PART I: Small Steps…In the Wrong Direction? - Megan Waterman

How the Use of the Health Belief Model and Stigmatizing Advertisements Are Flawed Methods to Improve Nutrition and Exercise

When a user visits the U.S. Department of Human Services Smallstep Adult and Teen website, one of the first facts listed is that two out of every three Americans are defined as overweight or obese (1). Certainly, obesity is a growing problem in America, and Smallstep is one of HHS’s responses to that problem. Smallstep Adult and Teen aims to decrease overweight and obesity in the United States by providing information on health, healthy eating, and physical activity. Smallstep’s website features informative sections, such as “Get the Facts,” “Eat Better,” and “Get Active.” It includes a personalized Activity Tracker with which users can upload information about their physical activity goals, activities, and progress. Smallstep also includes Public Service Announcements on television, radio, newspapers, interactive online, and outdoors to advertise its campaign to reduce overweight and obesity.
Although it is well-intentioned, I argue here that the Smallstep Adult and Teen program is a flawed approach to improving nutrition and physical activity among Americans. This paper will outline three arguments based on social science theories and scientific literature about nutrition and exercise promotion that demonstrate the flawed nature of Smallstep. First, I will discuss how Smallstep’s focus on the individual level of behavior and its disregard for the social context limit its effectiveness as a health intervention. Second, the centrality of choice in Smallstep’s intervention scheme will be shown problematic, considering the largely irrational nature of human decision-making. Third, I will criticize Smallstep’s Public Service Announcements as stigmatizing to obese and overweight individuals and demonstrate how this may be counterproductive to the goal of promoting positive nutrition and exercise behavior.
Are Tools and Information Enough? Individuals Out of Context
The Smallstep program draws heavily from the Health Belief Model (HBM)—a model that places individuals in a rational balancing act, weighing the perceived barriers to health behavior against the perceived benefits, which include their perceived susceptibility to and the perceived severity of the outcome if they do not perform the health behavior (2-5). Smallstep’s very first page, “Get the Facts,” includes links to “The Issue” and “The Consequences.” This is a very clear use of HBM. It highlights to its readers their susceptibility to poor outcomes if they do not exercise and eat healthy: “2 out of 3 Americans are overweight or obese” and “300,000 deaths each year in the U.S are associated with obesity,” according to Smallstep’s Fact list (1). The severity of the outcomes is also addressed; Smallstep lists diabetes, heart disease, high blood pressure, and problems with mobility as potential health problems linked to obesity and overweight.
What are the consequences of this intervention’s reliance on HBM as its framework? Others have written about the problems with HBM. Foremost, the HBM approach to health behavior seeks to influence people as individuals removed from a social context. David Marks has criticized health psychology for this flaw, writing, “Health psychology is culturally ridden with individualism” (6, p.13). Marks discusses how health psychology has drawn from the biomedical models, focusing on the personal level of behavior change. This approach is ultimately flawed, as it assumes that individuals have control over their lives and are able to change if they only decide to do so.
Further, the individual focus of health psychology has been reflected in current epidemiology, which focuses on individual risk factors for disease. Pearce writes about the rise of risk factor epidemiology, describing how risk factors came to be conceptualized and analyzed in individual terms with greater emphasis on individual lifestyle (7). He argues that exposures to disease must be placed in their social and historical contexts, because “epidemiology is inevitably tangled with society” (7, p.682). When exposures are reduced to abstract individual risk factors, Pearce argues that we may miss the true causal factors of disease. More importantly, when epidemiological assessments fail to take into account social context, interventions based on those assessments are likely to fail to do so.
The Smallstep program is a prime example of an intervention based on individual risk factors of disease causation. Its focus on physical activity and healthy eating assumes the individual has control over his or her life, even if it is a small level of control. Smallstep maintains a list of “Tips” on different topics, including foods that one should eat and ways to incorporate exercise into one’s day, but these tips are entirely removed from any true social context. For example, consider Tip # 136: “Focus on fruits. Bag some fruit for your morning commute. Toss in an apple to munch with lunch and some raisins to satisfy you at snack time” (1). This tip assumes that individuals exist in a vacuum with unlimited supplies of fruit and without social barriers to healthy eating behaviors.
