Monday, December 23, 2013

The Fallacy of Fat Letters: Why the Health Belief Model Does Not Work- Katherine Ulrich

The prevalence of overweight and obesity amongst children is climbing nationwide (5, 10). Childhood obesity is problematic from a public health standpoint obesity in childhood is linked  to many adverse health outcomes later in life, as well as obesity in adulthood (1, 2, 3). In fact, “for children and adolescents with BMI above the 95th percentile at any age during childhood, the probability of being obese at age thirty-five years ranged from 15 to 99 percent (3). Such adverse outcomes include hypertension, insulin resistance, metabolic syndrome, type 2 diabetes, asthma, obstructive sleep apnea, nonalcoholic fatty liver disease, and depression (1, 3).In many states the answer to this epidemic of childhood obesity is calculating BMI in schools and reporting the information in letters home to parents. In Massachusetts BMI reporting became a very controversial topic.
BMI reporting first became mandatory in Massachusetts public schools for 1st, 4th, 7th, and 10th grade students in 2009. The recording and reporting of individual students’ BMI information was to be confidential and reported only to their parents or guardians; nurses also reported aggregate data on all students was to the Massachusetts Department of Public Health by school nurses. School nurses were also carrying out the BMI screenings and calculations. Parents received BMI data regarding their individual children via mail or “secure internet portal” (7). Parents also had the option of opting out of having their child’s BMI calculated in school at any point. Healthy weight was defined as BMI from the “5th percentile to less than the 85th percentile”, underweight as BMI “[l]ess than the 5th percentile”, overweight as BMI from the “85th [percentile] to less than the 95th percentile, and obese as BMI “[e]qual or greater than the 95th percentile” (7). The results of BMI screenings from the 2010-2011 school year in Massachusetts showed that of children in grades 1, 4, 7, and 10 (n=205,975) 16.7% of students were overweight and 15.7% were obese. Prevalence of and obesity was also slightly higher in males (17.3%) than females (14.0%) (7).
            We can attribute the failure of BMI reporting in large part to its reliance on the Health Belief Model as a means of effecting change in health behavior. It is important to note that in the case of BMI reporting—in this context—the actors are the parents rather than the children. The Health Belief Model operates on the assumption that people will take “health-related action” because of (a) a specific health problem or concern that makes taking action important, (b) the idea of “perceived threat”, and (c) the conviction that adhering to a health behavior recommendation will reduce said “threat” or have some benefit (6). The use of the health behavior model as a method of framing BMI reporting proved deadly for the program and this is why.
Rationalization of Risk
            While data and literature support the reality that rates of overweight and obesity in children are on the rise in the United States—and Massachusetts specifically—this does not guarantee parents’ support for programs such as BMI reporting. The Health belief model posits that when people realize that their behavior or actions negatively impacts their health—or in this case the health of their children—they will cease these deleterious behaviors or actions (6). However, this assumption is based on the belief that human behavior is rational, a belief that is inherently flawed. Research demonstrates that parents often underreport their children’s weight despite the fact that they might be overweight or obese (9, 10). The reality that parents underreport their children’s weight points to the irrationality of the human thought process because despite the fact that they are aware of their children’s appearance they still do not register their weight as a potential health problem. This achieved ignorance highlights one reason that intervention based on BMI score reporting may not be the best option for effecting change in health outcomes.
            BMI reporting seeks to place irrefutable, concrete evidence of possible overweight or obesity in the hands of parents. However, the argument over the efficacy of BMI as a screening measure allows parents to rationalize the risk posed by ignoring BMI reports as the first sign of danger. As BMI reporting became a hot button issue in the media claims about the unreliability of BMI as a screening measure amplified parents’ feelings that BMI scores in percentiles denoting overweight or obese were not as much of a problem as schools and public health officials were making them out to be (12).        
            In only appealing to rational thought processes and rational evaluations of risk, public health professional made a grave error when rolling out BMI reporting programs in Massachusetts public schools. The health of their children is very important to parents and the assertion that they have done something wrong—or something that impacts their child’s health negatively—in their parenting is the message that BMI reporting sent as it played out in the media. This message activates a protective factor in parents—for both themselves and their child. Unfortunately, the best way to counteract this message that their parenting has fallen short in some way is to discredit BMI as a means of assessing their children’s health. Essentially, in the media portrayal of BMI reporting itself became the threat rather than obesity (6, 12).
The Danger of Victim Blaming
            In addition to overvaluing the place of rational thought in decision-making, the health belief model takes dangerous steps into the arena of victim blaming (6). The risk of overweight and obesity is much higher for children from socioeconomically disadvantaged backgrounds (1, 11). Because public health as a discipline has a stake in social justice in relation to health disparities, addressing health inequity such as disproportionate rates of overweight and obesity in socioeconomically disadvantaged populations is very important.
            Health belief model on the other hand assumes “that one can successfully execute the behavior required to produce the outcomes”, in this case referring to achieving BMI scores between the 5th and 85th percentile (6, 7). The assumption that everyone has the tools to “successfully execute” behaviors that will lead to positive health outcomes is erroneous. In the case of childhood overweight and obesity socioeconomic status is a social determinant, that has a great deal of influence over the increased vulnerability of a child to overweight and obesity. Health belief model has no allowances for social determinants however, which leads to the idea that all parents—regardless of circumstance—should be able to ensure that their children maintain a healthy body weight because they know that overweight and obesity increase the likelihood of negative health outcomes (6, 11).
            The implementation of a standardized measure of BMI reporting also fails to take into account the impact of social determinants that disparately affect specific populations more than others. This also has the potential to blame certain populations for being affected by these risk factors, which is incorrect as well as counterproductive. The best way to remedy this problematic standardization of programs is to implement specific, culturally competent interventions in populations and communities with increased risk for childhood overweight and obesity due to social determinants such as socioeconomic status (11). These interventions in high-risk populations should be carried out in addition to or in place of interventions implemented in populations that are not high risk.
The Crisis of Core Values
