Sunday, January 5, 2014

Fruit & Veggies – More Matters: How Changes to a Current Governmental Nutrition Program Could Change the Face of Obesity in the United States---John Usseglio

The Introduction. The concept of obesity is nothing new to Americans. During the past 30 years, the United States has gone through, and is in the middle of, an obesity epidemic. In the year 2009-2010, 35.7% of Americans over the age of 20 were obese (16). This means that over a third of American adults were obese in 2010. Why is obesity such a problem? It is a simple question with an extremely complex answer. The American diet and lifestyle most certainly play a role (6). The increases in body weight can partially be attributed to a per-capita increase calorie intake per day. The US food supply provides 500 kcal/day more than it did in the 1970s (21). The exercise patterns of adults in the US has not changed in nearly 30 years (21). These two factors combined increase the risk of obesity (21). While this combination is recognized by the public, there is another risk factor for obesity that is rarely discussed: poverty. Poverty creates an environment that fosters the growth of cheap fast food, food deserts, and consumption of processed foods (6). To combat this growing problem, a national public health initiative was started by the Produce for Better Health Foundation [PBHF] and the Center for Disease Control & Prevention [CDC]. The initiative is called Fruits & Veggies – More Matters.
            The Initiative. Fruits & Veggies – More Matters [FVMM] is an initiative that calls for American’s to increase their fruit and vegetable consumption (8). The US Department of Agriculture’s 2005 Dietary Guidelines recommends a variable amount of the number of servings of fruits and vegetables, depending on the caloric needs of the individual (19). Americans may need anywhere from 4 to 13 servings of fruits vegetables each day, which is the equivalent of 2 to 6.5 cups per day (19). The reason the Fruits & Veggies – More Matters initiative is needed to promote healthy eating and fight obesity can be seen in the statistics. Studies have shown that 90% of Americans do not meet their daily recommendations of fruits and vegetables. Indeed, most would need to double the amount they currently eat and then have more just to meet the recommendations (8). The end goal is for a healthy diet and this is important in the fight against obesity. Diets lacking fruit and vegetables are more likely to raise the risk of becoming overweight and a whole host of diseases (9). Taking the place of healthier options are: fast food, processed foods, and foods containing high amounts of sugar (6). It is known that eating high calorie, high sugar diets, along with a lack of exercise, increases the risk of obesity (9). Persons that are overweight or obese have a higher risk for many chronic diseases including: increased lipid concentrations, hypertension, and type 2 diabetes (16). Thus, obesity is a public health issue, as it affects the health of millions of people across the United States. A part of the epidemic is the American diet, and this is the focus of the Fruits & Veggies – More Matters campaign.
            The campaign is designed to reinforce the knowledge that fruits and vegetables are important in our diet, and their goal is for us to incorporate healthy eating into our lives (8). The campaign works through two avenues, the website and their promotional advertisements. The website offers ways to make fruits and vegetables taste better, guidelines for how much fruit and vegetables you need each day, recipes, ways to save money when shopping, and nutrition expertise and advice. A section of the website includes videos showing how to prepare and make some of the dishes. The promotional advertisement is focused on spreading the message that fruits and vegetables are important. They use both children and adults to get their message across. Healthy eating is portrayed to be fun, and a normal part of daily life (8).
            Critique 1.  The first critique is that the Fruits & Veggies – More Matters does not accurately portray the social norm for most average Americans. There are multiple public service announcements made by the initiative, all focusing on kids and nutrition. The first PSA is called School Daze. The video shows 3 children sneaking away from their school to have lunch. The lunch consists of pizza, nachos, and French fries. An undertone in the video is shaming: shaming the children that would sneak away to eat unhealthy foods (11). There are problems with this video; these are easily identified using the Social Norms Theory [SNT]. The SNT reasons that behavior is influenced by misperceptions of how our peers think and act. Over estimations of problem behavior in our peers will cause us to increase our own problem behaviors and under estimation of problem behavior in our peers will discourage us from engaging in the problematic behavior (1). The SNT ties into a health belief theory called the Social Cognitive Theory [SCT]. The SCT emphasizes the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others (14). Human behavior is explained by this model in terms of reciprocal interaction between cognitive, behavioral, and environmental influences (14). The School Daze PSA is efficient because it promotes that children should eat healthy when they are at school. The issue is that there really is not much choice for the children at their cafeteria. If pizza and hamburgers are an option to eat, that is what most kids are going to eat. If you provide the options and kids see their peers going in line to get pizza or a burger, the SNT shows how much more likely other kids will follow suit. The advertisement could have the opposite effect: it could be making children feel guilty about what they eat for school lunch. A la carte food lines (snack bars) are common in school cafeterias: a la carte programs are associated with lower intakes of fruit and vegetables and higher intakes of calories from total and saturated fats (15). When other kids are eating these kinds of food that are made available to them, what kind of message does that send?
