Tuesday, December 12, 2006

“5-a-Day For Better Health” Failure Campaign Among Low-Income Neighborhoods: A Critique Based on Social and Behavioral Science Principles–Dana Truhe

Nutrition is one of the 28 areas that the Centers for Disease Control and Prevention (CDC) identified when establishing the agenda for a comprehensive health promotion and prevention program known as Healthy People 2010 (CDC, 2005). One measure of good nutrition that the CDC recognizes is the consumption of fruits and vegetables. Studies have linked higher intakes of fruits and vegetables with lower risks of cardiovascular disease (Liu et al, 2000), reduced risks of many cancers (Steinmetz & Potter, 1991), and reduced risk of obesity (He et al, 2004). Under the guise of Healthy People 21010, the CDC sought to increase the number of servings of fruits and vegetables consumed by all Americans each day, and established the federally funded campaign known as “5 a Day For Better Health”. In 2000 the 5 a Day campaign was initiated and in 2004 in was evaluated; after the evaluation it was determined that there was little or no change in the amounts of fruits and vegetables that people were eating. One study of a large sample of U.S. adults found that between 1994 and 2000, the mean frequency of fruit and vegetable consumption declined slightly, and proportion of respondents consuming fruits and vegetables 5 or more times per day did not change (Serdula et al, 2004). So why did this campaign fail to achieve its goal, especially as the goal relates to low-income populations?

This campaign urged people to eat 5 servings of fruits and vegetables daily through a media effort including television commercials, billboards, websites, etc. The CDC felt that putting an awareness message about eating fruits and vegetables would be enough to change peoples’ behaviors, however if access to the healthy foods that are being encouraged to eat, then its difficult to change behavior. People may genuinely want to respond to the message of the campaign, and want to, but for a variety of reasons people may not have the ability to purchase enough fruits and vegetable for themselves and their family to meet this goal. For example, low socioeconomic status (SES) is associated with low or less frequent intake of fruit and vegetables (Rasmussen et al, 2006) This campaign could benefit from working with marketers to improve the food environment in poorer neighbors.

This campaign urged people to eat 5 servings of fruits and vegetables daily through a media effort including television commercials, billboards, websites, etc. The CDC felt that putting an awareness message about eating fruits and vegetables would be enough to change peoples’ behaviors, however if access to the healthy foods that are being encouraged to eat, then its difficult to change behavior. People may genuinely want to respond to the message of the campaign, and want to, but for a variety of reasons people may not have the ability to purchase enough fruits and vegetable for themselves and their family to meet this goal. For example, low socioeconomic status (SES) is associated with low or less frequent intake of fruit and vegetables (Rasmussen et al, 2006). Instead of working to change the underlying social conditions that cause differences in access, the CDC campaign superficially promoted increased fruit and vegetable consumption in a context in which this may simply not be possible.

The CDC could have worked with marketers to alter the environment in which in the campaign was operating in order to improve its success rate. One major component of marketing is place. There is a direct link between access to supermarkets and healthier dietary intake (Cheadle et al, 1991). But studies show that middle- and higher-income neighborhoods have two to four times as many supermarkets as low-income neighborhoods; in addition, low-income neighborhoods have fewer fruit and vegetable markets, specialty stores, and natural food stores (Morland et al, 2002). Unless a public health campaign addresses fruit and vegetable availability, campaigns that encourage fruit and vegetable intake are unrealistic. A theory on why grocery and fruit & vegetable stores are not located in these neighborhoods are that retailers do not think that these kinds of stores will be economically viable in these areas, this therefore reduces the initiative to open the type of store that will push the 5 a Day campaign. The government could support subsidies to encourage grocery store owners to do business in these locations, allowing for 5 a Day campaigns to be successful. Another theory is that there is a danger in opening a store in a low-income neighborhood since these are the locations that tend to have the highest crime rates (Bursik & Grasmick, 1993). To address this problem, the police forces in the area would have to work to make the streets safer. The addition of larger retail grocery stores into an area would make it more affordable for people to buy produce.

