By Pratt, Cornelius B
[P]eople have a responsibility to tackle this issue at an individual level, [even though] a large majority also sees a need for government to play some role in helping individuals accomplish those goals. – Trust for America’s Health (2007, p. 85)
But personal responsibility is not a free pass for corporate irresponsibility. It is easier to just say no when you aren’t being manipulated and marketed to say yes.
– Goodman (2003, p. A21)
Government agencies, foundations, and businesses use public- education and social-marketing campaigns to motivate the nation toward having better health through, among other things, healthful- eating habits and active lifestyles. Some of those efforts, however, have had modest successes. This article presents seven ground rules – or principles – that can improve the effectiveness of campaigns aimed at shrinking bulging waistlines. But the limits of such principles must be stated at the outset: Because social, interpersonal, community, and ecological factors influence health behaviors (Glanz, Rimer, & Lewis, 2002), well-crafted messages can help health communicators meet their campaign objectives only to the degree that those factors enable. Thus, on the one hand, a confluence of environmental and physiological factors inherently negates the effects of weight-management campaigns. Economics and social-psychological factors (e.g., cost of energy-dense foods, social networks, and interpersonal communication), on the other hand, affect the success of message themes, particularly those on intractable U.S. health issues such as excess weight gain and obesity. Consequently, even when well-crafted messages influence peoples’ nutrition and exercise regimens, they do not necessarily result in meeting overall campaign objectives.
Situation Analysis
On August 21, 2007, the U.S. Department of Health and Human Services (DHHS), one of several federal agencies that are tackling the overweight and obesity crisis that afflicts 66 percent of the U.S. population, announced the establishment of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, as a follow-up to its earlier initiative, Healthy People 2010. Less than a week later, a nonprofit organization, Trust for America’s Health (TFAH), announced in a report, the fourth in a series aptly titled “F as in Fat,” disturbing, yet predictable, findings indicating that our national battle against the bulge has yet again earned a failing grade and implying that the efficacy of many government programs and initiatives on obesity and overweight may be in question (Trust for America’s, 2007).
Who’s to blame? Are we, as individuals, doing our level best to reverse the obesity trend in the United States – or are we placing much of that responsibility on organizations? On October 19, 2005, the U.S. House of Representatives answered yes to the latter question by passing the Personal Responsibility in Food Consumption Act, which bars frivolous lawsuits on excess weight gain or obesity allegedly attributed to consumption of restaurant food. That bill failed to become law.
According to TFAH’s 2004 report on obesity, it had been viewed traditionally and exclusively as an individual problem; however, the report recommended that “the best way to achieve real, sustainable behavior change is through a combination of education plus community, state, and federal policies and programs that support individual action” (Trust for America’s, 2004, p. 4, emphasis added). And such programs inarguably run the gamut: the U.S. Food and Drug Administration, for example, in August 2003, set up an Obesity Working Group, which had policies on the labeling practices of food manufacturers, on having food manufacturers provide accurate information on serving sizes and calories count, on spreading the message that calories count, and on requiring restaurants to provide more nutritional information to consumers (Trust for America’s, 2004).
Also, DHHS’s Healthy People 2010 stated that health education should include information about the consequences of unhealthful diet and of inadequate physical activity. And, for at least a decade, a welter of similar government initiatives had been marshaled to boot: the Center for Nutrition Policy and Promotion’s Dietary Guidelines for Americans 2005; the Federal Trade Commission’s consumer guides on obesity that included Consumer Alert! Paunch Lines: The Skinny on Dieting; Setting Goals for Weight Loss; Pump Fiction: Tips for Buying Exercise Equipment; Tipping the Scales? Weight-Loss Ads Found Heavy on Deception; and The Facts About Weight Loss Products and Programs. All those public-education materials had long been touted as having the potential to alleviate overweight as a public-health challenge.
