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, “Climategate.com,” amongst other organizations, make a mockery out of climate change experts, and serve as resources to the public (11). Climategate.com 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.
 
References
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5. Maibach, E. W., Nisbet, M., Baldwin, P., Akerlof, K., & Diao, G. (2010). Reframing climate change as a public health issue: An exploratory study of public reactions BMC Public Health, 10, 299.
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8. Ebi, K. L., & Semenza, J. C. (2008). Community-based adaptation to the health impacts of climate change American Journal of Preventive Medicine, 35(5), 501-507.
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10. Moser, S. C., & Ekstrom, J. A. (2010). A framework to diagnose barriers to climate change adaptation Proceedings of the National Academy of Sciences of the United States of America, 107(51), 22026-22031.
11. Climategate. Anthropogenic Global Warming, history's biggest scam. www.climategate.com.
12. Folster, S., & Nystrom, J. (2010). Climate policy to defeat the green paradox Ambio, 39(3), 223-235.
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14. Carpenter, C. S., & Pechmann, C. (2011). Exposure to the above the influence antidrug advertisements and adolescent marijuana use in the united states, 2006-2008 American Journal of Public Health, 101(5), 948-954.
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Beat Bullying: All The Right Pieces, Not Fitted Together– Nora Ramirez

Introduction: bullying as a public health issue
Bullying, within the last decades, has escalated from its previous school yard prank to a scale reaching international audiences. Bullying has been defined as “a specific form of aggression, which is intentional, repeated, and involves a disparity of power between the victim and perpetrators”(1). It includes using electronic forms of contact such as email, social network sites, cell phones, and other mass communication tools among individuals in the rising trend of cyberbullying(2). Bullying has been associated with adverse health problems such as loneliness, depression, suicidal risk, impaired academic performance, physical injury, alcohol and drug use(3).
According to the health behavior in school-aged children survey (HBSC), 12% US boys and 11% US girls experienced chronic bullying, while 13% boys and 8% girls did the bullying. In recent years, the manifestation of bullying has become more devastating as victims have no safe haven with the internet able to enter their homes, leading young adults to commit suicide. Others suffer constantly and take vengeance in the form of school shootings injuring and killing their perpetrators as well as innocent bystanders.
Furthermore, bullying is becoming a cyclical process. Many times, as the bullied decide to defend themselves, they, in turn, become the bully. Bullying may now be done anonymously allowing for great escalation of actions(2).
As a response, several organizations ranging from local communities to entire countries have launch campaigns against bullying. Many are focused on increasing awareness and support. However, some have failed to realize their goals as a lack of understanding on how social science theories influence and act on each other.

Beat Bullying Campaign
In the United Kingdom, Beat Bullying launched a campaign in late 2004 in an effort to increase awareness and prevention of bullying. The campaign consisted of having celebrities endorse blue wristbands as a fashion item that is meant to take a stand against bullying. Wristbands were then sold to the public to represent those who are against bullying. Unfortunately, as the Guardian reported, the strategy failed and gave the opposite result, increasing bullying specifically on those who wore the bracelets(4). With celebrity endorsement and the support of the UK government, it left many surprised how the campaign could fail. Its flaws lie in the campaign’s lack of correctly understanding and using social theories such as diffusion of innovation, social learning theory and psychological reactance theory. The campaign continues and others plan on adopting the strategy. A critical look is needed so as to improve the campaign to achieve the desirable goals.

Fashion trend: diffusion of innovation theory
The campaign wanted to rely on a fashionable item such as the using a popular trend (silicone bracelets) to spread their message. They would have celebrities such as entertainers and star athletes model the bracelets increasing the attractiveness of having one. Advertising the wristbands was a grand success, to the scale that not enough bracelets were produced for the demand. This created a scarcity of the product and the focus shifted on obtaining the rare and fashionable item instead of spreading the message.
The diffusion of innovation theory looks at how fast a new product or idea becomes popular among a population(5). A product is adopted first by early adopters before the majority of people buy into the trend. How quickly a product is adopted depends on how observable it is(5). The majority will look to the early adopters for guidance on a product(6), in this case the bracelets. The campaign was designed to have the early adopters be a select group of people, celebrities, so as to force the diffusion. The message for the campaign went no further than wearing a wristband to represent a stand against bullying. This representation was very observable on the arms of high profile people, which lead to the majority adopters wanting the band. However, the message itself was lost when not everybody could obtain the product. It became a symbol of following the latest fashion trends unattainable by many of the general public, as is the usual case for most accessories owned by the rich and famous.
The message itself was uninformative even if the band did not become a fashion accessory. The aim was to increase awareness; however, to those it affects the most, the victims, they are aware of the problem already. According to leadership expert, Simon Sinek, people buy their beliefs. In order to pass a tipping point of any innovation, the core values must be tapped. Those campaigns that succeed are because the question of “why” we do something was satisfied(7). He has constructed the golden circle of marketing to successfully tip any innovation. He believes that every campaign should begin with “why” we do anything, invoking the core value. Next, the campaign should explain “how” it will do it, followed by “what” it will do, always referring back to the main reason of “why.” The message would have been stronger had the campaign made its message why it will not tolerate bullying. Instead, it began on the outer part of the Simon’s golden circle. The campaign began with an item, the “what,” and used celebrity endorsement to spread their popularity, the “how.” By the time they wished to explain the “why,” the quick diffusion of the bracelet as a fashion accessory shadowed the diffusion of the lagging message. The diffusion of innovation was a success, yet on the wrong focus. With no strong message, the campaign was on its way to failure.

