Sunday, December 10, 2006

Missteps to a HealthierUS: A Miscommunicated and Indiscriminate Campaign Targeting Asthma, Obesity, and Diabetes in Everyone!—Casandra Aldsworth


Steps to a Healthier US is a “national, multi-level chronic disease prevention and health prevention” campaign specifically targeting asthma, obesity, and diabetes by addressing certain underlying risk factors—physical inactivity, poor nutrition, and tobacco use. (Steps to a HealthierUS: About Steps) It is part of the national HealthierUS goal set by President Bush to help American citizens “live longer, better, and healthier lives.” (CDC Steps Brochure, 2004, 2) The Steps program funds states, tribes, and communities in order to address these health concerns. Although it is a national campaign, it specifically states the target population includes Hispanics, Native Americans, African-Americans, Asian American Pacific Islanders, immigrants, low-income populations, youth, senior citizens, uninsured/underinsured people, and people at high risk for or those who have been diagnosed with diabetes, obesity, and asthma. The intention is to work with all sectors of the community—public health, education, business, health care systems, community and faith-based organizations, and local government—and implement this program at all levels of involvement—individuals, interpersonal, organizational, environmental, and policy—in order to make this program effective. (Steps to a HealthierUS: About Steps)

Although the intention of this program appears genuine; the reality is that it will not be effective. The major weakness of the campaign is that (1) its scope is too broad. Other methodological flaws include: (2) too broad of a target group; (3) failure to identify diverse contributing factors to the diseases of interest; (4) unspecified behavioral objectives; (5) it is information-based; and finally, (6) inappropriate evaluation methods. By simply integrating current research and theoretical framework, Steps could significantly improve the impact of its campaign.

(1) The Scope is Too Broad

The most obvious problem with this campaign is its broadness. Targeting three health conditions and three possible underlying contributing factors to the disease will prove to be too vague. Additionally, it is not realistic to impose so many behavioral changes on individuals all at once. According to the social learning theory, behavior is influenced by the individual’s outcome expectancies (what the individual expects will happen when the behavior is changed) and self-efficacy (individuals’ perception of being able to change the behavior). (Bandura, 1977) Since this campaign is so broad, it bombards the public with too many behaviors to change at once, rather than focusing on one specific behavior which will not overwhelm people and can influence behaviors. For example, if a person is obese and suffers from diabetes, then exercising everyday and changing their diet might be too much to do all at once. Steps could encourage an individual to exercise only, which the person would perceive as a realistic and achievable goal.

The expected goals of Steps are overambitious and overstated for such an overarching campaign lasting only 5 years—“to produce accelerated outcomes in the three health areas.” (CDC Steps to a HealthierUS FAQ, 4) Similarly, President Bush’s Healthier US goal, of which the Steps campaign is based on, plans to improve American lives by encouraging Americans to be physically active everyday, eat a nutritious diet, get preventive screenings, and make healthy choices. This is an idealistic plan that doesn’t even account for individuals’ perceptions of how feasible these behaviors are nor individuals’ specific circumstances; however, in reference to both the broad goals of HealthierUS and also those of Steps, neither approach integrates theoretical framework nor individuals’ perceptions.

Whether President Bush is telling people to get exercise in order to combat their obesity or Steps is paying for advertisement space on the city’s buses, neither will work without understanding the appropriate barriers and contributing factors to obesity. Both lay the responsibility of less than desirable health behaviors solely on the individual without considering other factors contributing to the diseases, such as the social norms surrounding what constitutes nutritional food choices and portion sizes. Behaviors, particularly health behaviors, are more complex than this campaign assumes. A “one-fell swoop” approach to combat America’s health problems is the largest problem with this campaign; however, doing so without even considering basic social science teachings and theories is the development of an ineffective campaign.

(2) The Campaign has Too Broad a Target Group

One important element for a campaign’s effectiveness is the delivery of its message. In order for a message to be received, and subsequently encourage behavior change, it must be perceived by the receiving individual as relevant. (Kreuter & Wray, 2003) Tailored interventions are focused to appeal to specific people and groups in order to give more meaning to the message and intervention. These interventions also recognize that people are different and it capitalizes on these differences in order to distinguish and appeal to them.

