Sunday, January 5, 2014

Critique of a Public Health Intervention: Fatal Flaws of the Fruits and Veggies- More Matters Campaign and Recommendations for a Modern and Effective National Nutrition Campaign – Lindsay Johnson

Introduction
In 1991, a public health initiative was spearheaded by The National Cancer Institute (NCI) and the Produce for Better Health Foundation (PBH), called the 5- A- Day campaign.  Data was released showing that most Americans needed to double their fruit and vegetable intake in order to meet the amount recommended by the USDA Dietary Guidelines.  The 5-A-Day campaign aimed to increase fruit and vegetable intake among Americans to at least 5 servings a day; however, the campaign failed to produce positive results.  Ironically, over the course of the campaign, fruit and vegetable intake among Americans declined.  This failure resulted in wasted time, money, resources, and offered no improvement in the American diet.  The basis of the 5-A-Day campaign still exists, however in 2007 the campaign’s title was change to Fruits and Veggies- More Matters.  While the name has changed, and no longer stresses the exact number of servings one should consume each day, the concept behind the campaign remains the same, as do its flaws in attempting to be a successful public health intervention. 
This paper will serve as a critique to explain several ways in which the Fruits and Veggies- More Matters campaign is flawed.  One major flaw of the campaign includes its reliance on behavioral health theories that operate on the individual level.  The problem that arises with individual level theories is the assumption that people really care about their health and that their intentions will lead directly lead to behavior change.  Secondly, this campaign threatens one’s core value of freedom with the government dictating to the public what they should do, and specifically, what they should eat.  Another third flawed aspect of this campaign is the way in which it is exposed and marketed, lacking strategic use of media and newsworthiness.  Each of these three flaws will be discussed further and I will also provide my recommendations for how to improve upon these flaws.  With improvement in each of these elements of the Fruit and Veggies- More Matters campaign, a public health program can be born that resonates with Americans and ultimately brings forth positive change.   
Critique Argument 1- Reliance on an Individual Level Theory
The Fruits and Veggies- More Matters campaign is intrinsically flawed due to its reliance on individual level theories, namely the Health Belief Model.  This campaign applies the Health Belief Model concept that if you tell someone that something is bad, they will not do it or vice versa.  In Mark Edberg’s book, Essentials of Health Behavior: Social and Behavioral Theory in Public Health, he points out the flaws of the HBM stating that “the HBM is known as a value expectancy model, which basically refers to the assumption that people will engage in healthy behavior if 1) they value the outcome (being healthy) related to the behavior, and 2) they think that the behavior is likely to result in that outcome” (1).  This poses a flawed assumption that people care about their health to the extent that they will change behaviors solely because it is bad for them, regardless of the other influences impacting their life.  This concept is proven wrong everyday in the world of public health.  For example, it is common for a Registered Dietitian to advise their client to should stop eating fast food as it may lead to cardiovascular disease, or a Physician to tell their patient to stop smoking as it may cause lung cancer.  However, despite being informed about what is good for them, the person continues on with that risky behavior.  This common real-life example is proof that people are not guaranteed to complete an action simply because they are told it is for the benefit of their health.
The Behavioral Health Model also assumes that one’s intentions lead directly to behavior.   It is a major flaw of public health practitioners to make this assumption, as they are ignoring some of the most influential factors that play a role in one’s actions.  There are many external factors involved with the decision making process.  Some of these factors include the influence of friends, family, and society.  A person may have good intentions to make a health behavior change such as quitting smoking or losing weight, however if concern for how their friends will perceive them outweighs their will change the behavior, they will not follow through with that original intention.  Additionally, this model assumes that all people are on a level playing field with regards to information and access.  Not all people will have the appropriate health education needed to make an informed decision or have the access to resources that will support the behavior change.  In relying on the Behavioral Health Model to support the More Matters campaign, public health practitioners are sabotaging their own efforts by making flawed assumptions and ignoring many of the influential factors that play a role in what leads to one’s behaviors. 
Critique Argument 2- Threatening Core Values
  The Fruits and Veggies- More Matters campaign makes another fatal flaw by threatening core values.  Freedom is one of the strongest and most compelling of the core values that people will cling to and defend, especially when they feel this value is being threatened.  In the case of this campaign, the government is taking individuals’ freedom by dictating what their eating habits should be (increasing fruit and vegetable intake).  When this campaign first launched as the 5-A-Day campaign it gave clear orders for how many servings people should be eating in order to have a healthy diet.  These orders translate to the public as a loss of choice and a threat to personal freedom.  Although the name of this campaign has since evolved to appear less controlling, the message and tone of the campaign remains comparable with regards to preaching and imparting blame and feelings of shame on those who do not follow.