Another important marketing approach when assessing the 5 a Day intervention is that of promotion. In low-income neighborhoods, less-healthy food options also tend to be heavily promoted (Williams, 2005). If people are bombarded with messages that run counter to the 5 a day message, then it is less likely that they will adhere to the less popular choice, especially when access to the healthier option is limited. Increasing the amount of positive advertising may not have much effect as the message may become lost in the media-saturated environment. Therefore, a positive change may come in the form of limits on advertising of unhealthy and fast-foods. The 5 a day campaign did not take into account the opposing messages that people are faced with, and until public health officials do so, their messages may be lost. It is clear that incorporating the concepts of social marketing may increase the effectiveness of the 5 a Day campaign.

Social Learning Theory (SLT) helps to address one failure of the 5 a Day campaign. This theory, pioneered by Albert Bandura, supposes that an individual’s behavior is determined by his or her expectations about the health outcomes and his or her feelings of self-efficacy. The problem with the 5 a day campaign is that it does not address this issue of self efficacy. People may think that it’s completely impossible to reach this goal of 5 servings a day. Current data suggests that the average American eats less than three servings a day and 42 percent eat less than two servings a day. Eating two to three more servings a day may seem like an unattainable goal. This is especially true for those people who face the barriers to fruit and vegetable access. According to SLT, the lack of self efficacy will discourage someone from pursuing a healthy behavior. The 5 a Day campaign would have been more effective if it focused on increasing fruit and vegetable consumption in general without specifying the quantity. This message would then be inclusive of all people that increased fruit and vegetable intake and a positive encouragement can be far more effective than a message that promotes a standard that sets people up for failure. For example, a person doesn’t feel that he or she can achieve the 5 serving goal then they may not try at all to change behaviors and to increase their produce intake, rather people may just say, what’s the point? Research has supported this theory and shows that greater feelings of self-efficacy are positively correlated with increased fruit and vegetable intake (Steptoe et al, 2003). Thus, for a campaign to be successful it should boost people’s perceptions that this is an achievable goal.

Another reason the 5 a day campaign failed to increase fruit and vegetable consumption is that it does not address differences in thoughts and feelings about food and also different perceptions as to the negative health outcomes that this campaign seeks to address. One such difference is based on ethnicity and the reasons for ethnic variation in fruit and vegetable consumption are multifaceted and may include differences in level of acculturation, cultural beliefs and practices, and ethnicity-based differences in body image. Some culturally traditional diets do not emphasize fresh fruits and vegetables. For example, a typical Caribbean diet generally features meat, grain, and fried vegetables. A study in the Journal of Adolescent health indicated that African Americans and Hispanics have different attitudes than Caucasians regarding attitudes towards learning about healthier eating practices (Beech et al, 1999). The 5 a Day campaign failed to embrace Social Expectations Theory. Instead of simply promoting fruit and vegetable consumption it is important for the CDC to work to change cultural norms regarding eating. Values dictate behavior and unless a campaign strives to change values in way that is supportive of the intervention, it is certain to fail. Along with this, it has been found that having “family meals” is positively correlated with fruit and vegetable intake (Tavares et al, 2005), and that there are ethnic differences in the prevalence of family meals (Videon & Manning, 2003), which should be accounted for in targeting a public health campaign to alter social norms. Another difference regards knowledge about nutrition among parents. Parents with low educational attainment are shown to have les knowledge regarding nutrition, which influences the quality of their children's diet, thus becoming a self-reinforcing principle (Wardle, 2000). Lastly, there may be differences in the perception of health outcomes associated with this intervention. If a person is uncertain that eating more fruits and vegetables will, in fact, have tangible health benefits then the perceived costs of including them in the diet may be the overriding aspect of the decision making process.