How much impact have those programs alone had on overweight and obesity in the United States? Because of the complexity of factors that affect the maintenance of healthy weight, singular national effect of those programs is not known. What is known, however, is that an increase in adult obesity rates occurred in 31 states in 2006, with 22 such states having an increase for the second year in a row (Trust for America’s, 2007). Between 1980 and 2004, childhood obesity rate more than tripled, a rate that former U.S. Surgeon General Richard H. Carmona (The Obesity Crisis, 2003, [para] 21) attributed to two fundamental reasons: “Too many of our children are eating too much and moving too little.” And those trends occurred despite massive, concerted efforts by government, corporate, and interest groups to stem the tide of a health problem that 85 percent of respondents in a TFAH survey believe “has reached epidemic proportions in the United States” (Trust for America’s, 2007, p. 85).
Widely implemented education and publicawareness campaigns have been key elements in those efforts. But such institutional efforts have their limitations, as some outcomes of persuasive campaigns tell us. Let’s look at the Reagan administration’s much-vaunted “Just Say No” (to drugs) campaign, which was launched in the 1980s, grounded in social inoculation theory, and cost more than $929 million. Its results indicated an increase in youths’ using drugs, an outcome Andreasen (1995) described as a boomerang effect and Rains and Turner (2004) as a reactance toward a campaign.
It is, therefore, the purpose of this article to present seven ground rules – or principles – for developing message themes (and slogans) on excess weight-gain prevention and reduction within the framework of personal responsibility for one’s physical health that is, such messages must be personalized to emphasize the self, even as health-care institutions, organizations and businesses do their part to enable the nation meet its health goals. In essence, then, governments, foundations, and businesses can provide only part- answers to a vexing health issue, leaving some of that responsibility to the individual. Granted, that view is consistent with that of U.S. adults: “Americans see a role for government in helping to turn awareness into action, particularly in the form of helping to provide strategies to increase physical activity and maintain a healthier diet in people’s daily lives” (TFAH, 2007, p. 88). Therefore, the rest of this article is premised on the notion that, while there is “a role for government in helping to turn awareness into action,” an emphasis on individual efforts is required in a renewed attempt to wrestle a national health epidemic. Thus, as the epigraphs that introduce this article suggest, responsibility for the effectiveness of health-communication campaigns on weight management is twofold: that of the individual and of the organization.
Organizational and Individual Responses
A good number of U.S. organizations increasingly acknowledge the value of a healthy workforce. And some are questioning the economic rationale of focusing on profits to the detriment of the consumer. Perhaps in the same breath, foodand drinks-manufacturing and marketing companies are tinkering with their products and their marketing messages, demonstrating some level of responsibility for the nation’s healthful – or unhealthful – eating habits (e.g., Adams, 2007). Inarguably, some of that corporate action was a response to litigation brought against the food industry: McDonald’s settled for $12 million a lawsuit that alleged that it had failed to disclose its use of beef fat in its French fries; DeConna Ice Cream Company settled for $1.2 million a claim that it had understated fat and calorie content in a brand of its product, as did Robert’s American Gourmet Foods for $4 million; and Kraft agreed to remove trans fats, which it had not disclosed, from its Oreo cookies (Zernike, 2003).
A landmark agreement announced May 3, 2006, is yet another of a flurry of strategic attempts by advocates of healthful-eating habits to battle the obesity epidemic. On that day, some of the largest marketers of carbonated drinks – American Beverage Association, Cadbury Schweppes, CocaCola and Pepsi-Cola – agreed to sell only water, unsweetened juice, and low-fat milk in U.S. elementary and middle schools.
Just months earlier, a group of intrepid fourthand fifth-graders at North Side Elementary School, in Fort Lauderdale, Florida, refused to sell unhealthful snacks to raise funds for their trip to Washington, D.C., and Williamsburg, Virginia. They viewed as unconscionable the sale of sugared, high-calorie snacks because they had been taught at school to abstain from eating those same products. And, three years earlier, California had become the first state in the nation to ban carbonated beverages from cafeteria menus from elementary through junior high school. And high-school cafeterias are only now increasingly giving healthful food choices a much-needed boost.
Health Risks and Business Interests
The clinical implications of food choices for a nation’s health are far-reaching: they contribute in disparate ways to overweight and obesity in children and adults. In 2003-2004, 35 percent of U.S. children were overweight or at risk for overweight, and 66 percent of U.S. adults were overweight or obese (Ogden et al., 2006). Obese U.S. children and adolescents have increased risks for cardiovascular diseases and comorbidities such as Type 2 diabetes, hypertension, and dyslipidemia (Daniels, 2001). Among adults, obesity contributes to cardiovascular disease mortality and to a smorgasbord of diseases, including kidney disease, diabetes, stroke, and cancer (e.g., Flegal, Graubard, Williamson, & Gail, 2007; Friedrich, 2003).