Current research has examined the tailored and targeted messages compared to those that aren’t in determining how effective a campaign is. Specifically, in reference to physical activity, Bull, et al. (1999) found that individuals receiving tailored interventions demonstrated an increase in physical activity when compared to a group receiving general interventions. Ryan & Lauver (2002) found that people preferred tailored interventions rather than standard ones, and in their review, found that tailored interventions were more effective than standard ones in promoting health behaviors in more than half of the studies. De Bourdeaudhuij, et al. (2002) examined the relationship between family tailored interventions and individual interventions to reduce fat intake and determined that the tailored intervention was more effective when the family was involved rather than just the individual. Additionally, the researchers also revealed that the tailored letters were read completely by participants, and in half of the participants, the letters were saved and discussed with others. (De Bourdeaudhuij, et al., 2002) This finding is significant because it reveals that the letters were meaningful to the participants, so much that the message was shared with others.

Although Steps is a campaign designed as a prevention and an intervention mechanism targeting diabetes, obesity, and asthma in everyone, there is a very wide range of diversity among the diseases and within their targeted population. Steps could target an asthma campaign to Hispanic children, for example, and then tailor the message by focusing on inner-city Hispanic families who have children with asthma. In this instance, the parents would be directed to specific local resources for prevention and managed care of the condition. Although the campaign explains that it plans to coordinate its activities with local agencies already involved in these efforts, there is no indication that Steps is employing tailored interventions to communicate its messages and reach the goal of reducing asthma, diabetes and obesity outcomes. On the contrary, Steps is a very broad national campaign that intends to trickle its efforts to the community level.

One of the goals of the Steps campaign is to eliminate racial disparities in obesity, asthma, and diabetes rates. The target population emphasizes this focus on racial disparities; however, the inclusion in the target population of immigrants, low-income populations, youth, senior citizens, uninsured/underinsured people, and people at high risk for or who have diabetes, obesity, and asthma makes the population more inclusive—everyone is targeted! Tailoring interventions can be important to reducing racial disparities since the message and intervention would highlight important barriers and deliver information in a personalized and relevant manner conducive to changing behavior in those targeted. Tailoring can also emphasize differences in cultural beliefs and practices that can prove to be instrumental in eliminating racial disparities. Campbell, Carr & Allicock-Hudson (2005, as cited in Campbell & Quintiliani, 2006) examined the effects of tailoring cancer prevention messages to African Americans and Caucasians in North Carolina. Using a tailored newsletter, personalized counseling phone calls, and general mailings, they found that African Americans made the most improvement in fruit and vegetable consumption compared to Caucasians when they received a combination of the newsletter and personalized counseling calls.

(3) Steps Fails to Identify Diverse Contributing Factors

It is important that health campaigns identify specific barriers contributing to the diseases of interest in order to understand the entire scope of the problem. Subsequently, the campaign should consider these barriers and integrate theoretical framework in order to understand the problem and ultimately advocate for a behavior change. For example, the integrated theoretical model explains that behavior is driven by the intention to perform the behavior, the knowledge, skills and abilities to perform the behavior, and environmental constraints do not prevent the behavior from occurring. (Fishbein, 2000; Fishebein et al., 2002; as cited in Fishbein & Yzer, 2003) In order to effectively intervene in the process and change behavior, research needs to be conducted to understand the current attitudes, norms, and self-efficacy surrounding those the intervention will affect. (Fishbein & Yzer, 2003) There is no indication that Steps has integrated any theoretical framework into its approach. The campaign could have identified various reasons contributing to high asthma, obesity, and diabetes rates and in particular, identify why disparities might exist with these diseases. It advocates walking as an integral part of its intervention; however, there may be environmental constraints, as indicated by the integrated theoretical model, preventing a person from walking, which in turn perpetuates their disease. People with these diseases could be living in neighborhoods with high crime rates, where walking is not an option. The climate could be too cold, which would prevent people from walking outside. The model also indicates that an individual’s skills and abilities are important to behavior. In this instance, a person who is obese could have difficulty walking—making it laborious and too exerting—or these same individuals could present with other medical complication perpetuating their obesity.

Another example of a theoretical model that Steps could have integrated into their approach is the theory of reasoned action, which aims to understand factors that influence the intention of performing the health behavior (Fishbein, 1980). It explains that the attitude an individual has towards a behavior as well as the perception of social norms surrounding the behavior will affect whether a person has the intention of performing the behavior. In this instance, a child who has asthma might not particularly enjoy exercising due to discomfort of their condition while exercising (their attitude) and the child’s family may not encourage them to exercise as a result of the asthma (social norms). Both of these factors would negate the child’s intention to exercise. Steps could specifically address the social norms in its campaign by presenting testimonials of children with asthma who regularly exercise or who are part of a team.