However, emerging social science and public health studies have demonstrated that social context matters in terms of healthy food consumption. Turrell and colleagues conducted a food purchasing study in Australia, showing that people of low socioeconomic status and educational attainment were less likely to purchase recommended food items and people in the low income group lived in areas with fewer supermarkets (8). Whelan and others explored the recently coined terms “Food Deserts” and the “disadvantaged consumer,” studying food retail access and perceived physical and economic access constraints on food purchasing (9). Other public health researchers have investigated the relationship between physical activity and the built environment, finding that access to exercise facilities, home exercise equipment, social support, neighborhood crime levels, heavy traffic, child care responsibility, and aesthetic qualities of neighborhoods impact physical activity levels (10-13). Clearly, social and ecological factors matter in determining health behaviors. Brownson and colleagues write of the importance of addressing public health problems at multiple levels (10); Estabrooks states that individual approaches must be expanded (11). Yet, the Smallstep program, a program funded by the United States Department of Health and Human Services, fails to take into account the social and ecological factors in its intervention strategy. What are the consequences of this failure? To illustrate this, an example used by Schwartz and Carpenter is useful (14). These authors discuss homelessness and the use of individual versus structural models of intervention. They argue that examining differences between those who are and are not homeless will not identify the cause of rising homelessness over time. Rather, they argue that lack of affordable housing is a “basic” cause, and that only by changing this basic cause can we reduce the overall amount of homelessness (14, p.1178). The Smallstep program can be conceived of in a similar fashion. Its focus on individual risk factors does not address the structural problems of access to physical activity and healthy food options. Without addressing these, Smallstep can only hope to influence who, among those with access, will lose weight by changing individual behaviors, while those without access are left with empty tips without the ability to realize improvement.
“A Healthy Lifestyle Made Up of Lots of [Irrational] Choices”
The above section discussed Smallstep’s likeness to HBM in its focus on individual behavior; this section will demonstrate another of its similarities to HBM and argue that this is another flaw in its design. The HBM presumes that individuals weigh benefits and barriers and make rational decisions (2-5). Smallstep certainly follows this aspect of the model, including a “Choices” section for both healthy eating and physical activity (1). “A healthy lifestyle is made up of lots of small choices,” Smallstep claims (1). However, evidence from behavioral economics has shown that individuals do not make rational decisions about many aspects of life. Dan Ariely writes about the ways that we make predictably irrational decisions; his writings are certainly applicable to decisions about exercise and nutrition (15). Ariely discusses several concepts that help to describe the ways that individuals act and choose irrationally, including: “arbitrary coherence,” “self-herding,” arousal, procrastination, ownership, and choice overload. In light of his concepts, it is possible to understand how irrationality enters decision making about exercise and nutrition, and to examine how Smallstep fails to address this irrationality.
First, the issue of arbitrary coherence refers to certain initial experiences with price and items ability to influence later decision-making (15, p. 26). In the context of nutrition, the low price of unhealthy food enters individuals’ minds as an “anchor,” making it unlikely that someone will purchase healthier (and likely more expensive) food items if they surpass that price anchor. Smallstep does not address the issue of cost of healthier options. Second, people also perform what Ariely calls “self-herding,” in which past personal experiences anchor individuals into habitual (but not rational!) behaviors (15, p. 37). A relevant example of this would be someone’s failure to exercise as a habitual behavior. Smallstep tries to convince individuals toward healthier lives in a rational process by providing information and knowledge about health risks and benefits, but this is likely to be ineffective against strong self-herding habits of non-exercise or unhealthy eating. Third, Ariely describes how arousal affects decision-making, in which people make decisions in “hot” states that they would not make in “cold” states (15, p. 104). Smallstep operates only at the “cold” level, encouraging people to consider its health tips and create an “activity planner,” but when people are tempted by momentary arousal—say, perhaps, by the smell of McDonald’s—they are likely to make irrational decisions. Fourth, procrastination is discussed as an irrational behavior (15, p.116). While Smallstep seeks to prevent individuals from procrastinating and failing to change exercise levels through the use of its online Activity Planner, this is not a coercive enough tool. It is unlikely that an individual will consider his or her obligation to an online calculator when they feel tired and unwilling to exercise. Fifth, Ariely discusses how individuals overvalue what we already have, and that this process applies to points of view (15, p. 137). If individuals irrationally hold tightly to their previous beliefs and values about inactivity or food choices, Smallstep’s rationally based intervention will have limited success in persuading individuals away from their “owned” points of view. Finally, choice overload is important to consider (15, p. 152). Ariely writes that people who are given more choices on a matter have been shown to have lower satisfaction with that outcome. Although Smallstep attempts to appeal to this idea of choice overload, writing on its “Get the Facts” page: “We are bombarded everyday with conflicting information about our health” (1). However, Smallstep contributes to this bombardment in its “Resources” section, including a list of links to various other health websites and information sources. Which link should a user choose to get the correct information? Surely people do not spend hours reading each website. Rather, they are confronted with a long list of possible resources, and they may avoid reading any of them because they could not easily choose one. Of course, choosing not to read valuable information about health is not a rational choice, but the overload of information available on Smallstep likely contributes to this potential irrational behavior.
Ariely’s concepts are very useful in thinking about irrational behavior and applying them to exercise and nutrition behaviors. Content-specific research about nutrition and irrationality conducted by Osberg and colleagues addresses the issue more directly (16). These researchers used an “Irrational Food Beliefs (IFB) Scale” and compared it to a “Rational Food Belief (RFB) Scale” to study effects on weight gain/loss. They found that high scores on the IFB scale were associated with recent weight gain and poor weight loss maintenance in a sample of college freshmen, and found that RFB score was unrelated to weight change. People who held irrational beliefs about food were likely to fail to lose weight, while rational beliefs did not make a difference. Considering this, health interventions appealing to irrational tendencies would probably more effective. Clearly, concepts about irrationality and health behavior are important and are emerging in the scientific literature. Smallstep’s inability to deal with irrational behavior is a serious limitation of the intervention.