In threatening one’s core values, this campaign risks evoking the Psychological Reactance Theory.  When people feel their freedom or beliefs are being threatened, it forces them to cling even more tightly to those beliefs.  The tone that is set by the More Matters campaign is that one must consume more fruits and vegetables per day viewed in order to be healthy.  Preaching this campaign to the public immediately puts people on the defense to protect their beliefs and freedom of choice.  In this sense the campaign may backfire completely for those who either do not have the same nutritional beliefs as those being preached, or simply have the innate sense to rebel against what they are being told they must do.  This was exemplified with the 5-A-Day campaign as the tone caused people to be overwhelmed and turned off by the directions they were being given, reversing the positive intentions of the campaign.  This is evident in the failure of the 5-A-Day campaign with its decline in fruit and vegetable intake, as well as the More Matters campaign, which continues to correspond with less than 3 daily servings of fruits and vegetables combined for both adults and adolescents (2).     
Critique Argument 3- Lack of Exposure
Another flaw of the Fruits and Veggies- More Matters campaign is its method of exposure to the public and its lack of effective advertising and marketing.  This program lacks appeal to the media and has no real element of newsworthiness to gain the attraction of the public.  When visiting the Fruits and Veggies- More Matters website one finds a plethora of lackluster information based solely on health, which is known as a weak core value.  The website preaches what one should eat and in what amounts in order to avoid adverse health effects such as obesity, cardiovascular disease, diabetes, and cancer. However, it does not provide any elements that catch the public’s attention or provide motivation to follow the recommendations being given. 
  This campaign lacks the use of modern group level models such as the Agenda Setting Theory, which also relates to its lacks of attractiveness.  In order for the campaign to get on the public’s agenda the campaign must first get on the media’s agenda.  Unfortunately, the More Matters campaign lacks any elements of newsworthiness that would deem it appealing to media sources.  While the campaign does have an icon that they use as branding on food packages and on their website, the icon does not have any brand loyalty associated with it.  That is, people are unlikely to purchase or consume these items for reasons of loyalty or personal connection with the More Matters branded items.  In ignoring these modern theories of advertising, branding, and agenda setting the campaign is limiting the ways they will gain any support from the people they are aiming to reach, which is a major flaw affecting the success of this program.
Conclusion of the Critique
Despite the significant flaws with the Fruits and Veggies More Matters campaign, the intention behind the program is good.  Public health practitioners are well aware of the dangers of obesity and related diseases caused by poor diet and lifestyle choices.  Developing campaigns to increase the intake of whole foods, specifically fruits and vegetables, should remain an important area of focus; however, we must find an effective way to market these campaigns in order to reach our target audience.  With that positive intention in mind as well as the knowledge of mistakes made with the More Matters campaign, I would like to propose my own public health campaign that also aims to ultimately increase fruit and vegetable intake but through alternative methods.    

Articulation of Proposed Intervention- “The Real Deal”
My proposed public health campaign is called The Real Deal.  Like Fruits and Veggies- More Matters, my campaign is nutrition-focused; however, its structure is modeled after the success of Florida’s “Truth” anti-tobacco campaign.  The Truth campaign used unconventional counter-marketing strategies that were able to have a significantly positive effect in reducing the percentage of teens using tobacco (7.4 percentage points among middle-school children) in Florida within just 30 days (3).  The Truth campaign was successful for multiple reasons.  One of their strategies included using modern group level theories versus individual level theories with innately flawed assumptions (such as the Health Belief Model).  The Truth campaign also offered the public (teens in this case) their freedom back.   They were given a sense of control and rebellion against the wrongful tobacco companies, as opposed to having their core value of freedom taken from them.  And yet another element that led to the success of this campaign was the strategic use of media.  Their effective advertising approach stemmed from information acquired in teen focus groups and led to the development of shocking advertisements deliberately aired for maximum exposure.  Public health practitioners should learn from successful campaigns, such as Truth, and stop relying on hypothetical theories that will fail when put into practice.  My proposed intervention will use the success of Truth as a guide in order to allow the good intentions behind of Fruits and Veggie- More Matters to come to realization. 