Wrong incentive: Social learning theory
The message against bullying was further lost when trying to use the social learning theory via celebrities to change the public’s behavior. The social learning theory is based on how expectancies and incentives influence behavior(8). According to the theory, people can change behavior with proper reinforcement, such as following a role model. In this case, the campaigned wanted to increase awareness and decrease bullying by having celebrities act as role models who are anti-bullying. However, behavior is regulated by the reinforcements as understood by the individual(8).
During the campaign, the non-bullying public had no incentive to change a behavior they did not posses (bullying) and thus interpreted the role models instead. The celebrities were successful role models, but as fashion and cool people to imitate, wearing the same wristband as them. The campaign was not aimed at the bullies themselves so there was no incentive for them to change their behavior either. Introduce of a rare product and the desire to follow a fashion style escalates while the message of anti-bullying disappears.
In addition to not targeting bullying behavior, the role models did not efficiently target the victims or witnesses either. Part of the reason the message was lost is the connection between celebrities and their role in beating bullying was not made. The celebrities were only asked to wear the wristbands and say the slogan. Yet, they offered no advice or methods of defeating bullying. To the misfortune of victims, bullies quickly noticed this and knew the blue bracelet meant no harm to them. It in fact, empowered the bully to pick their targets more easily.

The gray between black and white: Psychological reactance
The campaign was directed with an aim to band together everybody who is against bullying, whether to them or peers. The campaign would separate those who bullied and those who do not, strengthening the divide by visualizing everybody’s position via who wears a bracelet and who does not. Creating a divide in where there are only two sides and everybody stands on one or the other invokes aspects of psychological reactance theory.
The theory states that when a freedom of behavior is threatened, depending on the magnitude and the importance of what is threatened, people will react (9). The campaign thought it was providing a choice for people to decide to take a stand on bullying or not. However, it did not foresee the alternative interpretation of their campaign and many saw it not as a choice campaign, but as a labeling campaign. People were either bullies and did not wear bracelets, or people were victims and friends of victims who wore the same bracelets as their beloved celebrity. As such, the message made it clear; a bully will always be a bully. This took the choice away from them to be anything other than a representation of evil. The reaction, in this case, was not surprising as the bullies then believe that if they had no choice, they will show the world only what they want to see in them.
This is similar to what has happened in the anti-drug campaign. Teenagers were constantly exposed to anti-drug messages with no tolerance for any drug use. By constantly being told not to do drugs, it threatened their freedom of choice. In reaction, the youth began to rebel and form strong pro-drug beliefs increasing use (10).

Making the pieces fit: Improving the intervention
The campaign has several social science models incorporated in it. Many have the potential to making the campaign a success if only they were executed differently. Beat Bullying has been in existence for over a decade, each year playing an important role during Anti-Bullying Week. As an established organization, their campaign could improve their strategy without wasting more time and energy that it would take to create an entirely new campaign. The proposed intervention is to improve upon the flaws of the current intervention by adjusting the theories in place and introducing new ones.

Cure for scarcity: Social network theory and spreading the “why”
As discussed above, diffusion of innovation worked against the campaign because it began by idolizing a material item, blue wristbands. The interest in them dramatically increased when the item became rare. To improve on this backfire, the campaign should refocus on beginning with the message: to take a stand against bullying behavior. The campaign needs to show more explicitly the reasons to reject bullying behaviors and resonate with people’s core values.
The use of celebrities is applauded, yet it would be better to use them as symbols of the message (the “why”) instead of the bracelet (the “what”). The campaign needs to reduce the scarcity of the props used. They can be mass produced and sold for a nominal fee or given away for free. This way when celebrities show a bracelet, they indicate value is not monetary as anyone can obtain one. Next, to increase the message, ties to core values need to be strengthened. The campaign can use social network theory and social norm theory. Targeting those who would have a strong leadership opinion to be the early adopters would ensure the diffusion of the message pathway through several networks(7). One method is weaving the message into everyday lives such as in television shows. US television shows began to increase the use of seat belts by characters (11). This increased the norm of using seat belts and soon the statistics of using seat belts rose (12). In the case of bullying, if the early adopters buy into intolerance to bullying behavior because it justifies their core values, they can spread it through their network because they belief is strong. This spread will diffuse quickly as more people’s core values are touched until it becomes the norm. Celebrities will be just part of the norm and not the idolized image of high fashion.

Blurring the dividing line and reintroducing choice: Fundamental attribution error
The campaign succeeded in naming the evils of bullying. However, it strongly labeled people into categories, bullies and victims, with no blending of the two groups. For this reason, and due to psychological reactance, those who engaged in bullying felt they had no choice but to continue bullying.
Fundamental attribution error suggests peoples behaviors are explained disproportionately with internal personality characteristics while underestimating the situational context(13). In the campaign’s case, bullies are explained to be bullies because it is inherent to their being. The campaign, and therefore society, has decided that their future will be to become criminals, drug users, and poor academic performers with no chance of redemption.
To prevent this mislabeling, the attribution could be shifted by simply changing the framing of the campaign so that a person is peaceful because it is who they are. Further, bullying should be framed as a behavior that everybody is capable of participating in. If the public is shown that they can be bullies, then when they behave peacefully, they will attribute it to their personality. In essence, nothing has changed, except that their docile side is mentioned and focused on. Likewise, this change of attitude in viewing bullying as a behavior instead of a person will give those who currently bully a choice to choose to stop. And if they stop, it will be attributed to their being.
An example of the success of this is in the reusable bags movement. Before the movement to care about the planet came about, it was acceptable to use plastic bags, and we attributed it to being smart consumers and relishing in our technological inventions that was versatile plastic. As soon as the use of reusable bags succeeded, people began to attribute the use of plastic to inconsiderate types of people. However, when reminded that we all used plastic bags in the past, the focus was no longer on whom are selfish polluters versus future caring saviors, rather, the focus shifted to behavior. Now those who would use 20 plastic bags a day are able to redeem themselves by allowing them a choice to use reusable bags.