            While the video shows the children sneaking away to have lunch, the commercial is actually directed towards parents. “You’ve talked to your kids about drugs and alcohol. You’ve even gotten through that situation about sex. Now isn’t it about time you talk to them about lunch?” (11). The commercial equates eating lunch to doing drugs, underage drinking and unprotected sex. That seems to be a little bit drastic. The video takes place at a school, where children’s options are often limited by what the cafeteria offers. It does not make sense for the video to ask parents to talk to their kids about what they eat for lunch at school. In fact, the video may even discourage parents from speaking to their children whatsoever. Having talks about drugs and sex with children is a delicate situation that could make many parents uncomfortable. Now the commercial is telling parents to sit down and berate their children for eating unhealthy foods. In reality, the parents are the ones providing the food at home and the cafeteria is providing the food at school. While the children can make healthier choices depending upon their options, the reality of the situation is that most of the food buying in their household is out of their control. How can they be blamed for something that their parents are responsible for? Putting food on the table.
            A second PSA made by Fruits & Veggies – More Matters is centered on childhood obesity and kids. The video shows a young girl cutting paper figures on a table. The dialogue starts: “There is a crisis in America: more than half of us are overweight” (5). The commercial goes on to talk about experts saying we need to eat more fruits and vegetables and ends by the little girl holding up the string of figures she cut out, and them are progressively bigger. The dialogue ends by saying: “… [A]nd get healthy America. Because the figures don’t lie” (5). This PSA takes a different approach. It uses fear and statistics to get people to change their behavior and eat healthier. The PSA raises an important issue with healthy eating: it is in the hands of the individual. They have to not only have access to the healthy food, but they have to believe in themselves to make healthy choices. Self – efficacy is the strength of one’s belief in their ability to reach a goal (14). The Social Cognitive Health Behavior Theory [SCT] incorporates self – efficacy. It states that individual’s behavior, personality, and beliefs are influenced by what they observe in others. The self – efficacy is developed by watching others attempt tasks, which influences the individual’s belief in their own ability to complete that task (14).  The second PSA by FVMM could be effective for middle-class and upper-class individuals who have access to supermarkets or farmers markets. Those in the lower classes have much less access to fresh fruit and vegetables (6). Food deserts create barriers to supermarkets, and the high price of produce is often not affordable (6).  Unfortunately, the social class hit hardest by the obesity epidemic is the lower class (6). By removing the access to fresh fruits and vegetables, the self – efficacy of the lower class is lowered; they likely are not able to access and afford food for a healthy diet. Thus, the PSA is not very effective for this target population. Instead it could reinforce the belief that it is not possible to eat a healthy diet and individuals could become further discouraged. The PSA is targeted for the wrong audience.
            Critique 2. The second critique of the Fruits &Veggies – More Matters campaign is the use of advertisement. The Agenda Setting Theory [AST] explains the ability of the media to influence the public agenda. If an issue is covered frequently and in depth, the public will be more likely to consider the story important (3). The Fruit & Veggies – More Matters campaign has not utilized the media to get its issue to the forefront of the news. In 2013, only 5 press releases were issued. The last video public service announce was made a year ago (11). The campaign is not getting the media attention it needs to create the awareness that is desired. Fruits & Veggies – More Matters is a program of the CDC. It should not have an issue utilizing resources to put together a cohesive message to the public. With the necessary research proving the relation between diet and obesity (7), there is no excuse for not garnering media attention, especially with a growing obesity epidemic in the United States. With the proper advertisement and by creating more press releases to draw attention to the issue, the FVMM campaign could be more successful. In order for that to happen, the message needs to be expressed to the public in a manner that will get a stronger response. Which leads to the third critique.