Overweight and obesity also nave economic implications: they result in increases in medical expenses, in absenteeism, and in health-care costs (Finkelstein, Fiebelkorn, & Wang, 2005). Overweight and obese workers are significantly more likely than their normal-weight counterparts to report health-related lost productive time (Ricci & Chee, 2005); poor work ability (Laitinen, Nayha, & Kujala, 2005); disability (Burton, Chen, Schultz, & Edington, 1998); and lost workdays (Burton, Chen, Schultz, & Edington, 1998; Wolf & Colditz, 1998). Such issues provide the impetus to several major U.S. companies – e.g., Coors Brewing Company, Hershey Food Corporation, Kimberly-Clark, and Sprint – to develop worksite wellness programs (Anderson & Kaczmarek, 2004; Zernike, 2003).
The major culprits of much of the nation’s overweight and obesity problem are excess caloric intake and physical inactivity. Americans eat at least one meal out of the home each day. Reported eating at fast-food restaurants has been associated with poorer eating and exercise habits and with higher body mass index Geffrey, Baxter, McGuire, & Linde, 2006a, 2006b). Other studies associate the Circean lures and the use of fast-food restaurants (Maddock, 2004), which, incidentally, tend to cluster around schools and expose students to poor-quality food environments (Austin et al., 2005), with the frequency of consuming restaurant foods and having higher intakes of calories (McCrory et al., 1999; Paeratakul, Ferdinand, Champagne, Ryan, & Bray, 2003); with high-fat, high-sugar food choices and inverse associations with healthful foods such as fruit, vegetables and whole grains (Bowman & Vinyard, 2004; French, Harnack, & Jeffery, 2000; French, Story, Neumark-Sztainer, Fulkerson, & Hannan, 2001); and with the consumption of fast food that has had an adverse effect on dietary quality of children and adolescents aged 4 to 19 (Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2004). Consequently, the U.S. Department of Agriculture designed a Healthy Eating Index (HEI) to help the U.S. public better understand the quality of diet that it consumes. HEI has 10 components, each of which identifies an aspect of a healthful diet, based on the agency’s Food Guide Pyramid and its dietary guidelines (U.S. Department of Health, 2005). An HEI score of 81 or higher indicates a good diet; a score from 51 to 80 indicates a need for dietary improvement; a score lower than 51 indicates a poor diet. The mean score for the U.S. population indicates a need for dietary improvement.
Seven Ground Rules
I present seven ground rules to help organizations develop key messages for motivating audiences to respond to their risk for overweight and obesity. I developed those rules by analyzing campaign messages that were either effective in meeting their goals or that failed to reach them. A key strength of major overweight and obesity campaigns in the United States is that they all subscribe to the cumulative-effects theory: complementary campaign themes are not only repeated over time but are placed in a variety of media, public and interactive outlets. But most such campaigns have limitations; hence, the proposed ground rules.
1. Be attentive. This is the first rule of every successful campaign. We should listen more carefully to what participants tell us in depth interviews, focus groups, pretest message research, pilot tests or other forms of messageevaluation programs. That way, a planner learns firsthand audience reactions, perspectives, and interpretations that could be brought to bear on campaign messages and slogans, sidestepping pitfalls and limitations that typically result from unexpected outcomes of campaigns improvidently rolled out, as was the case of the “Just Say No” campaign. The contractors who helped develop that campaign on behalf of the federal government had evidence of a vetting process, but the scientific rigor and disinterestedness of its planning phase left a lot to be desired. Regardless of how much scientific evidence one has accumulated during planning, art still has a fundamental role in testing copy: one still needs to listen to one’s gut.
2. Be personal. Because individual responsibility is a crucial element in health maintenance, it is important that key messages be replete with personal pronouns: “you,””your,””my.” The point here is to encourage audiences in a succinct way to understand their individual stake in the message and to embrace it. NIH’s “We Can! [Ways to Enhance Children’s Activity and Nutrition]” and Nevada’s Clark County’s “Healthy Eating and Physical Activity Campaign” illustrate the effectiveness of personalization.