Joining with arms: Cognitive dissonance theory
The campaign rested heavily on taking a stand against bullying. However, even with the use of celebrities, taking as stand meant little other than obtaining a blue wristband to wear for other to see. It created a movement, but not as hoped. With selective targeting, it divided the victims and participants, yet it helped neither. Those in support of the campaign were becoming targets unable to use anything from the campaign to help them. Those who bullied were not shown an alternative. In order to improve on the campaign, the movement they wish to create should be one that will be valued as well as useful for everybody.
Cognitive dissonance theory is the idea that people do not like to have their attitudes and behaviors contradicting each other(14). It is best seen in ownership. People will value an object or idea they own or feel they own, but when threatened to be taken away, the value of it goes up. If they do not own it or have lost its ownership, the value drops. It is best exemplified in the lottery of Duke basketball tickets. In Dan Ariely’s book, he demonstrates people value the highly sought out tickets depending on whether they own it(15). Those who own it need to justify their adventure (long lines, day and night rituals, money spent) to obtain the tickets by placing high value on them. If he tried to buy them, the price increased several fold the original price. Those who were not able to own it needed to justify their loss by devaluing the tickets. When the investigator offers to sell them a ticket, they would not pay near what the tickets were originally priced.
The same can be applied to joining a movement. If people join a movement, they will be a part of it and feel a sense of ownership to their commitment, valuing it more. If they own their commitment, they will not want to have their behavior contradict it because that would be devaluing. Therefore, they will ensure their behavior is akin to the movement’s ideals. In the case of the campaign, instead of making a movement for everybody to wear a bracelet, they can include or replace it with the movement focusing on how and why to prevent bullying. The victims may find ways to protect themselves by finding value in not tolerating being bullied. The once bullies will find a higher value in not engaging in bullying.

Completing the puzzle:
How to get people to join the movement will depend on the use of celebrities again. However, instead of using them as mannequins for a wristband, they can be used as role models for core values. As mentioned previously, celebrities can be early adopters to diffuse the correct message. Yet, how that message is given determines the success. Asking them to speak against bullying is not enough as it does not show how they value what they are saying. As opinion leaders and the early adopters who will lead the majority adopters, it is important for them to set the tone of the movement. For example, celebrities can make short videos or write a personal story where they were once bullied, bullied others, or witnessed bullying and how they successfully handled it. This can serve as a model for those who experience it every day. With stories, it will humanize celebrities attributing their positive outcome to their being. If people join the movement, they will hold onto the core values of respect and success as modeled by the celebrities.
Beat Bullying campaign had flaws embedded in the execution of some social science theories that lead to a misfortunate outcome. Understanding how the theories work together will help in improving the intervention.











References
1. Wang J, Iannotti, RJ, and Nansel, T. School Bullying Among Adolescents in the United States: Verbal, Relational, and Cyber. Journal of Adolescent Health 2009; 368-375.
2. Sourander A, Klomek AB, Ikonen M, Lindroos J, Luntamo T, Koskelainen M, Ristkari T, Helenius H. Psychosocial Risk Factors Associated With Cyberbullying Among Adolescents. Archives of General Psychiatry 2010; 720-728.
3. Molcho M, Craig W, Due P, Pickett W, Harel-Fisch Y, Overpeck M. Cross-national time trends in bullying behaviour 1994–2006: findings from Europe and North America. International Journal of Public Health 2009; 225-234.
4. Curtis P. Anit-Bullying wristband scheme backfires. Guardian 2004.
5. Vaccaro V, Ahlawat S, Cohn D. Diffusion of innovation, marketing strategies, and global consumer values for a high technology product. s.l. : International Journal of Business Strategy 2010.
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11. McGwin G, Modjarrad K, Reiland A, Tanner S, Rue LW. Prevalence of transportation safety measures portrayed in primetime US television programs and commercials. Injury prevention 2006; 12
12. Vasudevan V, Nambisan SS, Singh AK, Pearl T. Effectiveness of media and enforcement campaigns in increasing seat belt usage rates in a state with a secondary seat belt law. Traffic injury prevention 2009; 10.
13. Tetlock P. Accountability: A Social Check on the Fundamental Attribution Error. Berkeley : Social Psychology Quarterly 1985; 48.
14. Fischer P, Frey D, Peus C, Kastenmüller A. The Theory of Cognitive Dissonance: State of the Science and Directions for Future Research. Springer Netherlands 2008.
15. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. Harper Perennial 2010.
16. Calvete E, Orue I, Estevez A, Villardon L, Padilla P. Cyberbullying in adolescents: Modalities and aggresors' profile. Computers in Human Behavior 2010; 1128-1135.
17. Juvonen J, Gross EF. Extending the school grounds?--Bullying experiences in cyberspace. Journal of School Health 2008; 496-510.
18. Perren S, Dooley J, Shaw T, Cross D. Bullying in school and cyberspace: associations with depressive symptoms in Swiss and Australian adolescents. Child and Adolescent Psychiatry and Mental Health 2010; 28.
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Using Marketing Models and Principles to Maximize Success of a Print Social Marketing Campaign: A Critique of the Get Healthy Campaign – Ignacio De La

