Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Connecticut “Make Healthy Fish Choices” Campaign-Amanda DeLoureiro

On October 16, 2008, the Connecticut Department of Public Health and the Connecticut Food Association began publicizing a statewide campaign entitled “Make Healthy Fish Choices” (1). This campaign is geared towards women and children, and its purpose is to educate people about the health benefits and dangers of consuming different varieties of local and store-bought fish (1). This has involved the publication in English and Spanish of take-home cards entitled “Healthy Fish Choices for You and Your Family”, which are being distributed in participating supermarkets and grocery stores statewide (1). The cards contain information specific to pregnant women, nursing women, women of child-bearing age, and young children about the health merits and dangers of eating fish, and suggestions about how often different types of fish should be consumed (2).
Problems of the “Make Health Fish Choices” Campaign
The “Make Healthy Fish Choices” campaign is a clear example of an intervention that follows the Health Belief Model. This model is based on the idea that an individual’s perceptions regarding health behavior are rational, and an intervention can be used to alter the attitudes of the individual (3). This particular health behavior intervention focuses on changing how individuals view their perceived susceptibility, or the degree to which they think they are at risk of getting sick from the toxins found in many fish (4- 37). There are three main problems with this type of an intervention based on the Health Belief Model, in addition to a major problem with how the issue of fish contamination is being framed through this campaign. First, this intervention focuses on individual-level decision-making, and does not take into account the fact that there are environmental factors that can also affect decisions that people make about the consumption of fish (4-38). Secondly, this campaign assumes that everyone in Connecticut will have equal access to the information provided in the guides, which is untrue because of the large segment of the population that is not literate in English or Spanish, and will not understand all of the vocabulary presented in the document (4-38). Thirdly, this intervention assumes that those affected by the campaign will make rational decisions about their consumption of fish, and in doing so discounts the impact of cultural norms on choices regarding fish consumption (4-38). Lastly, this campaign frames the issue of contaminated fish in such a way that it ignores the root cause of this problem, pollution, and instead focuses on what the consumer can do to decrease the health risks associated with consuming this fish. The “Make Healthy Fish Choices” campaign should have done two major things differently: 1) it should have been modeled after a different type of health model that was more community-based, in order to address the influence of outside impacts like culture on behavior, and 2) it should have framed the issue in such a way as to address the root causes of fish contamination in Connecticut.
Individual-level decision-making ignores outside influences on behavior
A major problem with the “Make Healthy Fish Choices” intervention is that it is targeted at the individual, and was not developed to address social and environmental influences on behavior related to health. This campaign involved only a handout that was read by an individual person, instead of a more community-based effort that would address outside influences on diet, such as cultural norms. The focus on the individual person that is used in this campaign, like the example set forth in other interventions based on the ideas of individual-level models like the Health Belief Model and the Theory of Reasoned Action, reflects the value that North American and Western European cultures place on individualism (5). These societies are very focused on the concept that individuals have complete control over their behavior and decision-making, and in doing so tend to overstate the influence of personal behavior on health (5). Most of the original behavioral health models were built on various assumptions, such as 1) the individual is the key decision maker, 2) individuals value good health and will change their behavior in order to attain positive health outcomes, and 3) cognitive predisposition, like beliefs, attitudes, and perceptions, are a major driving force of health behavior (6-5). All of these assumptions are not inherently correct, because they ignore other influences that may impact individual decision-making and make people choose unhealthy habits, like consuming large amounts of contaminated fish. This intervention ignores the extent to which pre-existing beliefs, attitudes, and perceptions regarding fish consumption may counteract the information being put forth in the pamphlet.
In recent decades, researchers have begun to question the validity of relying solely on health behavior models that are based on individual-level decision-making in achieving substantive and sustainable changes to health behavior (6-6). It is thought that many individual-level models, like the Health Belief Model, do not lead to large-scale behavioral change because they are focused on changing the behavior of individuals. More recently developed models have focused on community-based campaigns, through which it is hopeful that norms within an entire community of people will be changed to encourage more healthy behaviors (6-6). Whereas the “Make Healthy Fish Choices” campaign focuses on changing individual perceptions of the health risks involved with fish consumption, community-based initiatives would prioritize changing the perception of an entire population regarding these health risks. Instead of focusing solely on the individual, health behavior campaigns should recognize the impact that factors like community, living and working conditions, and socioeconomic, cultural, and environmental impacts have on decisions people make about their health (5). It is doubtful that this intervention, based on the Health Belief Model, will be adequate to initiate widespread behavioral change in this case because the change for which the campaign is advocating ignores contextual meanings that are entrenched in group qualities, for example cultural practices, skills, and languages (3). Instead, the campaign would have been wise to take into account the outside influences that can significantly impact the choices that people make regarding fish consumption.