3. Be selective. Organizations have a responsibility to help people make wise food choices and engage in physical activity. It is an individual’s responsibility to develop healthful-eating habits by, for example, consuming five or more servings of fruits and vegetables per day, while acknowledging that total calories consumed count. As noted in a preceding paragraph, research links fast-food consumption to obesity (e.g., Mancino, Lin, & Ballenger, 2004), which is further exacerbated by the limited nutritional information that is available to patrons of restaurants and fast-food chains. Granted, this consideration is undermined by realities that low- income households tend to have less access to high-quality foods than middle- and upper-income households (Moore & Diez Rous, 2006; Zenk, et al., 2005). Low-income neighborhoods tend to have a significantly higher concentration of fast-food chains than middle- and upper-income neighborhoods (Block, Scribner, & DeSalvo, 2004; Horowitz, Colson, Herbert, & Lancaster, 2004; Zenk et al., 2005).
4. Be casual. People are responsible for taking mini-steps as a complement to an exercise regimen that requires more frequent physical activity. Wellness programs tend to overemphasize a routine – that is, setting aside 30 or so minutes for a workout; rather, messages will be more beneficial to the public if they focus on the small steps that we can take toward becoming active. An illustration: Granville C. Coggs is an 82-year-old radiologist (and exercise aficionado) who uses the slightest of opportunities to burn calories. At his workplace, he parks his car some 440 yards from the main entrance to his office building. Why? Because he sees that distance as yet another opportunity to maintain his level of physical activity by running into and out of his building. While running through the grounds or parking lot of an office building might be a risky activity, walking longer distances from parking areas to a place of appointment is a passive mini-step toward being in frequent motion and moving toward better physical health. In 2005 and 2007, Dr. Coggs won gold medals in the 400- and 1,500-meter races in his age bracket at the Texas State Senior Games; in 2006, he won a gold in the 400-meter and a silver in the 1,500-meter competitions.
Organizations contribute to such small efforts in the workplace. Cars are banned from Sprint’s 200-acre headquarters in Overland Park, Kansas, forcing employees to park in garages as far away as one-half mile from their offices, where they are also encouraged to use the stairs, not elevators, between floors (Zernike, 2003).
5. Be active. People are responsible for having an active lifestyle. The “Verb: It’s what you do” campaign that the Centers for Disease Control and Prevention hoped will help children ages 9 to 13 become physically active did not even use the active verb. Parts of that campaign, reported to have cost nearly $190 million, raised questions about its efficacy, resulting in the Bush administration’s withholding funding from the campaign in its second year. Consider, for example, one of its abstruse, albeit personal, messages: “Everywhere you go, everywhere you look, there are verbs out there just waiting for you to get into.” Simple exhortations that start with a personal pronoun coupled with an active verb as in “you exercise daily,””you play often””you swim weekly,””you run every day,””you jump rope frequently,””you skate with friends,” or “you walk every day” could have been much more communicative to campaign audience.