            Critique 3. The third critique of the Fruit & Veggies – More Matters campaign is the framing of the message. Framing Theory is a way to examine the concepts and theoretical perspectives that influence how people perceive and understand an issue (13). For the FVMM initiative, the issue of healthy eating is framed in the health perspective. People should eat more fruits and vegetables because it is beneficial to their health. They will feel better, have more energy, and a better quality of life if they eat more fruits and vegetables (20). The problem with the health frame, as noble a cause as it might be, is not a great way to motivate people to change their behavior. An explanation can be found by looking at Maslow’s Hierarchy of Needs: a pattern that human motivation generally follows. The most pressing issue is physiological needs, or the necessities of food, water, sleep, etc. The next issue is safety, or having security of body, employment, resources, property. After safety is love, and then esteem (22). It is at this level that the quality of health and the concern of health will motivate people. That is to say, in order to be motivated to become healthier, a person’s physiological and safety needs must have already been met (22). Thus, to the Americans living in poverty and trying to make it day to day, a health frame will have no effect. A health frame will only affect part of the population in the United States. If the advertising by the FVMM campaign do not target everyone, their ability to make the change they want to see in America is reduced. In fact, poverty may be a root cause of the obesity epidemic (6). The cheap prices of snack foods, full of fat and sugar, make them more accessible (2). They are available at every corner store in the country. This is not the same case for fruits and vegetables, which are generally only available in supermarkets and farmers markets (2). Thus, not only will a health frame not be effective because of poverty, but the availability of that healthy food may be restricted in impoverished areas. Supermarkets can be scarce, creating food deserts that restrict certain neighborhoods from having a healthy diet (2). Even if there was a supermarket, the high prices of fruits and vegetables deter many people from purchasing them. If more food can be bought to feed an entire family compared to some fruit and vegetables that cannot, what is someone supposed to do? Spend the money on the food that can feed their entire family. The frame of the issue that the FVMM is fighting for needs to be changed.
            Conclusion of Critiques. The FVMM initiative is a strong movement. The concept of healthy eating is an important one, and it is one that Americans need to be aware of. Unfortunately education alone is not enough to make change. The FVMM needs to become more pro-active about creating real, sustainable change. The three critiques given were areas of the campaign that can be improved upon to start making change. The social norm of obesity in this country is not acceptable. It is a public health hazard and will only lead to increased health problems and costs down the road. The media involvement has been minimal, and that could be such a great way for American to learn about the mission of FVMM and other groups like it. They can learn and be inspired to take action if the right measures are taken. Lastly, the way the issue is discussed with the public needs to be changed. The health frame, while well intentioned, is not the best way to call people to act for change. Other frames are better suited to inspire change. These areas of concern are addressed in the proposed interventions below.
Articulation of Proposed Intervention. The Fruits & Veggies – More Matters is a good initiative, and it is well intentioned. There are some approaches and changes that could be made to the program to enhance and further the effort to encourage Americans to eat healthy. This includes more governmental and public policy action, increasing media awareness, and changing how the average person looks at the issue of obesity and healthy eating. The proposed changes occur in three stages, each corresponding to a critique of the FVMM program. In order for the changes to be effective, they will address the critiques in the opposite order. That is to say the frame will be addressed first, then media attention, and ending with changing the social norm in America. The current health frame that is used by the FVMM campaign is not effective. This can be easily seen by the rising prevalence of obesity in America, especially in adult men (16). Freedom is the frame that can be used by these public health advocates to empower and encourage individuals to change their habits. Media coverage needs to bring attention to the underlying issues of unhealthy eating. Only by garnering public attention can real change happen: when citizens go to their congressman and protest for a change to be made. The last stage of change in the campaign is pushing for a change of the social norm of obesity and unhealthy foods. While this last stage will take time to occur, it will be the defining point of change in the public health battle FVMM is fighting.
            Defense of Intervention Stage 1. The first stage of intervention in the FVMM campaign deals with how the public perceives the issue. In other words, the frame needs to be changed. The current frame being used is health. FVMM is promoting good health by using nutrition expert statistics and general health statistics about obesity (8). The population most at risk of obesity is the lower class (6). This is the population that the FVMM needs to focus on to make real, sustainable change. While the current frame addresses the issue at hand, the health of individuals in America, it is not an approach that will motivate the audience of interest.  This is for two reasons: the first is Maslow’s hierarchy of needs, as was described above. If the individual does not have the physiological and safety necessities of life, they will not be concerned with eating healthy. They will be trying to make it day to day, earn enough money to pay for rent, light, and water bills, and put any kind of food on the table for their family to eat. That means the cheapest food in the most bulk, which is processed, fatty, sugary junk food (2).