Introduction
Since 1985 obesity rates have crept up at an alarming pace, and obesity has become a significant national and local public health problem (1). In 2008, around 68% of Americans over the age of 20 were overweight or obese (2). The problem has spilled over to the youth, with 18% of adolescents aged 12-19 years, 20% of children aged 6-11 years, and 10% of children aged 2-5 considered obese in 2008 (2). This dramatic increase in obesity has been tied to poor eating habits and a sedentary lifestyle (3).
In order to address this growing problem, local public health boards across the nation have started programs which seek to reduce the factors that lead to obesity. In line with this trend, The Get Healthy Campaign is an initiative of the Boston Public Health Commission whose mission is to “raise awareness about four key behaviors that contribute to a healthy lifestyle” (4). It consists of a series of print advertisements which inform and invite the readers to learn more about the campaign and ways to stay healthy on its website: http://www.bphc.org/programs/cib/chronicdisease/heal/ gethealthy/Pages/Home.aspx (4). The four behaviors which the Get Healthy Campaign focuses on promoting are eating healthy foods, drinking healthy beverages, walking more often, and turning off the television.
This initiative is faced with an uphill battle. Very few Americans adhere to healthy lifestyle habits and the number of those who do have been decreasing over the years (5). The food industry annually invests billions of dollars into marketing unhealthy foods to consumers and in 2002 alone it spent 1.6 billion dollars in advertising to children (6). This has translated into 8 commercials selling unhealthy foods for every 10 minutes of television (7). The combined amount of money invested by the nation’s public health offices does not even begin to match the vast amount of resources at the disposal of the corporations, even less so the Get Healthy campaign. In this context, public health practitioners must make use of all the arsenals available to them, including social behavior principles which more accurately account for how people go about changing behaviors.
An important principle to keep in mind when attempting to shape people’s behaviors is the principle of psychological reactance. When people believe that their ability to behave as they freely choose, their autonomy, is being threatened they “experience reactance, a motivational state aimed at restoring the threatened freedom (8).” Psychological reactance is an important principle to keep in mind; it leads the individual to more strongly uphold their freedom by doing the opposite of what they are told to do, thereby defeating the purpose of the advertisement.
The framing effect has been heavily researched and is often used to great advantage by marketing firms (9, 10). A frame is “the decision maker’s conception of acts, outcomes and contingencies associated with a particular choice. The frame that a decision-maker adopts is controlled partly by the formulation of the problem and partly by the norms, habits, and personal characteristics of the decision maker.” Using the correct way of framing the issue can thus bolster the chances of the social marketing influencing a person’s opinions and of having the desired behavior change effect.
The lessons that the concept of ownership can bring to the designing of social marketing campaigns is often overlooked. Once you own something you value it disproportionately to its actual value. This ownership effect is not only felt for objects, but also for their unhealthy behaviors. People will not easily give up unhealthy habits, thus the alternative that you offer them must be made to appear better and more attractive to them.
Psychological reactance, the framing effect, and ownership are just a few of the social behavior principles which more accurately account for how people go about changing behaviors. It is principles such as these that inform my critique of the Get Healthy Campaign which follows.
Critique 1: Reliance on the Health Belief Model and Rational Choice
The Get Healthy Campaign is predicated upon the health belief model. As such, a critique of the approach taken by the Get Healthy Campaign must include a discussion of the health belief model and its inherent flaws.
The theory’s main assumption is that behavior is a result of a person’s reasoned decision. The health belief model has been shown to have had very limited success in helping initiatives accomplish behavior change, such as occurred with the 5-a-Day For Better Health campaign (11, 12). In fact, it has even been used by the tobacco companies in order to increase smoking rates in adolescents. This was accomplished through the implementation of smoking prevention programs which were constructed under the health belief model, such as the Talk: They’ll Listen campaign (13).
Since they have used this model as the basis of how people change their behavior, the Get Healthy Campaign believes that by providing facts and about how the four lifestyle behaviors that they will get people to adopt them. It views people as rational, and as such provides them with information about their health. However, human psychology is such that rational decision making doesn’t always play central role in determining behaviors (14, 15).
Two examples of how the human mind fails at rationality are the fundamental attribution error and the effects of stereotype priming. The fundamental attribution error illustrates the importance of context and how people tend to overlook it when they explain the behaviors of others. Rather, people tend to attribute a person’s behavior to that person‘s personality. An often cited experiment which illustrates this phenomenon was conducted by John M. Darley at Princeton Theological Seminary. As opposed to what most people would have predicted, the main predictor of whether the subjects helped out a stranger depended on whether or not they were late, the context, and not on their personalities (16).
Under the effects of stereotype priming, a person’s behaviors are significantly affected when faced with stereotypes which apply to them (17, 18). A study which examined this effect gave a group of American female Asians the Graduate Record Exam. Those females primed by gender did worse, and those primed by race did better off, when compared to the group which was not primed (18). Wholly rational beings would not be swayed by such priming. Another study looked at the effects of age-stereotype priming on memory abilities of older adults. They found that older adults’ memory performance suffered when they were reminded of their age (17).
Another flaw of this model is the way in which it views the link between thought and behavior. Informing people of the facts and statistics does not necessarily bring about change in behavior, and often people are already aware of the negatives which are associated with their unhealthy behaviors (19). People are motivated by differing values and beliefs. Rather than brush them all with the same stroke, the target audience should be broken up and catered according to their experience and values (20). This is especially relevant in a city as diverse as Boston, in which over 140 languages are spoken and foreign born residents make up over 25% of its population (21).
As the preceding paragraphs make evident, using the health belief model will not maximize the potential of the Get Healthy Campaign. Rather than using a model which relies upon the rational choice as its linchpin, the print social marketing campaign would benefit from relying upon other social behavior constructs.
Critique 2: Triggering Psychological Reactance
A large problem with the Get Healthy Campaign is the way they phrase their messages. From the title of the print social marketing campaign down to the advertisements they put out, the language used is one of ordering the target audience to eat healthy or turn off the television. The advertisements all include messages which command people to do a health behavior: “Turn it off .” “So walk the extra block to the store. And take the stairs instead of the elevator.” (22)