The Real Deal campaign will aim a spotlight on the questionable use of ingredients by large food manufacturing companies and the fast food industry to steer people toward a whole foods diet.  It will focus on showing the ways these companies exploit the public in order to coax us into buy their unhealthy products.  This campaign will expose the multitude of artificial ingredients and chemicals that the food industry puts in their products.  They will be uncovered for trying to hide potentially harmful information from the public knowing that they will lose business and support from their customers.  The campaign will also unveil unfair business strategies used by the industry in order to financially benefit themselves and oppress honest farmers and local food companies.  Bringing forth these truths will cause the public to be outraged with these companies mass-producing convenience foods with heinous ingredients that they try to keep hidden. 
Through The Real Deal campaign, people will feel they are being given back their core value of freedom as they are shown what ingredients truly go into the unhealthy foods they were previously consuming.  Ultimately, this will push the public to rebel against these large food manufacturing and fast food companies and steer them toward whole natural foods (including fruits and vegetables) from local farms they can trust.  With the use of focus groups, The Real Deal will consult the public for the developing this program.  In doing this, we will gain insight as to what campaign and marketing techniques will yield the greatest impact on the public. 
The Real Deal campaign will also form partnership with schools in order to grow its spread its popularity and brand.  Elementary, middle, and high schools will have the opportunity to be branded as “Real Deal schools”.  With this branding, the schools will commit to provide only whole foods without artificial ingredients and purchase produce and meats from trustworthy and mostly local farmers.  Student organizations will be formed to promote The Real Deal and opportunities for employment will be offered to these students by the farms who supply to the schools.  Through sleek advertising and partnerships with popular celebrities, The Real Deal will become popular among youth.  With gaining popularity, The Real Deal campaign will become a known brand to which the public feels connected and loyal, ultimately leading to its success for improving the American diet.  The following sections will outline the ways that my public health intervention will improve upon the flaws of the Fruits and Veggies More Matters campaign.       
Defense of Intervention Section 1- Use of Group Level Models
In the field of public health, many campaigns rely on individual level behavioral health models, grounded in the idea that people will not do something they are told is bad for their health.  Reasons the public health field continues to base campaigns on individual health models despite their lack of strength may include the narrow scope of the medical field from which public health arises; the thought/ hope that individuals are in control of their decisions; and grant structure that perpetuates the use of these select models.  Although all public health professionals would like to believe that people make decisions based on how their health will be affected, we must recognize that individual level models ignore many important facets of human decision-making and behavior change.  My intervention, The Real Deal, will be successful in part because of its foundation of group level (alternative) models versus individual health theories.  As outlined earlier, The More Matters campaign relies on the Health Belief Model, which makes incorrect assumptions that people care enough about their health to make significant behavior changes, and that people’s intentions will directly lead to the expected behavior.  My intervention will be significantly stronger than the More Matters campaign as it will avoid false assumptions from individual models, and conversely will be supported by realistic group level theories that can predict behavior of the masses.     
The majority of significant changes that take place among large groups of people can only be described by group level models. Malcolm Gladwell describes group changes well when he writes “It is the best way to understand…any number of the other mysterious changes that mark everyday life is to think of them as epidemics.  Ideas and products and messages and behaviors spread just like viruses do” (4).  The Real Deal will take advantage of this concept to which Gladwell refers.  It will do this by utilizing the Advertising and Marketing Theories in order to reach enough influential people that word of mouth will allow the campaign to spread rapidly to others.  My intervention will also utilize the Diffusion of Innovations Theory by recruiting students to join “The Real Deal” organizations in which they will promote whole foods, namely fruits and vegetables, and the local farms from which they are supplied.  According to Thaler and Sunstein’s words on herd mentality, “sometimes massive social changes, in markets and politics alike, start with a small social nudge” (5).  My intervention’s use of schools and forming influential student groups plays off this idea, as these students can be the nudge to bring about massive social change.  With the use of influential student groups at various schools around the country, the campaign can reach a tipping point at which the program will take off exponentially, resulting in a significant public health impact.
Defense of Intervention Section 2- Giving Back Freedom
Rather than threatening freedom like the More Matters campaign, my campaign would bolster people’s sense of freedom around fruit and vegetable consumption.  The Real Deal will give the public a sense that they are winning back their freedom through knowledge and the ability to choose.  This is a complete juxtaposition to the More Matters campaign, which actually threatens the core value of freedom by dictating and preaching to people what they should eat to achieve good health.  The Real Deal campaign will provide the public with information that has been kept hidden from them, allowing them to form their own opinions of large food manufacturing companies and the fast food industry.  This knowledge will open the opportunity for people to have freedom to make their own dietary choices.  In turn, this will likely move them away from processed convenience items and fast food and towards whole foods including fruits and vegetables.  The freedom provided by my intervention removes the threat of the Psychological Reactance Theory invoked by the More Matters campaign, or the powerful instinct to protect what is perceived as being taken. 