            Core values are extremely important in framing the way that public health interventions are implemented and perceived. In the case of BMI reporting in Massachusetts public schools public health officials unfortunately chose to frame this intervention around the core value of health. The Massachusetts Department of Public Health represented BMI reporting as a way of protecting the future health of children (7). There are two distinct ways in which selling the idea of BMI reporting as protective of children’s future health is flawed. First, people are less interested in modifying health behaviors when adverse health outcomes relating to their behaviors are years down the road. Second, this campaign for BMI reporting in public schools is based around health, which as a core value rarely inspires immediate action; even less so when the threat of adverse health outcomes is not immediate.
Because health in this case is refers to the health of children—for whom protection is a vested interest of parents—this frame of health is stronger than it is typically. However, the frame of health is still not strong enough. Rather than choosing health as a core value for BMI reporting as an intervention targeting reduction in overweight in obesity, public health professionals would have been much better served by choosing core values such as autonomy or family unity and basing interventions around these values.
How Can We Create a Culturally Competent Intervention?
            While BMI reporting was not necessarily a poor intervention in Massachusetts public schools in and of itself, the way it was carried out—following assumptions made by the health belief model—predicted its downfall earlier this year. Rather than trying to tweak BMI reporting, or reframing based in more competent public health theories I will propose an entirely new intervention.
            Historically, many public health interventions targeting children have been school-based because it allows for a more equitable and further reaching intervention, under the assumption that the vast majority of children in the United States are attending public schools. School based interventions also allow for a more equitable spread of interventions across populations, demographics, and communities (11). This is why housing interventions addressing childhood overweight and obesity in public schools seems the best and most equitable means of reaching the largest amount of children. School-based interventions are then also the best way of reaching populations of children in the United States who are at higher risk for overweight and obesity—such as children from socioeconomically disadvantaged backgrounds (8).
            Keeping all of this in mind, I propose a two-pronged approach targeting two different populations of children within and intervention addressing rates of overweight and obesity in Massachusetts. First a widespread intervention in public schools integrating health and gym classes with an after school program that focuses on making physical activity fun (8). Second a program providing realistic nutritional advice to lower-income families and communities.
 In health and gym classes, a curriculum pertaining to nutrition and healthy eating will be integrated with the current curriculums in place. Building on this foundation of nutrition and healthy eating afterschool physical activities will place emphasis on giving children agency in making decisions about how and in which kind of activity they would like to participate (11). In making decisions as a group about what will constitute physical activity that day, children are empowered to make positive decisions about their health. The nutrition and afterschool programs focusing on physical activity would have to be both integrative and interactive to ensure these goals. It is also important to begin these interventions early on to facilitate the formation of healthy habits among young children, increasing their likelihood of maintaining healthy habits later on. I hope that these programs would be at least partially staffed by community volunteers (both members of the community as well as dedicated community volunteers such as AmeriCorps service members) as well as college or professional students studying relevant areas.
            This intervention would need to be available to all children in order to make it effective. It is important to note however, that for higher-risk populations more focused intervention would be necessary. Research shows that rates of overweight and obesity disproportionately affect children from socioeconomically disadvantaged backgrounds (4). In order to address this dedicated community involvement would be necessary. An online learning module as well as phone interviews and training would be cost and time effective in disseminating community and parental learning curriculums based around what constitutes proper nutrition as well as ways that proper nutrition can be maintained through economic hardship (i.e. how to make healthier food choices). These interventions seek to address both the complicated needs of diverse populations as well as the weaknesses of the BMI reporting intervention.
Risk Identification
            These two interventions mitigate the miscalculation of the risks of childhood overweight and obesity that plagued BMI reporting. By dedicating time and resources to provide culturally competent services and education to parents and communities these interventions do not leave parents feeling ineffective in the face of hard line statistics--such as BMI scores—and without realistic options regarding how to improve their children’s health. The intervention in schools also gives children a sense of agency and ownership in their own health, making it more likely that they will maintain healthy behaviors.
Empowering Communities
            Rather than blaming communities or populations for their increased risk of overweight or obesity, these interventions empower them to change them (1). More importantly, the interventions also give them tools by which they can effect this change in the health of their children. Children learn how to make healthy choices in the context of their circumstances. We cannot chastise them for not choosing a healthy option, when one is not realistically available to them. In the same way, parents are empowered to learn how to make healthier decisions for their family, again within the context of their circumstances. In fighting childhood overweight and obesity, it is important to set realistic expectations for populations that are affected disparately by factors such as finances, access to food, and access to places where physical activity is safe. This is one reason that schools are an ideal setting for after school programs dedicated to fun, rather than competitive, physical activity. For some children schools represent the only space in their built environment that being physically active is safe.
Enhancing Core Values
            While both of these interventions a based around improving children’s health outcomes and influencing positive health behavior, health is no longer the core value. Instead of health, we use empowerment as a way to frame both interventions. In changing the core value and the framing of the interventions, the interventions challenge parents’ authority roles in their children’s lives less. Rather than telling them that there is some deficit in their care for their children, because their child has a BMI score that qualifies them as overweight or obese, we are giving both parents and children tools to empower them in making healthy decisions and maintaining healthy physical activity. Rather than passing a mathematical judgment, we are providing a service.

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12. Miller T. Massachusetts Mulls Doing Away With “Fat Letters” That Report Schoolkids’ BMI to Parents. In: NY Daily News. 2013.

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