Upon assessing reasons preventing people from performing the desired health behaviors, the campaign needs to be designed in such a way that it addresses these deficits and effective promotes the behavior. If it is determined that people are not performing the behaviors because they don’t know how to perform them, then the campaign should be designed in a way to teach them how to perform the behaviors; however if it is determined that people do know how to perform the behaviors, but subsequently are not, due to circumstantial or environmental conditions, the campaign should address how to overcome these limitations. (Bandura, 1997; Miller, 1980, Sulzer-Azaroff & Mayer, 1977, as cited in Graeff, Elder & Booth, 1993) It is not clear if Steps has researched whether people don’t know how to perform the behaviors or aren’t performing the behaviors due to environmental limitations. The campaign is designed in a way that assumes that people do know how to perform the behaviors but aren’t for reasons that Steps does not specify. Steps does not teach people how to walk for your health nor does it tell people how to eat nutritiously. Rather, it assumes that people know how to walk in terms of exercising, which explains why it doesn’t define exercising in terms of how often or how far.

(4) The Behavioral Objectives are Not Specific

Steps has indicated that it will focus on diet, exercise, and tobacco use in combating these diseases; however, these interventions have not clearly been defined and operationalized. According to the integrated theoretical model, changing specific behaviors (amount of time performing a specific type of exercise and frequency) is more effective than focusing on behavioral categories (exercise, walk, etc.). (Fishbein, 1995, 2000, as cited in Fishbein, et al., 2003) The Boston Steps program has advocated walking and walking groups and in the national campaign, Steps encourages walking; however, it is not described in either campaign in terms of how far, how long, and how often. (Boston Steps) A diabetic could receive the message of “walk” and not understand why they still have diabetes because they do already perform the action of walking one day a week for ten minutes. Similarly, Steps intends to reach a goal of “healthy,” which also isn’t defined in the campaign. (CDC Steps to a HealthierUS) It should be clearly explained in terms of how much and how often to exercise, what and how much to eat, etc. The campaign infers that being free of asthma, diabetes, and obesity demonstrate “healthy”; however, the term healthy is relative and the experience of being healthy is subjective. On the other hand, an individual could also eat nutritiously and still be overweight. The interventions described in the campaign are vague, in that they have not been clearly operationalized, and this translates into barriers for behavior change. In order for the intervention to work, the behavioral objectives must be operationalized.

(5) The Campaign is Information-Based

Steps is an information-based campaign in that it relies on data to convey an informative and standardized message of behavior change. However psychology and communication theory has indicated that human-processing plays a central role in health campaign and message receptiveness. Similar to tailored interventions, the message must be delivered in manner that makes it salient to the receiver, meaningful and relatable, and also appeal to their arousal level, affective appeal. (Ray & Donohew, 1990) Yerkes and Dodson (1908, as cited in Donohew, 1990) found that behavior was a response to arousal. In applying these concepts to public health campaigns, the activation theory of information exposure (Donohew, et al., 1980, as cited in Donohew, 1990) explains that messages need to appeal to arousal and stimulation, rather than providing only information.

(6) Steps Employs Inappropriate Evaluation Methods

Steps intends to use risk factor surveillance as a means of monitoring and evaluating their campaign. (Steps RFA, 2003) Risk factor surveillance is a way to track and monitor individuals’ health conditions and risks through the use of telephone and survey methodologies. It allows health officials to observe health trends among states. Primarily, it provides estimates of health conditions through statistics but these numbers do not reflect the intricate and complex relationships between the risk factors and the diseases. Numbers produce limited inferences and correlations, and they do not allow the perspective of the whole picture of the disease (integrating environmental limitations, for example). It is a basic tool used to assess a situation; however, it is not appropriate to base a campaign’s direction and goals on the data obtained from risk factor epidemiology. Steps used risk factor surveillance at the start of the program to determine the baseline prevalence and incidence rates of asthma, diabetes, and obesity. Throughout the program, these rates will serve to guide the campaign and ultimately determine its effectiveness. The problem with relying on these data is that there could be multiple factors influencing the increase or reduction in these rates, aside from the Steps campaign. For example, a new drug treatment for obesity that proves to be effective may become popular at next year, which results in reduction in the obesity rates. The reduction in obesity rates then would be unrelated to the Steps campaign. The campaign would believe that their tactics were successful according to the reducing rates, since it would not be complicated to tease apart the campaign’s effects from the drug treatment’s effects. Steps should implement individuals’ personal experiences, through interviews or focus groups, with the campaign and their condition into their evaluation methods.