These statements, which are telling people to change behaviors, impinge on their freedom of choice of behaviors. Instead of convincing the audience to follow the healthy behaviors being touted, all that the messages are doing is triggering psychological reactance (23). In the end, this type of message is leading people to strengthen the unhealthy behaviors which the commands were hoping to change.
Other messages used in the campaign come off as derisive: "Is your TV babysitting your kids? Turn it off (22)." "Those who think they have no time for healthy eating will sooner or later have to find time for illness (22).” These strong and direct messages invoke confrontation and lean towards accusations of being in denial; neither of which are not taken well by the target audience (24). Rather than causing them to take up the planned healthy lifestyle behavior, they directly lead to the target audience wanting to display and reaffirm their freedom of choice through strengthening their unhealthy behaviors (25).
Several studies have been conducted which provide proof of psychological reactance and flesh out its theoretical underpinnings (26-31). One of the studies, while trying to determine whether reactance could be measured, conducted two parallel experiments in which they showed participants two versions of a message that advocated flossing and urged students to limit their alcohol intake (30). The messages varied in the degree to which they posed threats to the freedom of behavior of participants, with the high threat message being phrased similarly to Get Healthy Campaign messages. As would be predicted through the use of psychological reactance theory, the high threat version elicited the highest level of psychological reactance.
Critique 3: Ignoring Relevant Core Values
Marketing campaigns extensively research their target populations (32). This allows them to get a better hold on what they relate to and how they react to various versions of their advertisements. Coined as formative research, it is the cornerstone of successful marketing campaigns (20). Despite its wide practice by marketing firms, many public health social campaigns still fail to incorporate it. That the Get Healthy campaign falls into this camp is evidenced by the core value which it mainly targets.
The core value that its advertisements are molded around the most is health. The advertisements, and the whole campaign, is built around the promise that if the target audience picks up eating healthy food, drinking healthy beverages, walking more, and watching less television their health will improve. The support which backs up this promise are the claims backed up by scientific evidence which can be found on the campaign website.
In contrast, their successful competitors use support of a different kind to back up their promises. Just searching for food commercials on youtube.com illustrates this gaping difference in approaches. The “I Am Man - Burger King” commercial never once tells its audience to buy food at Burger King. Rather than use scientific evidence or throw numbers at the audience, it visually ties eating at Burger King with the identity of being a man (33). The producers of this commercial have done their research well, and have decided to target the core value of identity which is held by their audience.
Health is not as strong a core value in the target population (20). Focusing on health is a big loss in opportunity, especially considering the advertisements that the Get Healthy Campaign is up against. According to Jeffrey J Hicks, an employee of the firm behind the “truth” campaign, the “truth” advertising campaign was so effective in part because their message in tune to their target population’s core values (32).
Proposed Intervention:
My proposal would be to shift the approach of the campaign away from the health belief model. Instead, marketing theories and principles that do not rely on the rational choice theory would be used to inform the creation of the advertisements. Specifically, this means making use of formative research, psychological reactance, the framing effect and ownership to inform the creation of the Get Healthy Campaign advertisements.
Before creating advertisements, the Get Healthy Campaign would go about assessing what exactly each target demographic holds as their core values. Once the research had been conducted, advertisements which have been molded around target audience’s core values would be tested in sample groups of the target audience. This would allow the advertisements to be tested for the amount of psychological reactance which they inspire with the hope of reducing.
An example could illustrate the shift from the current framework used by the Get Healthy Campaign to the one in which I propose. One of the behaviors which the campaign is pushing is to get people to eat more healthy foods. One of the advertisements which they have put out promoting this goal consists of the message, “Fruits & Vegetables. No prescription required (22).” It covers about a third of the real estate, and below that there is a short message about the health benefits of eating fruits and vegetables, preceded by the command to “Eat your fruits and veggies (22).” The promise is that if you eat five cups a day you will be healthy. This is a message that any rational person would heed, but which only 26% of Americans were following in 2006 (5).
Instead, an alternative would be to access the core value(s) of our target audience. Hypothetically, let’s say that our target is young adults and their core value is sex. The ad could display an attractive young couple in the middle of preparing a healthy, visually pleasing meal full of vegetables and fruits. The message could be something like, “Fruits and vegetables, providing you with the energy you need to go strong throughout the day and night.” The first print advertisement focuses on telling people to change their behaviors in order to improve their health to. The second print advertisement focuses on trying to get people to believe that being by adopting the new behavior they will obtain something that they already value. Improved health ends up being a side effect.
Defense 1: Using Proven Marketing Tools
Corporate campaigns which seek to influence the behaviors of consumers are successful precisely because they masterfully put to use the tools of marketing theory and social principles such as framing. Apple is able to sell electronics at much higher prices than other companies because it appeals to consumers’ ideals of community and identity.
The “truth” campaign is an example of a public health campaign which used these marketing tools to successfully reduce adolescent smoking rates in the state of Florida during the late 1990s (32, 34). In the early stages, they realized that the campaign would “need to address the tobacco issue in a way and with a tone that reflected how youth viewed tobacco (32).” After several months of formative research, they realized that their target audience’s core values were control and rebellion. With this insight the people behind the “truth” campaign were able to frame their entire campaign in terms of teenagers, the target audience, rebelling against the tobacco industry.
These same techniques can be applied to other public health campaigns; including the Get Healthy Campaign. The first lesson which can be applied from these examples is that the Get Healthy Campaign would frame the issue in terms that would draw the attention of the target audience. In order to do this, their core values would be used to create an appealing message.
Another lesson gleaned from these examples is to present issue as something the target audience is affected by; as an issue that they can identify with. The target audience needs to see itself as having ownership of the campaign. One way to foster this sentiment would be to host videos of people talking about their journey to living a healthy lifestyle. The participants could elaborate on the ways in which their lives improved. They could also pass on encouragement to those on the road to healthy living. The videos would avoid using fear appeals and delivering negative stories so that the target audience may accept it more easily (35, 36).