The 5 a day for better health campaign was an unsuccessful public health endeavor. The campaign did not take into account the socioeconomic differences in communities. There are some places where fresh fruit and vegetables are not readily available or are too expensive. The campaign is overwhelming and sets people up for failure. Those who think that there’s no way that they can eat 5 servings a day may feel badly about it, and not try at all to increase their consumption. Lastly, it does nothing to address cultural differences in thoughts and feelings about food. Fresh fruit and vegetable may not be a particularly important staple in certain ethnic cuisines, and so a campaign that does nothing to address this will not succeed. Instead of focusing on the Health Beliefs Model, public health officials need to harness the powerful tools made available through the social and behavior sciences, especially with the use of Social Marketing, Social Learning Theory and Social Expectations Theory.

References

Beech BM, Rice R, Myers L, Johnson C, & Nicklas TA. Knowledge, attitudes, and practices related to fruit and vegetable consumption of high school students. Journal of Adolescent Health. 1999;24:244-250.

Bursik RJ and Grasmick HG. Economic Deprivation and Neighborhood Crime Rates. Law and Society Review. 1993; 27:263-284.

CDC. 2005. Accessed December 11, 2006. Available at: http://www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa19-nutrition.htm
Cheadle A, Psaty BM, Curry S, Wagner E, Diehr P, Koepsell T, & Kristal A. Community-Level Comparisons Between the Grocery Store Environment and Individual Dietary Practices. Preventive Medicine. 1991;20:250-61.

Cullen KW, Baranowski T, Owens E, de Moor C, Rittenberry L, Olvera N, & Resnicow K. Ethnic Differences in Social Correlates of Diets. Health Education Research/. 2002;17:7-18.

He K, Hu FB, Colditz GA, Manson JE, Willett WC, &Liu, S.
Changes in intake of fruits and vegetables in relation to risk of obesity and weight gain among middle-aged women. International Journal of Obesity/. 2004; 28: 1569-1574.

Liu S, Manson JE, Lee I, Cole SR, Henneekens CH, Willett WC, & Buring JE. Fruit and vegetable intake and risk of cardiovascular disease: the Women's Health Study. /American Journal of Clinical Nutrition. 2000; 72: 922-928.

Morland K, Wing S, Diez Roux A, & Poole C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. American Journal of Preventative Medicine/. 2002: 22; 23-29.

Rasmussen M, Krolner R, Klepp KI, Lytle L, Brug J, Bere E, & Due P. Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part I: quantitative studies. International Journal of Behavioral Nutrition and Physical Activity. 2006; 3.

Serdula M, Gillespsie C, Kettel-Kahn L, Farris R, Symour J, & Denny C. Trends in Fruit and Vegetable Consumption Among Adults in the United States: Behavioral Risk Factor Surveillance System, 1994–2000. American Journal of Public Health. 2004; 94: 1014-1018.

Steinmetz KA and Potter JD. Vegetables, fruit, and cancer. I.
Epidemiology. Cancer Causes and Contro. 1991; 2: 325-357.

Steptoe A, Perkins Porras L, McKay C, Rink E, Hilton S, & Cappuccio F. Psychological Factors Associated with Fruit and Vegetable Intake and with Biomarkers in a Low-Income Neighborhood. Health Psychology. 2003;
22: 148-154.

Tavares EM, Rifas Shimon SL, Berkey CS, Rockett HRH, Field AE, Frazier AL, Colditz G, & Gillman MW. Family Dinner and Adolescent Overweight. Obesity Research. 2005; 13:900-906.

Videon T and Manning C. Influences on adolescent eating patterns: the importance of family meals. Journal of Adolescent Health. 2003; 32:365-373.

Wardle J. Nutrition Knowledge and Food Intake. Appetite. 2000; 34:269-275.

Williams J. Advertising of Food and Beverage Products to Children, Teen, and Adult Multicultural Markets. University of Texas at Austin Working Paper. 2005

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