Steps, as a national campaign, is collaborating with local agencies at the state and community level in order to reduce replication of efforts. However, the main problem with this approach, which will be evident during the evaluation phase, is that all local agencies have different approaches to disseminate the message within their regions. For example, Broome County’s Steps to a HealthierNY is encouraging the “Walk your Child to School Day” focusing on elementary school children and their parents (Broome County Steps) while Boston Steps is implementing Neighborhood Walking Groups (Boston Steps). When evaluating these programs, the data will not be consistent because in the case of the New York program, adults with children are encouraged to walk, while in Boston Steps, whole neighborhoods are encouraged to walk. It will be very difficult for surveillance epidemiology to account for these differences the programs in addition to the risk factors previously mentioned.

Randolph and Viswanath (2004) discuss that most campaigns evaluate their measures through focus groups or marketing surveys; however, campaigns should evaluate the salience and exposure of their message in order to determine first the visibility of the campaign. Steps has indicated that they will evaluate their campaign based on the reduction in prevalence rates of the diseases of interest. This is not a reliable method to evaluate the campaign, since there are many factors other then the campaign that can affect the reduction in prevalence rates. The campaign’s salience could be very limited to certain populations or neighborhoods, and the reduction in rates could be attributed to other events. For example, crime rates could decrease in the city which would affect stress levels and in turn reduce the burden of asthma to people living in the inner city. Steps could conduct questionnaires assessing the visibility of their campaign, and determine how, if at all, this campaign has affected the targeted health behaviors.


Steps is a very broad campaign that will not be effective in reducing and preventing the burden of asthma, diabetes, and obesity rates in everyone within the next five years it intends to operate. There are six flaws in the Steps campaign that will significantly hinder its success. (1) The broad scope of the Steps campaign will be detrimental to achieving its intended goal of decreasing asthma, obesity, and diabetes in everyone. Rather than being so broad, Steps could narrow its focus to one condition, such as obesity, in children and adults. Focusing on a condition such as obesity might prove to be helpful in counteracting the other conditions too; albeit indirectly. (2) Steps also has too broad a target group and it is not a sufficiently tailored campaign. Steps could target specific groups of people who are more vulnerable to the condition of interest and tailor the message to them. In the example of obesity, geographically speaking, there are higher rates among those who live in more rural areas, such as Maine. The targeted group could be those who live in rural areas and the message could offer specific suggestions as to how to incorporate activity into their daily lives.

In addition to its broadness, (3) the Steps campaign fails to identify and confront barriers to the conditions. This will severely limit the ability of Steps to effectively intervene and change behaviors. By integrating theoretical models, such as the theory of reasoned action, a more thorough understanding of the condition is available and will permit improved intervention strategies. Again, in the case of obesity, the theory of reasoned action would address the individual’s attitude and/or the social norms surrounding inactivity and obesity. Similarly, (4) Steps also fails to specify its behavioral objectives. It advocates walking and exercise to address all the diseases; however, it doesn’t specify how long or how far to walk. Steps should clearly explain that walking one mile or for a half an hour three times a week will help to reduce obesity in individuals, rather than just telling people to walk.

Another problem with the campaign is that (5) Steps is an information-based message campaign. This will not be an effective means of disseminating its messages. Research has shown that messages that appeal to arousal and stimulation are more salient to the receiver (Donohew, et al., 1980, as cited in Donohew, 1990). Finally, (6) Steps employs inappropriate evaluation methods. Risk factor surveillance, which is being used by Steps, provides only statistics and numbers and does not explain the intricate relationships that may exist with these diseases. The Steps campaign also does not uniformly implement intervention strategies across cities and states. Steps should uniformly implement their tailored strategies, and incorporate personal experiences from the public into their evaluation measures. In conclusion, this campaign will not be effective in reducing the burden of disease; instead it will prove to be a cost-effective measure taken by the government to make it appear to be addressing the rising rates of asthma, diabetes, and obesity.


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