Minnesota’s activity-packed “do” campaign, launched in Duluth and in Minneapolis-St. Paul in November 2004 by BlueCross BlueShield of Minnesota and by the American Heart Association, is an exemplar of a long-range persuasive, multimedia effort to encourage adult Minnesotans to “grove your body every day” by adding physical activity to their daily routines at work, at home, at play. This physical-activity campaign, part of a four-goal “Prevention Minnesota” effort, uses television commercials (and a theme song), billboards, street media, and transit ads to drive home its messages, in which are embedded simple auxiliary verbs to motivate audiences into action: do bike, do canoe, do dance, do garden, do hike, do hopscotch, do move, do shovel, do skate, do sled, do walk. The campaign’s two television commercials show a heavy-set middle- age man “do dance” in one and “do walk” in the other; in both, the man shakes his body vigorously and rhythmically to a theme song, “Move Something.” The campaign is being expanded to other major cities in Minnesota, where the mass media, community involvement, point-of-decision prompts (e.g., use stairs, skip this bus stop for the next one down the block) have raised public awareness of the campaign. (Another facet of “Prevention Minnesota” focuses on healthful eating.) Granted, studies have shown that neighborhood safety, walkability and disorder are related to the frequency of outdoor physical activity (e.g., Burdette & Whitaker, 2004; Burdette & Whitaker, 2005; Burdette, Wadden, & Whitaker, 2006; Miles, in press); and that dimensions of the built environment (land use, access to public transit and population density) are significantly inversely associated with body size, while controlling for the potentially confounding effects of demographic factors (Rundle et al., 2007). But U.S. city roads are generally more conducive to driving than to walking, biking, or weaning the public from motorized vehicles – unlike, say, in European cities such as Amsterdam and Paris, where bicyclists tend to have better advantages in road use and where wider sidewalks and more tree-lined streets give pedestrians additional reasons to be outdoors and to be physically active. (Paris’s Mayor Bertrand Delanoe has pledged to reform the city’s transportation system by, among other things, eliminating motorized traffic in parts of the city and reducing the city’s car traffic by 40 percent.) Consequently, a good number of residents of U.S. cities often fail to take advantage of available neighborhood walkways to engage in some regular exercise: walk to a nearby convenience store or to a public facility, and reduce particulate pollution as they become healthier.
6. Be sparing. Audiences’ compliance is enhanced by messages that are clear, simple, tailored and actionable. Marketers and advertisers, on the one hand, understand full well that information clutter is dysfunctional, in that it leads to consumer skepticism toward the message; to viewer opposition, hostility and resentment toward, and defiance of, the message; and to message avoidance strategies (Goldman & Papson, 1994, 1996; Mendoza, 1999; Speck & Elliott, 1997). Rumbo (2002), on the other hand, argues that marketers can convert the subculture of consumer resistance movements into a strategic advantage – one that capitalizes on both consumerism and on marketers’ insights on the lived experiences of ahti-consumerist groups.
In both situations, tailored messages delivered through appropriate channels should convey to audiences that engaging in two major activities eating healthfully and exercising regularly – in small steps can contribute to expected outcomes. Personalized nutrition-only campaigns such as “TrEAT Yourself Well” indicated the effectiveness of focused campaigns in promoting healthful dining (Acharya, Patterson, Hill, Schmitz, & Bohm, 2006), as did the “5 A Day” in promoting consumption of fruits and vegetables (Centers for Disease Control, 2005). Similarly, nutrition-cum-physical-activity campaigns (e.g., “California Project LEAN [Leaders Encouraging Activity and Nutrition] and the NIH’s “We Can!”) are examples of such focused attempts by campaign planners to zero in on one or two expected outcomes, without taxing the cognitive and behavioral limits of their audiences.
But message themes must be actionable for audiences, a principle on which parts of Nevada’s “Healthy Eating and Physical Activity Campaign” fall short. The reason: Its “Walk Around Nevada,” introduced June 2006 as an online program to increase physical activity, may not sit well with people without easy access to such technology, which, in any event, encourages sedentary behavior. The program’s paper alternative for those without online access may not have the same cachet as that associated with entering one’s activity online and may also be so cumbersome that it further discourages disadvantaged residents who are already struggling with a health challenge. Likewise, simplicity in message themes was also lost in “Calories Count,” a nutrition-awareness campaign at the University of California, Los Angeles. Its key messages are buried in a ponderous, text-heavy tutorial on one’s daily calorie needs for a healthy body weight, making audience’s message comprehension and compliance challenging in their own right.
Similarly, elements of “What Moves U,” a national campaign launched October 2006 by the National Football League and the American Heart Association to encourage physical activity among youths are text-heavy and also have Web-based activities (contests and games), which can inadvertently encourage physical inactivity.
7. Be credible. Audiences comply more when information is inarguably and demonstrably accurate. Message themes must be unassailably factual, a consideration that was lost on both the American Dairy Association and the National Dairy Council whose “3- A-Day of Dairy” campaign morphed into a “Healthy Weight With Dairy.” Launched in January 2003, “3-A-Day of Dairy” was a nutrition-based, award-winning campaign aimed at encouraging the public to consume calcium (in milk, cheese and yogurt) for stronger bones and healthier bodies.
