issue of the reducing the self stigma of those with a mental illness diagnosis. It allows those with a mental illness to work, to engage with the public and to take ownership of their disease. However, it does not work effectively to educate the public about mental illness or reduce the stigma about those with the diseases. The lack of focus in reducing public stigma derives from the NAMI definition of recovery, from the requirement of an invitation to speak, which limits the scope of the message and from the fact that the only people to speak at these events are those in the stigmatized group.

Lecture from the Out-Group Member

Rosenhan writes “Psychiatric diagnoses carry with them personal, legal and social stigmas”(6). Corrigan states that stigma on the mentally ill leads to difficulty for the stigmatized in securing employment and housing (7). The social and legal aspects of the stigma are the result of intergroup bias. Per the intergroup theory, intergroup bias refers to the tendency to view one’s own group, the “in-group”, more favorably than the other, “out-group” and its members (8). Chester Insko found in an experimental study that there is trust extended to in-group members, but not to out-group members (9). This lack of trust can have a negative impact on out-group members in their day to day lives, but also in their IOOV lecture, degrading their message.

The cornerstone of the IOOV lecture series is that the presentation is given by two people with mental health issues. These lecturers are trained by the NAMI organization to talk about their disorders and that disorder’s ramification on their lives. Though this is empowering for those that give the speech, the power of the message is weakened by this structure. Those hearing the lecture are members of organizations that invite IOOV to speak, most often schools and work-places. Therefore, those receiving the message are not members of the mental health community, and so, would classify the lecturers as part of the “out-group”, according the intergroup theory.

According to Marilynn Brewer, it is not always the case that in-group favoritism and out-group negativity are reciprocally related (10). It can be the case that the in-group views themselves more highly than those unlike them, but shows the out-group only indifference (10). If the IOOV lecture was able to avoid that hostility, then the program could work. However, when out-groups do not share the same social norms, indifference is replaced by fear, disgust and contempt (10, 11). Various studies have found that those with mental illnesses are believed to be dangerous, violent, fear provoking and unpredictable by the general public (7, 12, 13). These behaviors are not the social norms held by the general population, therefore the mentally ill are considered a hostile “out-group”.

Since the mentally ill are viewed as a hostile out-group, there is a serious deficiency in the IOOV structure, since its only two speakers are members of the mentally ill out-group. The in-group views them as untrustworthy (10), so their message is not readily believed. Additionally, the out-group does not easily engender empathy in members of the in-group (10), so even the most touching and powerful stories in the IOOV lecture series lacks persuasive force.

Recovery as an Issue of Perception

The NAMI website states that: “mental illnesses are serious medical illnesses. They cannot be overcome through ‘will power’ and are not related to a person's ‘character’ or intelligence”(5). The IOOV educational series however, has a different message with regards to recovery stating:

[R]ecovery is not a singular event, but a multi-dimensional, multi-linear journey characterized more by the mindset of the one taking it than by his or her condition at any given moment along the way. Understanding recovery as having several dimensions makes its uneven course easier to accept… Recovery is the point in someone's illness in which the illness is no longer the first and foremost part of his or her life, no longer the essence of all his or her existence. Ultimately, recovery is about attitude and making the effort (5).

This angle again focuses on speaker empowerment at the expense of the power of its message to those who are being spoken to. The IOOV lecture furthers the stereotype that those with mental illness have a lack of willpower and desire to be well.

The medical community at large has generally embraced a holistic approach to the treatment of those with mental illness. The best known is the assertive community treatment (ACT) model, in which intervention teams take a holistic approach to providing services, helping with medications, housing, finances and everyday problems in living (14, 15). Another holistic approach is the more medically centered Intensive Case Management model (ICM) (16). Both the ACT and ICM methods have shown a decrease in symptoms among those treated and an increase in quality of life compared with their baseline treatment method (17). The Illness Management and Recovery model is a structured program that helps those with severe mental illness learn effective ways to manage illness and pursue recovery goals (16). It would be more in line with these views in the medical community and with the greater NAMI organization if the message within the IOOV lecture portrayed mental illness as a medical issue with a complex and varied treatment plan required to achieve recovery, as opposed to the mind over matter approach it utilizes.