Defense 2: Limiting Psychological Reactance
Social marketing campaigns can sometimes lead the audience to behave in the opposite manner of what they intended by triggering psychological reactance (8, 25, 28). Advertisements have to be able to make the target audiences relate to their message in order to maximize the chance of persuading the target to change behavior (8, 35). The current campaign advertisements are just simple sketches of healthy food, a spoonful of sugar, a leg, and a television. Instead, of health facts and admonishments the Get Healthy Campaign would put out advertisements that show people who are similar to the target audiences doing the healthy behaviors which are being promoted.
Another way that psychological reactance would be limited would be to the target demographic test run the several versions of the advertisements in order to gauge which one inspires the least amount of psychological reactance. This is used with success by various public health campaigns and has been shown to be a fairly valid practice for predicting psychological reactance (28). Advertisements should be built upon the beliefs of the target audience which will smooth acceptance (20).
Defense 3: Accounting for Core Values
A very important step which the Get Healthy Campaign seems to have overlooked is analyzing the core values of its target audience. By first conducting formative research on each demographic, the core values of the target audience would be known. Below is a table modeled in the style of a core value table presented in the book “Marketing Public Health: Strategies to Promote Social Change” (20). Freedom, control, and identity are three core values held by teenagers.

At that point, rather than attempting to ingrain the target audience with new core values, their established core values would be used to shape the messages that the campaign projects. The advertisements would create a frame which illustrated eating healthy, drinking healthy, walking, and limiting the amount of television in such a manner as to make them natural extensions of the target audience’s values and beliefs.
Conclusion:
The Get Healthy Campaign is predicated upon the health belief model. There are three flaws which are hindering this public health intervention: Its reliance on the health belief model and the rational choice paradigm, its triggering of psychological reactance in the target audience, and its overlooking of core values held by its target audience. In order to increase the success of its messages, the Get Healthy print social marketing campaign should instead use social behavior principles which more accurately account for how people go about changing behaviors. The elements of such an intervention would have a greater chance of causing a shift in the way that healthy lifestyle behaviors are viewed by its targeted audience, giving a chance for other interventions to build upon its effects. The campaign would be a practice run for a new way of planning health interventions in which the old paradigm of the rational decision maker is replaced with that of the predictably irrational person.

REFERENCES
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7. Boston Public Health Commission. Get Healthy Campaign: Turn Off the TV. Boston, MA: Boston Public Health Commission. http://www.bphc.org/programs/cib/chronicdisease/heal/gethealthy/turnoffthetv/Pages/Home.aspx
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Combating Childhood Obesity: A Critical Review of Jamie Oliver’s Food Nation—Sarah Weas