Beginning September 2004, however, the campaign was expanded to include a link among dairy consumption, weight loss and weight management, a link so tenuous and controversial that it stoked the ire of an activist group, Physicians Committee for Responsible Medicine (PCRM), which petitioned the Federal Trade Commission (FTC) in 2004 to halt the campaign. A fact sheet distributed in that campaign stated in part that for “adults needing to lose weight, a growing body of research shows that enjoying 3 servings of dairy a day as part of a reduced calorie weight-loss plan can help them achieve better results, when it comes to trimming the waistline, than just cutting calories alone and consuming little or no dairy.” Thus the campaign had television, print and radio commercials with slogans such as “Milk your diet. Lose weight” (from the National Fluid Milk Processor Promotion Board); “3-a-day. Burn more fat, lose weight” (from the National Dairy Promotion and Research Board); and “More Yummy…Less Tummy.” The dairy industry had relied on results that indicated significant positive relationships between dairy consumption and weight loss (Zemel, Thompson, Milstead, Morris, & Campbell, 2004). Those findings were challenged (e.g., Barr, 2003; Lanou, 2005). In May 2007, the FTC axed the campaign, opening the flood gates to further criticism of the industry’s intentions. Absent conclusive evidence on an association, the dairy industry charged ahead to extend its “Healthy Weight With Dairy” campaign toward accomplishing goals that had earlier been deemed questionable, if not controversial.
At its inception, the U.S. government’s cancer-prevention campaign, “5 A Day,” promoted consuming five or more servings of fruits and vegetables daily. Later food research interpreted that consumption as a tool for weight management. While there are reasons for promoting consumption of fruits and vegetables as a useful strategy for preventing overweight, evidence is sparse to support the association between fruit and vegetable consumption and weight (Sherry, 2005).
Conclusion
Communication campaigns – e.g., “TrEAT Yourself Well” and “We Can!” – are a standard response to the epidemic of overweight and obesity in the United States. But most such campaigns are not demonstrably guided by all the seven ground rules this article proposes as guideposts for planners of weight-management communications. Does such absence explain the nation’s failure to rein in its increasing overweight and obesity rates? We don’t know.
What we do know, however, is that health campaigns whose message themes and slogans reflect the hallmarks identified in this article tend to meet their objectives and to have better audience reception. And the campaigns tend to subscribe to the notion that their effectiveness lies at two levels that of the individual and of the organization. To the degree that campaign themes collectively reflect those ground rules, as well as the dual responsibilities of the individual and the organization for combating the epidemic, it is likely that the latter will be much better contained, if not reversed. Failing that, the epidemic could morph into a permanent fixture on the nation’s health landscape, where there is only spotty evidence of success. To avert such an outcome, then, there is an urgent need for a national campaign on overweight and obesity that involves both a commitment from and a partnership among government agencies, foundations, and businesses.
References Available Upon Request
…an increase in adult obesity rates occurred in 31 states in 2006…
…responsibility…of weight management…that of the individual and the organization.
…some of the largest marketers of carbonated drinks…agreed to sell only water, unsweetened juice, and low-fat milk in U.S. elementary and middle schools.
…obesity contributes to… a smorgasbord of diseases…
We should listen more carefully to what participants tell us…
Wellness programs tend to overemphasize a routine…
…ads to drive home its messages, in which are embedded simple auxiliary verbs to motivate audiences into action…
…information clutter is dysfunctional… …to encourage physical activity among youths are text heavy and also have web- based activities… which can inadvertently encourage physical inactivity.
…evidence is sparse to support the association between fruit and vegetable consumption and weight…
Cornelius B. Pratt (Ph.D., University of Minnesota at Twin Cities, 1981; APR, 1983) is a contributing editor of PRQ and a professor at Temple University School of Communications and Theater. Before joining the Temple faculty in 2006, he served for nearly six years in the U.S. Department of Agriculture, in Washington, D.C., and for 11 years on the faculty at Michigan State University. His research interests include health-care delivery and global and strategic communication. E-mail: [email protected]; telephone: (215) 204-3214.
Copyright Public Relations Quarterly 2008
(c) 2008 Public Relations Quarterly. Provided by ProQuest Information and Learning. All rights Reserved.
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