The serious flaw of threatening freedom will be avoided in my campaign through the strategic use of group levels models including the Marketing Theory, Advertising Theory and Branding.  Through the Marketing Theory, my intervention will appeal to strong core values of freedom and choice.  If offered the choice to eat healthful foods with real ingredients that make a person feel good, people would likely choose this option over consuming artificial chemicals and unknown ingredients.  However, people need the to feel they have the option and freedom to make this decision on their own will, not because a public health practitioner tells them they must.  Selling the promise of freedom of choice for what the public is consuming provides much stronger motivation, compared with the promise of health, which people tend not to care about until it is gone.
 Defense of Intervention Section 3- Maximizing Media Exposure
“The Real Deal” campaign will have effective methods of exposure to the public allowing it to flourish into a successful campaign.  My intervention will sell the promise of freedom and choice (which far outweigh the promise of health), and will be supported through captivating visual and anecdotal messages.  Advertisements will expose shocking and dishonest practices of unethical food manufacturing companies and the fast food industry, which will capture the public’s attention and prompt them both consciously and subconsciously to make changes to their diet.  The advertising techniques will focus on exposing the truth about the concerning ingredients added into many processed foods that aim to improve taste and preservation but that are also developed to increase our consumption causing detrimental affects to people’s health.  My intervention will partner with successful advertising companies in order to research what types of marketing grabs the public’s attention and captivates the audience.  The marketing techniques will utilize television commercials and air them during popular shows, especially targeting youth.  It will also capitalize on the popularity of music and will air commercials both on local radio stations as well as Internet radio channels such as Pandora and Spotify.  Our marketing will also utilize the power of celebrities (as many are health conscious) and with carefully chosen representatives their fans will automatically jump on board. 
Branding will also play an important role in spreading the influence of this campaign.  Although More Matters does have a brand icon, people are not given reason to feel connected to or loyal with the brand, as the concept does not appeal to a strong core value.  My intervention will have effective branding through the use of its media, advertising, and support through students and schools.  The student organizations will be run through The Real Deal Schools.  These groups will have the ability to influence their peers, families, and friends to be a part of this movement to step away from processed convenience foods manufactured by dishonest companies and move towards the freedom of fresh fruits and vegetables grown by honest local farmers.  With the combination of enticing visual and auditory advertising in addition to word of mouth spread by student organizations, The Real Deal will reach large groups of people leading to mass behavior change.
Our elements of newsworthiness including scandal, controversy, shock value, and visuals will get my campaign into the media’s agenda and therefore to the public’s agenda. Utilizing the concept of the Agenda Setting Theory will contrast with the More Matters campaign, which lacks any element of newsworthiness that would potentially get their message into the media’s agenda or the public’s agenda.  With the More Matters campaign only offering the value of health, there is no strong element of appeal.  Although there is a More Matters brand and icon, it is weak, as people do not feel a personal connection with it.  My intervention’s use of the Agenda Setting Theory will remedy this flaw of the More Matters campaign in order to gain popularity and reach as many people as possible.
Conclusion
The Fruits and Vegetables- More Matters campaign made fatal flaws, which caused it to be unsuccessful.  We can learn from the mistakes made in this program in order to make improved campaigns that truly yield behavior change and affect the masses.  The Real Deal is an example of a campaign that does not have a basis of hope that people will make lifestyle changes simply for health reasons.  This campaign relies on the understanding that a group is more than just a sum of individuals.  With the appropriate knowledge of group level models, an appeal to strong core values, and effective media exposure we can develop public health campaigns that can make monumental changes to populations of limitless boundaries. 

References
1.  Individual health behavior theories (chapter 4).  In: Edberg, M.  Essentials of Health Behavior: Social and Behavioral Theory in Public Health.  Sudbury, MA: Jones and Bartlett Publishers, 2007.
2.  Centers for Disease Control and Prevention.  State Indicator Report on Fruits and Vegetables 2013.  Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, May 2013.
3.  Hicks JJ.  The strategy behind Florida’s “truth” campaign.  Tobacco Control 2001; 10:3-5.
4.  Introduction.  In: Gladwell M.  The Tipping Point: How Little Things Can Make A Big Difference.  Boston: Little, Brown and Company, 2000, pp. 3-14.
5.  Following the herd (chapter 3).  In: Thaler RH, Sunstein CR.  Nudge: Improving Decisions about Health, Wealth, and Happiness.  New Haven, CT: Yale University Press, 2008, pp. 53-71.


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