Introduction
Childhood obesity has become a major problem in the United States. The health of our youth is at risk with the alarming statistics that indicate that approximately 17% or 12.5 million children and adolescents in this country are obese1. This number is on the rise and has nearly tripled in the past 30 years. Childhood obesity is seen across all ethnic backgrounds, sexes, and income levels and can be attributed to several factors: a child's eating habits, physical activity level, hormones, genetics and environment2. Obesity carries with it both physical and emotional problems. Children who are overweight or obese have an increased risk of heart disease, Type II Diabetes, high blood pressure, depression, and sleep disorders to name a few1. Furthermore, overweight children face an increased risk of suicide, depression, bullying, and low self-esteem, which can have equally devastating effects on child development.
Limited access to affordable and healthy food has led to higher levels of childhood obesity. Millions of low-income children live in “food deserts,” neighborhoods saturated with fast-food restaurants and convenience stores but that lack convenient access to supermarkets3. Additionally, healthy, low calories meals that contain fruits and vegetables can be almost twice as expensive as the high-energy meals so often purchased at fast- food restaurants and convenience stores4. Our over reliance on packaged and overly processed food is causing real harm that is not just damaging the health of our children but the health of all of us.
We have created an entire generation that has a severely limited understanding of where food comes from and how it is produced. Modern agricultural practices, in order to produce mass quantities of the highly packaged and processed foods consumed by so many Americans, have resulted in polluted soil, air and water, a dependence on imported oil and a loss of biodiversity5,6. In a time of global climate change, where the consequences of our over consumption of finite natural resources is being revealed, there has been a call for a revolution: to attain sustainable food production in order to reduce the environmental impact of the agricultural system.
When we examine school food service across the United States, we become acutely aware of the reasons for childhood obesity rates and the environmental impact of our eating habits. The school food programs heavy reliance on factory pre-cooked and processed foods combined with the fact that French fries are considered a vegetable make these problems apparent7. Recently, there has been a call for a revolution across the country. Advocates motivated by childhood obesity rates and the environmental impact of eating behaviors have pushed for a change in the foods served in our schools8. Grass root campaigns across the country are urging schools to use fresh, local foods in schools to make meals that include nutritious fruits, vegetables, and whole grains in hopes of changing our eating habits as well as the health of our children and our environment.
Celebrity chef Jamie Oliver has joined this movement by creating a campaign calling for a dramatic change in eating habits of our children. Through his “Food Revolution” movement, Oliver has waged a war against obesity9. Through his American television series aptly named “Jamie Oliver’s Food Revolution,” Oliver has brought much needed attention to the quality of food we offer to our children in schools. During the first season, Oliver visits Huntington, West Virginia, identified as one of the unhealthiest cities in the country with staggering obesity rates to try to improve eating habits7. He does this by both working with school kitchens and by providing some community education. While Oliver’s television program brings the school food situation to the national stage, his movement has fatal flaws that will cause him to be unable to bring about the changes that he hopes to see. Without considering limitations of the Health Belief Model, the impact of reactance, or the importance of self-efficacy, Oliver’s goal of bringing the “food revolution” to schools and communities across America falls short and could do more harm than good.
Health Belief Model
According to Oliver, knowledge about food will make families self-sufficient so that they will be able to prepare their own meals and eliminate their need for junk foods. Oliver argues that a major problem with eating behaviors in the United States stems from the household. In a recent TEDtalk presentation, Oliver demonstrates the need to educate families. In one scene, Oliver examines one mother’s weekly food choices for her family (pizza, corn dogs, casseroles, and soda):
Oliver: “I need you to know this is going to kill your children early. How does that make you feel?”
Mother: “I’m feeling sad and depressed. I want my kids to succeed in life… but I’m killing them.”
Oliver: “Yes you are. But we can stop that.”10
Oliver emphasizes that to stop parents from killing their children, we need to teach them how to shop and how to cook healthy meals at home. To do this, he strives to create educational programs within the community to teach and promote home cooking. This emphasis on individuals making better choices through education is problematic because of its reliance on the Health Belief Model to predict a change in behavior. Developed in the 1950’s by the U.S. Public Health Service and refined in 1966 by Irwin Rosenstock, this model was created to predict the conditions in which people take action to prevent, detect, and diagnose disease11,12. The premise of the Health Belief Model is that individuals make decisions by considering their perceived susceptibility to disease and their perceived severity of disease along their perceived costs and benefits of the behavior change11. It expects that individuals weigh the positives and negatives and will then make a rational choice of which action to take. For instance, individuals will adopt a healthy behavior if they perceive that the threat of disease is very immenent and severe, that there are benefits to their health, and that there are few barriers.
A limitation of the Health Belief Model is its reliance an individual’s perceived susceptibility to and severity of disease. Several studies have shown that individuals do not recognize increased personal risks and tend to underestimate their susceptibility to disease13-15. On account of this optimism bias, the Health Belief Model cannot accurately influence personal behavior because the individual’s perception of risk and severity is inaccurate. Oliver’s reliance on this model and the lack of accountability for optimistic bias may make his campaign ineffective. The tear-jerking moments of his television program that depict scenes of morbidly obese children and mothers realizing that they are killing their children will unlikely be able to convince viewers that this could be them and that they are just as susceptible to the effects of their eating habits.
The Health Belief Model is widely criticized for its over simplification of the decision making process11. It overemphasizes individual decisions and fails to address the larger social and environmental factors that can affect an individual’s actions. What is more, it assumes that individuals are rational when in reality, their behaviors are quite irrational and often spontaneous. Oliver’s “Food Revolution” campaign places much of the blame and responsibility on families without addressing the current food environment, societal factors, or socioeconomic factors that affect access to healthy foods. By limiting the focus of the campaign to the behavior of the individual, the “Food Revolution” fails to account for the influence of society on behaviors.
Psychological Reactance
Despite Oliver’s attempt to overhaul school lunches by providing fresh, healthy meals and eliminating flavored milk, a boomerang effect occurred causing children to receive less nutritious meals than before his intervention was implemented. In the first two months after Oliver’s “Food Revolution” started in the public schools of West Virginia, the lunch participation rate dropped from 75% to 66% and there was a 25% reduction in milk consumption16. Children who dropped out of the school lunch program in turn brought food from home that was ultimately less nutritious than the school lunches provided before Oliver’s intervention. Furthermore, the drastic drop in milk consumption indicates that the students were no longer receiving the vitamins and nutrients that the flavored milks had been providing.
This boomerang effect can be explained by Jack Brehm’s Psychological Reactance Theory, which states that people value their ability to choose between different options17. When a person’s perceived freedom is threatened or eliminated, they enter into a reactance state and try to regain control by not complying.
Psychological Reactance Theory attempts to explain behavior changes that occur when individuals are told not to do something. Psychological reactance can create adverse responses to regulations or impositions that impinge on an individual’s freedom and autonomy. People are motivated by their basic need of independence and their ability to influence their environment17. They often feel vulnerable when a choice of behaviors is threatened or eliminated and will react emotionally rather than making reasonable and calculated responses. As a result, most people will do the opposite of what is expected in an attempt to restore their freedom. As a core belief, the need to control the food one consumes is discounted by Oliver’s removal of flavored milk. Removing control of food selection by reducing preferred, less healthy foods will intensify psychological reactance and increase the students’ desire for junk food.
The magnitude of reactance is proportional to how much a person values the threatened freedom18. The greater the threat to a behavior, the more likely a person is to commit those same behaviors again once told not to. Thus Oliver’s demand of eliminating flavored milk would cause varying levels of reactance depending on the extent of the student’s unhealthy eating habits. Oliver’s elimination of choice threatens to cause children with the unhealthiest of eating habits to assert their freedom by refusing to drink milk at all and most likely consume a less nutritious drink instead.
Self-Efficacy
Oliver’s “Food Revolution” campaign failed to address the importance of self-efficacy in promoting behavior changes. Self-efficacy is one of the main principles of Albert Bandura’s Social Cognitive Theory that suggests that behavior is best predicted by an individual’s confidence in their ability to accomplish a given task19. An individual’s decision to engage in a particular behavior is influenced by the perception that he or she can successfully complete the behavior and achieve the desired outcome. People with high levels of self-efficacy are more likely to try new behaviors and stick with them. Self-efficacy can influence the adoption of healthy behaviors, the cessation of unhealthy behaviors, and the maintenance of behavioral changes when faced with difficult situations19. Self-efficacy is influenced by an individual’s accomplishment of completing the behavior as well as encouragement or discouragement from others.