The second reason is people know what is healthy; if they do not have the means to access and pay for healthy food, then no amount of healthy eating promotion will make a difference. What can work is a Freedom frame. My proposition is to get rid of the health frame and introduce both a Freedom frame and a Family frame. By changing the mindset of the issue, the public will be more likely to become involved. The idea for this method is taken from the public health battle against smoking. The tobacco control movement has shift their frames from health effects to exposing the lies, deceits, and youth targeting of the tobacco industry (13). The food industry can be taken on as the cigarette industry was. Basically the responsibility is shifted from the individual to the food industry and the government. The freedom frame will ask why the freedom of choice is taken away from millions of Americans who are just trying to put food on their table and have no choice but to pick the unhealthy options. Why is it so easy to get junk food and candy in an inner city than it is to get fresh produce (2)? Why are processed foods and industry given subsidies when farms growing healthy fruits and vegetables are not (18)? These subsidies lower the price of processed foods while fresh, healthy foods are left out to dry (18). This freedom of choice is taken away from millions all across the US. By using this frame, Americans can unite under a cause that their freedom of choice has been taken away from them. America has shown in the past how effective it can be in fighting for the rights the citizens deserve. This should be what the freedom frame is all about.
The second frame is family. Family is the sense of longevity, of parents growing old and being there for their children. To watch their children go to college, get married, and have children. To be around for all of the special and important moments in life. Combining this frame with the freedom frame will create motivation for the public to make change. Emotion is a powerful tool that is used often by companies to get people to buy their products (10). Commercials are designed to create nostalgic emotion and happy memories (10). The goal of the family frame is to do exactly that: to fight fire with fire. The issue needs to be personalized. If the FVMM just quotes statistics about half of America being overweight, nothing is going to happen (5). People cannot relate themselves to statistics. They can relate to the story of a father who was obese and lost his battle with diabetes before he sees his daughter get married. That creates real emotion, which can create motivation for change. To be successful, the FVMM campaign needs to move from the health frame to the freedom and family frames.
Defense of Intervention Stage 2. Stage 1 of the proposed intervention change has been completed. The frames of freedom and family have been created. The next stage of intervention is getting the message to the people who are affected. The way to do this is by media. News, social media, etc. In the second critique, the advertising done by the FVMM was questioned. It was not an effective way to promote the issue and motivate people to make behavioral health changes. Using Agenda-Setting Theory [AST] to look at how FVMM interacted with the media, it can be seen that there was not enough media attention. Of the 5 press releases in 2013, none were calling a meeting to be had to discuss the real reasons behind obesity in this country. There has not been a commercial released in over a year. This needs to change. The AST expounds on the power the media has over public opinion of important issues (3). With 24 hour news channels and social media overload, the time is perfect to get America engaged.
To do this, a press release should be announced stating that the FVMM initiative will be hosting a press conference held at the CDC headquarters in Atlanta. The title of the press release: Potato Chips, Pizza, and Poverty: Why the Food Industry is Robbing You of Your Freedom. At the press conference, the representatives of FVMM should discuss the relations between poverty and unhealthy food. To really get their point across, they should put together a grocery list of healthy food that would last a family of 4 a week. Then can then compile a grocery list that an American family living just above the poverty line can afford and compare the two lists. The difference will startle a lot of people. By discussing how cheap junk food is and how there are no subsidies for farms, the issue can be brought to light in the public. People can begin to question why subsidies are not given to farms, and why is it that foods that are healthy for everyone are so expensive and so hard to get.