Lack of access of information to low literacy populations
Another major problem with this campaign is that the information about healthy consumption of fish is only offered in the form of a written handout. There are two major problems with this document that may inhibit access to the information provided: 1) it is available in only English and Spanish and 2) it makes use of scientific vocabulary. The availability in only two languages is of concern because in Connecticut, 12.9% of the population is foreign born and this number is predicted to rise in the coming decades (7). The large proportion of immigrants contributes greatly to the percentage of the adult population of Connecticut that is not literate in English. In 2001, 16% of Connecticut’s adult population was in the lowest of five literacy levels, which means that this group of people will be unable to understand the information as it is currently being presented (8). This segment of the population will not fully comprehend the suggestions being made, nor are they apt to know the different types of fish that are listed.
Populations with low literacy face various problems properly understanding health risks, including inadequate comprehension of available health education material, social networks that are not well-informed regarding health problems, and inadequate access to health services (9). A previous intervention geared at addressing the health needs of low literacy populations designed a book which promoted understanding through color coding, graphic symbols, simple language, and clear type (9). The “Make Healthy Fish Choices” intervention did not follow this example, and instead presented health-related information using extensive vocabulary, including words like “PCBs” and “omega-3 fatty acids”, in a manner that was not very clear (2). Low levels of literacy in a large proportion of Connecticut’s population, coupled with low understanding of scientific concepts, means that this intervention provides information in a way that many Connecticut residents will not fully comprehend.
Assumes people will make rational decisions without considering cultural practices
Another major problem with the “Make Healthy Fish Choices” campaign is that it assumes that people will make rational decisions without considering other factors that may have a significant impact on fish consumption, such as cultural practices. The Health Belief Model is known to ignore these outside impacts and instead focus on affecting how the individual makes decisions related to health (4). However, there are many groups of immigrants in Connecticut whose diet is composed of a large quantity of fish that may not, even given the information, choose to change their dietary habits. For example, between 2000 and 2006, the Brazilian population of Connecticut grew 82%, from 10,379 to 18,871 (7). Due to its large coastline, vast rivers, and the influence of Portuguese conquistadors who brought their dietary practices to the new world, the diet of many Brazilians includes a large amount of fish (10). Although the diet of this population may be altered due to the influence of living in the United States, diets of particularly the new immigrants cannot be expected to change dramatically with an individual-based intervention like the “Make Healthy Fish Choices” campaign. This intervention provides information that goes against the Brazilian’s cultural norms of consuming large quantities of fish, and yet it is questionable whether this information will be strong enough to change people’s perception of the health risks related to consuming fish. Many immigrant populations, particularly recent immigrants, tend to live in communities that have large populations of others from their country, as well as markets with food from their country. In order to change dietary norms for groups such as this, it would be necessary to create an intervention to address an entire population of people like the recent Brazilian immigrants.
Downstream approach that ignores the cause of the pollution
Another key problem with the “Make Healthy Fish Choices Campaign” is that it focuses on providing information to fish consumers about the dangers of fish consumption, instead of framing the issue in such a way that it places blame on the companies that contribute to the pollution of Connecticut’s fish. In Connecticut, 75% of fish samples taken have mercury levels that exceed the safe limit for women (0.13 ppm), with an average of 0.42 ppm (11). Sampling in Connecticut waters of specific fish species, such as smallmouth bass and certain predator fish, have found that 100% of fish exceed the safe mercury levels for women (11). Much of this mercury comes from businesses along the rivers of Connecticut, such as power plants. In order to reduce mercury pollution in the rivers of Connecticut, the state passed a law in 2003 that limited emissions to 0.6 pounds of mercury per trillion Btu, or 90% efficiency (11). However, the pollutants in Connecticut rivers do not originate solely in the state of Connecticut, as the Connecticut River estuary includes parts of the states of Massachusetts, Vermont, and New Hampshire.
The intervention as it currently stands does not address the underlying causes of pollution of fish from sources like coal fired power plants, and instead focuses on putting the responsibility of healthy fish consumption on the individual consumer. Institutional framing is the way that public health practitioners can social construct risk (12). In this case, the issue should be framed in such a way that people see the corporations from throughout New England that they are polluting their fish and their water as an enemy, so that they become angry with this group and hopefully work to initiate change. The Connecticut Department of Public Health should make use of the frame-alignment process, which involves linking individuals and social movement organizations with the same set of interests, values, and beliefs (12). In framing the issue in this way, the department could help to initiate a movement for change that would ultimately affect all people who consume fish from the waters of Connecticut.