Providing healthly food options at lunch is not enough to promote self-efficacy and bring about a permanent behavior change. Children need to feel as though they can be successful engaging in these behaviors in all aspects of their lives. Oliver’s campaign will not succeed unless the parents provide their children with emotional support and encouragement to try eating the healthy foods. Several studies have found that family social support has a positive influence on promoting healthy behaviors and that students with a negative social support network are especially at risk to develop poor health behaviors20,21. Without providing both children and parents the tools necessary to promote self-efficacy, just implementing healthy lunch foods in schools will be unable to do anything about improving the eating habits of our children. Jamie Oliver’s campaign in West Virginia did include some aspects of community education, but at most, it was a one-time only event which could not provide ongoing support to parents. Thus, it could not promote self efficacy over time.
Intervention
As discussed above, the high rates of childhood obesity and the environmental impact of our food system needs to be addressed. Despite the flaws in Oliver’s “Food Revolution,” he made a strong effort to bring about a much-needed change in the foods our children are eating. Through his television program, Oliver has brought this issue to the attention of the nation. However, it has proven unsuccessful in not only changing the eating habits of students but also as a popular television program. The program was pulled from its prime-time slot during the middle of its second season due to disappointing ratings22. This provides insight to the situation showing that Americans are not ready for a food revolution.
Support should be applied instead to the grass root campaigns that have popped-up around the country such as the one described below. These grass root campaigns are often started by community members and offer a more approachable and acceptable method of instigating change. These groups are working to make local and organic food ever more appealing, accessible, and economical to a wide variety of people.
We propose to create our own grass root campaign called “Healthy Foods, Healthy Me!” that will integrate healthy activities into school curriculum in order to educate students about healthy food and to promote healthy eating habits. Integration of healthy activities into the school curriculum would start at the elementary level. This campaign would provide teachers with various lesson materials on ways to encourage healthy choices.
An integral part of this campaign will be to provide students with a complete understanding of all the steps required to eat the foods they enjoy. Teachers will be encouraged to start gardens with their students, planting fresh herbs and vegetables. This will allow students to learn how fresh herbs and vegetables are grown and all the different requirements that are needed to make them flourish. This will allow for the incorporation of lessons about different agriculture methods and their environmental impacts. The importance of local and organic foods can be taught to students during these lessons as well.
Once the gardens are harvested, teachers will work with the children teaching them different cooking skills using the vegetables that they cultivated together. This will provide students with a sense of pride and ownership, as they are able to experience all of the hard work they put into the garden when they are able to create a tasty and nutritious meal that they can enjoy. Furthermore, this will help encourage students to make healthy choices about all of the food that they eat while they are learning about where food comes from.
Additionally, throughout the curriculum, the teachers will be able to engage the parents by providing monthly or bi-weekly letters to the parents. These letters will update the parents on the progression of the garden as well as provide an opportunity to educate parents on ways to support their child’s growing education of the way food is grown and produced. The parents will be able to discuss the vegetables and herbs that the students are growing and support further education by showing their children what the vegetables look like in the grocery store. The letters could include simple recipes that the children have used in class and could also be enjoyed at home. They could also encourage parents to pack healthy snacks as well as provide simple nutrition facts that will help continue the students’ education of healthy eating habits in the home.
Reshape Food Environment
Unlike the “Food Revolution” campaign, we would not base our intervention on the Health Belief Model. We understand that an individual’s food choices are shaped by many other influences than simple knowledge about the health topic, benefits and risks of certain diets. Societal pressures, food environments, and the availability of healthy foods shape food choices. The decision of choosing what to eat is a complex topic and the simple communication of the health risks and benefits will likely be unable to create sustained behavior changes.
Instead, we need to recognize the social context in which these eating habits appear in order to create a healthier food environment for our children. There are numerous systemic issues that have influenced the unhealthy eating habits of our children: widespread poverty, junk-food advertising to children, corporate control of the food system, the prevalence of cheap fast food, and subsidies and policies that make meats and sugars cheaper than fresh fruits and vegetables2. Most of these issues are multifaceted and a substantial amount of effort is needed to change them. Although all of these issues need to be addressed, this campaign will be unable to address all of them.
We can help to shape the environment in which children eat through this campaign. By adding agriculture to the school curriculum, students will be able to learn where food comes from and how it is produced. It will provide an opportunity to educate children about modern agricultural practices as well as the environmental consequences of producing mass quantities of highly packaged and processed foods. Teachers can also provide students with different techniques to encourage students to make healthy choices amidst advertisements for unhealthy food that surrounds them. Such activities as learning about foods in the major food groups and their relationship to the food pyramid and keeping a food journal can be used to teach children about all kinds of food and food choices. These modifications in the food environment will help reduce the burden of making positive health decisions.
Minimize Reactance
As mentioned above, one of the main flaws in the “Food Revolution” campaign is the negative reactions caused by the implementation of healthier foods at lunch. The campaign restricted the freedom of the students and took away their ability to decide their own actions. This caused a boomerang effect that may have actually increased the likelihood of unhealthy eating behaviors in the students.
The “Healthy Foods, Healthy Me!” campaign does not utilize any restrictive or authoritative language to force children to change their eating habits. Rather, the newly proposed campaign features hands on learning and promotion of self-efficacy that encourages children to choose healthy foods for themselves. Children will be praised for bringing healthy snacks from home and praised for making good food choices. We will not refer to “good” foods and “bad” foods but rather to the benefits of eating a particular food. If we can link that to the individual interests of the child, it will be all the better. It is expected that the limited use of restrictive mandates will decrease the tendency for students to react against the intervention. If we are successfully able to limit reactance, then we could also expect greater compliance with the healthy eating habits among students as promoted in the intervention. If psychological reactance can be minimized, we can decrease the number of unhealthy eating habits in our children as well as increase the awareness of the population about healthy eating habits.
Promote Self-Efficacy
The “Healthy Foods, Healthy Me!” intervention addresses one of Oliver’s major flaws by providing students with the necessary tools to enhance their self-efficacy. The integration of starting a garden and cooking lessen in school would promote self-efficacy by providing the opportunity for modeling from other students and encouragement from teachers. Students will be able to participate in all aspects of food preparation, from the growing of the food to the cooking and preparation of a meal. This will help support students’ perception of successfully engaging in healthy eating habits.
Additionally, through the monthly letters to parents, parents will learn to provide emotional support, encouragement, and further education on the importance of healthy eating habits. This parental support will provide additional opportunities for modeling from those who are closest to the child. By providing both children and parents with the tools necessary to promote self-efficacy and environment supports at school, “Healthy Foods, Healthy Me!” would be effective in increasing healthy eating habits.
Conclusion
There have been a number of calls for action across the country to make changes in our food habits in order to stop the spread of childhood obesity and to reduce the environmental impact of our agricultural system. Jamie Oliver’s “Food Revolution” campaign brought national attention to the fact that drastic behavior changes are needed to secure our children’s futures. However, his efforts have not show any significant results, which can for the most part be blamed on the structure and implementation of the campaign. The way in which the campaign is delivered does not incite any new behaviors in the students or within the community. And at least in West Virginia, Oliver’s interventions that have been forced on children actually encouraged negative behaviors as fewer students now participate in the school lunch program and drink milk at school. As a result, there would be no expected change in the unhealthy eating habits of children across the United States. By creating a more inclusive school curriculum that educates students about how food is grown, processed, and consumed and provides support both in the school and home environment, we are expecting to promote healthy behavior changes. I believe that this campaign along with other grass root campaigns across the country will decrease the frequency of childhood obesity across the country.

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