Beyond the first press release, public service announcement commercials need to be made. There should be three different types of PSAs. The first kind should be focused on an urban community. Individuals can show what food they generally keep in their home, talk about how far they have to walk to get to a grocery store, and how they have no choice but to choose the cheaper, unhealthy food in order to feed their family. The ad can end by having the individuals asking for help. Asking for a freedom of choice. Asking why their children do not have the right to a healthy diet, why they must suffer and be set up for a life of complications from the threat of obesity. The second type of advertisement should be educational. It should discuss the government’s role in subsidies and the food industry. By offering substantial subsidies to producers of healthier foods, research has shown there can be a positive impact on the prevalence of obesity (18). Pictures of farmers who are struggling just to get by in comparison to huge factories pumping out chemically created foods by the truck load. A CEO of a food company sitting in a ridiculous office while the farmer is breaking his back working. The commercial should discuss how much money the junk food industry makes every year, and how much the farming community brings in. Why are companies being rewarded? Why are farmers not given help from the government? America was built on the backs of hard working people. Those people should be rewarded. Americans deserve to be able to eat a healthy meal. They deserve the choice to have fruits and vegetables. Our rights to a healthy life are being compromised, and the government needs to do something about it. As the commercial fades to black, there will be a call for help. A call for Americans to fight back and take back their freedom of choice. To call their legislative representatives and make change happen. To write to the white house. Join a movement to change how our food industry works and create a healthy America.
The third type of advertisement will be on a personal level. There will be a series of commercials of individuals and families affected by obesity and unhealthy foods. The voice of a father will play over the images of his life, watching his children grow up. He will talk about how hard it was to put food on the table. How most of the time what his family ate was not healthy. How he knew he should be eating better but he could not afford it or access it without much struggle. His difficulty with obesity and a diagnosis of type 2 diabetes. The commercial could end with him talking about how he passed away from complications due to the diabetes before he was able to watch his daughter walk down the aisle. He will call for a movement: what happened to him cannot happen to his children and millions of others around America. How he was put in a position to have poor health and he had no choice in the matter. It will be a call for change, for people to get involved and make healthier food more affordable. This type of emotional and personal advertisement can do more to relate and inspire people than statistics ever could (4). A series of these types of stories should do a world of good to get people involved in the FVMM campaign.
Defense of Intervention Stage 3.
The last stage of intervention change comes as a result of the media blitz of the second intervention stage. The first critique of the FVMM initiative addressed the Social Norm Theory [SNT] and Social Learning Theory [SLT]. According to the SLT, much of an individual’s behavior is based up what they learn from observing others (14). The dynamic of America is changing, with 50% of the population now classified as being overweight (5). Being overweight will soon become the norm. That should not be allowed to happen. The third stage of intervention will aim to make sure that does not happen. The public should be reminded a healthy weight is normal, and what everyone should strive for. A very simple way to get this point across would be to show a series of pictures in a commercial. The CDC has a series of pictures of the United States starting from 1985. Each state is color coded based on the prevalence of obesity (17). As the years go from 1985 to 2010, it can be seen how the prevalence rates in every state are increasing. The commercial should end asking what has happened to create such a change in our population dynamic. It is up to us to break this trend and return the perceived norm back to what it should be: normal weight, not overweight. It is up to us to get the freedom of choice back, to allow us to make the decision of what we eat.
This is the stage of the intervention where social media needs to be involved. Workers in the FVMM initiative need to get on Facebook and Twitter to get the word out. To start conversations about healthy eating and poverty. Encourage college students to get involved and make a difference. The power of persuasion from social media cannot be understated (12). It is a powerful tool that can help change the norm of American society from overweight to underweight.
Conclusion. Change can be made in America. We do not have to be a country where the norm is to be overweight. There are ways to inspire people and get them involved in local government to start changing public policy. By creating freedom and family frames, people will become connected to the issue at a personal level. People will begin to wonder why they are not able to eat healthy food. Why they must be punished just because of where they live or how much money they make. Drawing in the public through informative and emotional public service announcements on major news networks will broaden the number of individuals that become involved.  Applying these changes to the FVMM initiative will increase its effectiveness and start changing the way Americans eat healthy fruits and vegetables.