Alternative intervention
An appropriate alternative intervention will need to address the problems associated with the Health Belief Model, as well as the root cause of water pollution that is resulting in the contamination of fish. The proposed intervention would provide educational programming to people throughout Connecticut, which would teach them about the dangers of consuming certain types and amounts of fish, and also about the causes of water and subsequent fish contamination. The education programs would be advertised in and provided in local libraries, schools, and religious organizations, in order to reach a large segment of the population. The information would need to be provided in such a way that it addresses the needs of individual communities, consequently there would be a need for flexibility so that each presentation of the information would be designed for people of different backgrounds and cultures. The intervention would also provide people with a form to send to their government representatives about the environmental hazards associated with water pollution and its effects on fish. It is hopeful that this would cause a significant change in policy, and encourage the government to properly address the root cause of fish contamination.
This intervention would address the major problems associated with the Health Belief Model that have been previously outlined. Firstly, it is a community-based intervention that is aimed at changing the behavior of a population, not specific individuals. Secondly, the intervention would educate low-literacy groups of people because the information would be provided verbally. Finally, this intervention would address the need for information to be presented in a culturally sensitive manner, by altering the presentation to speak to the cultural dietary norms of each represented population.
It is also hopeful that, by providing information about the causes of water pollution, and by giving people forms to send to their representatives, they will bond together in order to fight major contributors to water pollution. This intervention would be much more successful than the “Make Healthy Fish Choices” campaign because it 1) deals with the problems associated with the Health Belief Model and 2) properly frames the issue in such a way that the root cause of fish contamination is addressed.
Group-level intervention addresses outside influences on behavior
One major problem with the “Make Healthy Fish Choices” intervention is that it focuses on changing the behavior of individual people and ignores the influence of groups on behavior. Some of the more recently developed behavioral theories have emphasized that groups are different than simply a collection of individuals, and that groups of individuals can be affected at the same time (13). One example of how the emphasis in social behavior models has been altered to address the needs of groups is seen in the Social Expectations Theory, which states that people act in mass based on the prevailing social norms (13). Thus, interventions based in the Social Expectations Theory attempt to alter the social norms of an entire group of people (13). For example, an intervention in Finland that made smoking in the workplace illegal was found to be successful at changing social norms, so that non-smoking at work is now seen as normal behavior in this nation (14).
The proposed intervention can be similarly productive because it addresses behavior change at the level of the community instead of at the level of the individual by having members of a population learn about and discuss the causes and implications of fish contamination. It is hopeful that, though discussions in the education programs and follow-up conversations with their peers, citizens of Connecticut will come to see the consumption of reduced amounts of fish as a societal norm.
Provides information to low literacy populations
Another major problem with the “Make Healthy Fish Choices” campaign is that it assumes that people will have equal access to the information provided in the pamphlets, when in reality low literacy populations will be unable to adequately understand the suggestions being put forth. One study of functionally illiterate populations made the suggestion that preexisting health literature should be extensively reviewed by assessing readability and comprehensibility, editing written material, and evaluating the effectiveness of less complex written documents (15). The researchers found changing the educational intervention so that used less complex language and an easy to read format made it more effective in addressing the needs of low literacy readers (15).
The proposed intervention goes even further than the previous example, as it properly addresses the difficulties in comprehension associated with low literacy populations by educating people through verbal presentations. These presentations will be made in different languages depending on the needs of individual populations, and will provide universal access to the information to all people who attend the education sessions.
Considers cultural practices
Another problem with the “Make Healthy Fish Choices” campaign is that it assumes that an individual’s intention to reduce fish consumption, as a result of an educational intervention, will actually result in behavior change. However, this ignores the impact that cultural norms have on diet, such as the example of Brazilian immigrants discussed in a previous section. The proposed intervention addresses the needs of people of very different cultures by encouraging public health professionals to be flexible in how material is presented based on the needs of varying communities. The results of a previous study that looked at the effects of socio-cultural factors on food selection practices suggest that in order to provide information about food in a culturally sensitive manner, public health professionals need to 1) incorporate cultural information into education approaches, and 2) incorporate the entire household in educational programs (16).
The proposed intervention is designed in a way that will be sensitive to the dietary norms of different cultural groups, even recent immigrant populations, by including cultural information in the programming and by encouraging all members of a household to attend. For example, if public health practitioners wanted to address fish consumption in the growing Brazilian population in Hartford, they might teach people how to incorporate other types of meat into recipes that traditionally have fish. In this way, the behavior of a population that has distinct cultural norms regarding food can be changed by encouraging slightly altered behavior that is sensitive to that population.