Even if recovery could be achieved with a change in the attitude towards the diagnosis in the eyes of the affected, the ability to achieve recovery and shed the title of mentally ill is not held by the population at large. Research published in 1979 by Rosenhan showed experimentally that for 8 healthy volunteers, once labeled with a mental health diagnosis, it was impossible to be re-labeled as “sane”. In his experiment, the volunteers were admitted into a mental health hospital with the diagnosis of schizophrenia. Their hospitalization lasted anywhere from 7 to 52 days, with an average length of stay of 19 days. All were discharged with the diagnosis of schizophrenia in remission. None of these patients showed any symptoms of schizophrenia in the clinical setting, yet they could not be “cured” from the illness (6). Given the social stigma of mental illness, this can be a significantly limiting label and one that is lasting. Thus, even if no longer symptomatic, the negative effects of the mental illness label brand the person as mentally ill and they are unable to move beyond the label and have it fade into the background of their lives.

Limited Scope of the Message

IOOV purports that the power of their format is that the audience benefits from the personal stories of mental illness and recovery, since they learn, first hand, what it means to have a serious mental illness and how the recovery process works (5). This view is supported by the literature. According to Solomon Asch’s Normative Social Influence theory, people will generally conform to the beliefs of the majority in order to seem like them (18). Though the majority of the research on this theory was done in the 1950s and 60s, experimental tests on a variety of topics done recently show that people continue to conform. A study performed in 2008 on reasons that Californians conserve natural resources found that descriptive normative beliefs were more predictive of behavior than were other relevant beliefs and that that normative social influence produced the greatest change in behavior compared to information highlighting other reasons to conserve (19). This shows that normative messages can be a powerful lever of persuasion.

Unfortunately, the scope of IOOV is too limited to have a profound effect on the generally held beliefs about the mentally ill. From 1996 to 2007, about 200,000 people heard an IOOV lecture. This is only two-thirds of the population of the city of Boston (20) and much less than one percent of the American public. Such negative characteristics as untrustworthiness, aggressiveness and disturbance inducing still persist about those with mental illness (21). In order to use normative social influence theory to its fullest extent, and thus reduce or abolish these negative stereotypes, a more aggressive approach must be used, targeting the general public.

The Stop Mental Health Bullying Campaign

The goal of IOOV is to provide education to the public about mental illness by involving those with mental illnesses. The campaign successfully reduces self stigma in those who suffer from mental health issues by providing them training to be an IOOV lecturer, a job and a purpose. However, IOOV is not effective in the first part of its goal; increasing the public’s knowledge about mental health issues due to the shortcomings mentioned above. I propose a new campaign aimed at reducing the public stigma on those with mental health issues, placing focus on the public’s need to reduce their stigmatizing beliefs. This intervention will be broadly based, so as to be seen by as many people as possible. It will utilize both the mentally ill and the mentally sound, so that there can be messages that are personal yet avoid the “out-group” being the only bearer of the message. Finally, this message will spotlight the difficultly of recovery, the importance of treatment and the integration of the illness into society as something to live with, not hide from.

The first part of the campaign will take advantage of the current awareness of bullying in schools. I propose a radio and television media campaign featuring a school yard scene. Children will be heard taunting another child with phrases like “four-eyes” or “metal mouth” an adult will intervene and scold the child. That scene will end and an adult will say “You don’t let your children call others names, why do you do it those with mental illness?” Then there will be another scene, this time with two adults talking about the behavior or treatment of a colleague. The adult scenes will revolve around talking about erratic behavior, the need for antidepressant or antipsychotic medications or the use of mental health services. The commercials will end with a mental health patient briefly mentioning their illness, their job and their social standing. This will be to encourage the perception that the mentally ill are not an “out-group”, but the “in-group”.