Works Cited

1.     Berkowitz AD, PhD; Ed. Perkins W. Applications of Social Norms Theory to Other Health and Social Justice Issues. The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, Clinicians. Jossey-Bass, San Francisco; 2002.

2.     Block JP, MD, MPH; Scribner RA, MD, MPH; DeSalvo KB, MD, MPH, MSc. Fast Food, Race/Ethnicity, and Income: A Geographic Analysis. American Journal of Preventative Medicine 2004; 27(3): 211-217.

3.     Brown N; Deegan C. The public disclosure of environmental performance information – a dual test of media agenda setting theory and legitimacy theory. Accounting and Business Research 2012; 29(1): 21-41.

4.     Certain Trumpet Program. Framing Memo: The Affirmative Action Debate. Washington, DC: Advocacy Institute, September 1996.

5.     Childhood Obesity and Kids Nutrition PSA: Paper Dolls; Upload from Fruits & Veggies – More Matters. Youtube.com 2010. http://www.youtube.com/watch?v=g390zSk2bQE&list=UUD5KyUog0k4UCN9Q4j3m0lQ

6.     Drewnowski A, PhD. Obesity and the Food Environment: Dietary Energy Density and Diet Costs. American Journal of Preventative Medicine 2004; 72(3S): 154-162.

7.     Flegal KM, PhD; Carroll MD, MSPH; Ogden CL, PhD; Curtain LR, PhD. Prevalence and Trends in Obesity Among US Adults, 1999-2008. The Journal of the American Medical Association 2010; 303(3): 235-241.

8.     Fruits & Veggies – More Matters. Produce for Better Health Foundation 2008-2013. http://www.fruitsandveggiesmorematters.org/

9.     Heimendinger J; Van Duyn MAS. Dietary behavior change: the challenge of recasting the role of fruit and vegetables in the American diet. American Journal of Clinical Nutrition 1995; 61(suppl): 1397S-1401S.

10.  Holbrook MB; Batra R. Assessing the Role of Emotions as Mediators of Consumer Responses to Advertising. The Journal of Consumer Research 1987; 14(3): 404-420.

11.  Kids and Nutrition PSA: School Daze; Upload from Fruits & Veggies – More Matters. Youtube.com 2010. http://www.youtube.com/watch?v=arXfqq05zrs&feature=c4-overview&list=UUD5KyUog0k4UCN9Q4j3m0lQ


12.  Lenhart A; Purcell K; Smith A; Zichuhr K. Social Media & Mobile Internet Use Among Teens and Young Adults. Pew Internet & American Life Project: An initiative of the Pew Research Center 2010: 1-6. http://pewinternet.org/Reports/2010/Social-Media-and-Young-Adults.aspx

13.  Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues – United States, 1985-1996. Journal of Health Communication 1998; 3(4): 307-325.

14.  National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp.9-21 (NIH Publication No. 05-3896).

15.  Neumark-Sztainer D; French SA; Hannan PJ; Story M; Fulkerson JA. School lunch and snacking patterns among high school students: Associations with school food environment and policies. International Journal of Behavioral Nutrition and Physical Activity 2005. http://www.ijbnpa.org/content/2/1/14

16.  Ogden CL, Ph.D.; Carroll MD, M.S.P.H.; Kit BK, M.D., M.P.H.; Flegal KM, Ph.D. Prevalence of Obesity in the United States, 2009–2010. National Center for Health Statistics Data Brief 2012; 82: 1-7.

17.  Overweight and Obesity. Centers for Disease Control and Prevention. 2013. http://www.cdc.gov/obesity/data/adult.html

18.  Powell LM; Chaloupka FJ. Food Prices and Obesity: Evidence and Policy Implications for Taxes and Subsidies. The Milbank Quarterly 2009; 87(1): 229-257.

19.  U.S. Department of Health and Human Services; U.S. Department of Agriculture. Dietary Guidelines for Americans 2005. http://www.healthierus.gov/dietaryguidelines

20.  Van Duyn MAS, PhD, MPH, RD; Pivonka E, PhD, RD. Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: Selected literature. Journal of THE AMERICAN DIETETIC ASSOCIATION 2000; 100(12): 1511-1521.

21.  Young LR, PhD, RD; Nestle M, PhD, MPH. The Contribution of Expanding Portion Sizes to the US Obesity Epidemic. American Journal of Public Health 2002; 92(2): 246-249.

22.  Zalenski, RJ, MD, MA; Raspa R, PhD. Maslow’s Hierarchy of Needs: A Framework for Achieving Human Potential in Hospice. Journal of Palliative Medicine 2006; 9(5): 1120-1127.


No comments:

Post a Comment