Addresses cause of pollution
The final strength of the new intervention is that it deals with the issues associated with the consumption of contaminated fish by addressing the root cause of this problem, which is water pollution from industrial waste. It does this by giving participants of the education programs the opportunity to fill out a form to be sent to their governmental representative, which would outline the problem and the changes that would be necessary to reduce fish contamination. This method makes use of framing theory, which states that an issue can be seen from many perspectives and can be viewed as having implications for many considerations (17). Interventions of this kind use framing to reorient how people think about a certain issue (17). Framing theory has been successful in many public health interventions, the most notable being the anti-tobacco Truth campaign. This intervention frames tobacco smoking in such a way that it encourages young smokers to have anti-industry attitudes towards producers of cigarettes (18). A study in 2004 found statistically significant increases in anti-industry attitudes among youth since the Truth campaign was introduced (18).
The proposed intervention is similar to the Truth campaign in that it encourages the general public to speak out against producers of fish pollutants. It frames the issue in such a way that contaminated fish are not simply a food that they should avoid, but also a problem that they can work to prevent.
The “Make Healthy Fish Choices” campaign of informational handouts regarding the benefits and health risks related to fish consumption is not efficient in relaying this information to the general public of Connecticut. This intervention, which is based on the Health Belief Model, is poor because it is based on an individual-level model of decision-making, ignores problems that people may face in accessing the information, and assumes that citizens will make rational decisions about fish consumption once provided with information. Additionally, this intervention ignores the root cause of the need for the campaign, which is water pollution, and instead focuses on changing consumer behaviors.
In order to be a more effective intervention, the Connecticut Department of Public Health needs a campaign that addresses the significant problems associated with the Health Belief Model in a way that encourages Connecticut residents from all backgrounds to want change from corporations polluting local bodies of water. The proposed intervention would address the flaws of the existing campaign by creating a community-based initiative to address the needs of Connecticut’s diverse population in a linguistically and culturally sensitive manner, while also addressing the underlying cause of the fish pollution.
Works Cited
(1) Connecticut Department of Public Health. Connecticut’s Fish Consumption Advisory and the Safe Eating of Fish Caught in Connecticut. 7 Nov 2008. phPNavCtr=#47464.
(2) Connecticut Department of Public Health. State Health Department “Reels-In” Fish Eaters. 16 Oct 2008.
(3) Thomas, Linda W. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professionalism 1995; 11(4): 246-252.
(4) Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett Publishers, 2007.
(5) Marks, David F. Health Psychology in Context. Journal of Health Psychology 1996; 1(1): 7-21.
(6) DiClemente, R., Corsby and R., Kealer, M., Eds. Emerging Theories in Health Promotion Practice and Research. San Francisco: Jossey-Bass, 2002.
(7) Mejia, Rafael and Canny, Priscilla. Immigration in Connecticut: A Growing Opportunity. Connecticut Voices for Children. Oct 2007.
(8) Gelb, Jennifer. Summary of Connecticut Plan for Adult Education and Family Literacy. OLR Research Report. 16 February, 2001.
(9) Berger, David, Moira Inkelas, Sonya Myhre, and Alanna, Mishler. Developing Health Education Materials for Inner-City Low Literacy Parents. Public Health Reports 1994; 109(2): 168-172.
(10) Fish, Warren R. Changing Food Use Patterns in Brazil. Luso-Brazilian Review 1978; 15(1): 69-89.
(11) US Public Research Group Education Fund. Reel Danger: Power Plant Mercury Pollution and the Fish We Eat. Aug 2004.
(12) Zavestoski, Stephen, Kate Agnello, Frank Mignano, and Francine Darroch. Issue Framing and Citizen Apathy Toward Local Environmental Contamination. Sociological Forum 2004; 19(2): 255-283.
(13) Siegel, Michael. SB 721 Class Lecture. 9 October 2008.
(14) Heloma, Antero and Jaakkola, Maritta S. Four-year follow-up of smoke exposure, attitudes and smoking behavior following enactment of Finland’s national smoke- free work-place law. Addiction 2003; 98: 1111-1117.
(15) Horner, Sharon D, Dawn Surratt and Sarah Juliusson. Improving Readability of Patient Education Materials. Journal of Community Health Nursing 2000; 17(1): 15- 23.
(16) Gittelsohn, Joel and Vastine, Amy E. Sociocultural and Household Factors Impacting on the Selection, Allocation and Consumption of Animal Source Foods: Current Knowledge and Application. Constraints on Animal Source Food Consumption 2003; 4036S-4041S.
(17) Chong, Dennis and Druckman, James N. Framing Theory. Annual Review of Political Science 2007; 10: 103-126. (18) Thrasher, JF, J Niederdeppe, MC Farrelly, KC Davis, KM Ribisl, and ML Haviland. The impact of anti-tobacco industry prevention message in tobacco producing regions: evidence from the US truth campaign. Tobacco Control 2004; 13: 283-288.

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