In order to provide an in-depth message about mental illness, there will also be a website that is linked to the commercials. The site will feature personal stories about the damage that stigmatizing beliefs have caused the sufferer. These video testimonials can be linked into popular social media like YouTube and Facebook to maximize views. The site will also include medical professionals to give credence to the information provided by the mental health patient. They will: substantiate their claims that there are organic causes for mental issues, ensure that the mentally ill can be functioning members of society and show evidence that various treatment scan be effective. By using several speakers and several avenues to reach the target audience, I hope the campaign is wide-spread and effective.

Use a Broad Advertisement Base

To achieve the goal of a positive change in public perception of mental illness, the campaign should utilize a broad advertising base, so that as many people as possible are exposed to the message. This can be done by launching the advertisement campaign nationally and framing it in a way that encourages those who see or hear the radio and television messages to go on the internet and view a more in-depth campaign. The message there can contain additional content, videos from mental health professionals talking about the biologic causes of mental illness, mental health patients talking about their disease and its ramifications, common misconceptions about the mentally ill and links to additional resources. The messages on television and on radio should vary, as research shows that varying the message in advertising regarding a product or service can be an effective technique in integrated marketing communications (22). The content of the negative gossip regarding the mentally ill can vary among advertisements, as can the mental health spokesperson at the end of each segment to utilize this theory.

A Multi-Spokesperson Approach

The spokesperson at the end of each advertisement and on the web videos will be a person who has a mental illness or a medical professional in the mental health field. This will take advantage of two theories in order to improve the intervention. The first, the informational social influence theory, states that when a group of individuals give their judgments in the presence of others, the group establishes a range of norms. Those norms persist in the individual once they have been established (23). The second theory, relates to Snyder and Hamilton ideas on the “role model” message. The role model message is delivered by a member of the target audience who has already changed his or her behavior with regards to the target action. This could be done by the family members of people with mental health issues, who have come to realize that the mentally ill should be treated as anyone else with an illness would be. As more and more individuals in society begin to change their thoughts regarding the social and medical treatment of the mentally ill, the national perception can be changed.

Spotlighting Various Treatment Avenues

The Stop Mental Health Bullying campaign will spotlight the various mental health issues and the myriad ways to treat them. There will be advertisements highlighting the many different mental disorders: depression, post-traumatic stress disorder, schizophrenia and bi-polar disorder, for example. Each of these illnesses have different standard treatment regimens, and this will be emphasized. The aspect that IOOV emphasizes, that people can aid their recovery through effort and attitude will be deemphasized in this intervention. This is because there is already a stigma that those with mental illnesses are lazy, indolent and unwilling to recover (24-26). In pointing the theory that the mentally ill can be in control of their own recovery through mental effort, they are furthering this stigma and hurting the group they want to aid.

A study by Farina et. al. exposed groups of students to two different messages regarding mental health patients. One group was shown a message describing mental illness as a disease and the other as a product of social learning. Results showed that those receiving the disease message thought that a victim of mental illness could do less to help himself and herself than did those receiving the social learning message (27). By extension, this provides evidence that change is possible with regards to the current public belief that those with mental illness are lazy and unmotivated. This will hopefully open the door to larger social change, such as more willingly employing those with mental illness and not passing them up because of perceived laziness.

Conclusion

The stigma of mental illness has effects that alter the fabric of the life of the individual suffering the illness. The effects of stigma have been shown to decrease treatment compliance, help-seeking behaviors and self esteem while increasing joblessness, homelessness and the average length of prison sentences (28). Reducing this stigma and the behaviors of the general population that cause it will be an effective way of changing some of the effects of stigma so commonly seen in the mentally ill.

Though the IOOV lecture series is effective in reducing the self-stigma that the mentally ill have for themselves, the program is less effective in reducing the stigma the general population has for them. My intervention is aimed at this general population, targeting them through the informational social influence theory, the principals of the “role model” model, and integrated marketing communications. By utilizing a mixture of theories and models both on the cutting edge of research science and those tried and true methods, I anticipate a modestly successful campaign.

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