Obese and Stigmatized: Media Images’ Perpetuation of Obesity
A third critique of Smallstep concerns its Public Service Announcements (PSAs) used in newspapers, television, radio, interactive internet, and outdoor ads (17). These PSAs emphasize that individuals can take “small steps” toward weight loss, but they do so with images of unclothed overweight and obese individuals. These images probably produce strong reactions with viewers, but what kind of reactions are they producing? What are the effects of these reactions, and do the PSAs encourage overweight and obese people to lose weight, as they purportedly intend?
These are important questions, considering sociological theory about stigma and labeling. In their article, Link and Phelan summarize Erving Goffman’s theory of stigma (18). They write that human characteristics become labeled, and certain labeled individuals are linked with undesirable characteristics. These labeled or stigmatized persons are thought of as separate from the “normal” group and experience discrimination due to their labeled statuses. Howard Becker, another sociologist from Goffman’s era, wrote of a similar concept, called deviance (19). He explained that deviant persons—people who do not behave according to social norms or rules—often continue their deviant behavior precisely because they have been labeled as such. Once labeled as deviant, individuals often continue to live up to the stigmatized label that they have been publicly given.
Smallstep’s PSAs have a great potential to invoke or encourage the stigmatization of obese people as vilified, disgusting, lazy individuals without self control. Obese people with dotted lines showing a slimmer version of the models are featured in the ads; along the dotted lines are written phrases about how one might lose weight with Smallstep. For example, one magazine ad, “Bikini,” contains phrases to describe an obese woman’s progression from obese to “obscene” with the following: “Started going for short walks during lunch hour,” “Stops ordering take-out and starts cooking healthy meals,” and “Just bought bikini that challenges some obscenity laws” (20). While this ad attempts humor with its final phrase, the image of an overweight/obese woman’s hip is not a pleasant one. Seeing images of overweight individuals may simply serve as a reminder of stigmatization and the label of overweight/obesity for afflicted individuals. Furthermore, the connection between the image of an obese person and the individual-based phrases that describe behavior change allow for continued stigmatization of obese persons who do not succeed in losing weight. Cohen and others write that common stereotypes about obese people include laziness, lack of self-control, low intelligence, and noncompliance to health recommendations (21). The authors state that these stereotypes are “played out in the daily popular media,” especially in advertisements that emphasize personal control (21, p. 155). Smallstep’s PSAs certainly fit this description. “Normal” individuals may see the Smallstep ad and think: “Obese people are just lazy individuals who don’t have enough self control to go for simple walks and cook healthy.” The images of obesity tied to personal control level changes—for example, walks during lunch breaks—allow stigma to continue and stereotypes to be affirmed.
What are the consequences of stigma? Cohen and colleagues address the issue of anxiety and mental health issues among the obese and attribute this to stigmatization (21). Link and Phelan discuss how stigma leads to stress, which may have negative effects on hypertension (18). Finally, we must consider Becker’s labeling theory, which predicts that labeled deviants continue deviant behavior precisely because they have been labeled (19). “Treating a person as though he were generally rather than specifically deviant produces a self-fulfilling prophecy,” Becker writes (19, p. 34). According to this theory, obese people who experience stigma will actually continue to act in manners that make them deviant. Thus, if Smallstep’s PSAs stigmatize obese and overweight individuals, the PSAs will actually have the opposite effect as intended, causing these people to be less inclined and hopeful to change their health behaviors.
Conclusion
This paper has focused on the U.S. Department of Health and Human Services’ Smallstep program, laying out three arguments to demonstrate its flawed nature as a public health intervention targeting overweight and obesity. Smallstep’s reliance on the Health Belief Model as its organizing framework is clear, with its emphasis on knowledge-building and rational choices. This paper has used existing social science and public health literature to attack Smallstep’s use of the Health Belief Model, arguing that (a) individuals cannot be removed from the social and ecological frameworks in which they exist, and (b) individuals often do not make rational decisions and that irrationality comes into play. Also, Smallstep’s advertising strategies have been discussed as potentially stigmatizing. Based on sociological theory and current research, I have shown that Smallstep’s use of unclothed images of obese people tied to personal control messages is likely to exacerbate the stigmatization of obesity, influencing stress, anxiety, depression, hypertension, and worse health behavior change results due to the “self-fulfilling prophecy” of labeling theory.
However, the arguments discussed here are relevant beyond a critique of the Smallstep program alone. Rather, they can be applied to a multitude of existing health interventions and used in the creation of new ones. As public health practitioners, we must always think critically about the flaws of existing interventions and seek to avoid interventions based solely on individual-based, rational models and those that use stigma to influence health behavior. I have drawn from several pieces of public health literature that call for the emerging use of social, ecological, historical, and geographical perspectives on health. Only with multidisciplinary and multi-level approaches such as these can we hope to effectively impact health behavior.

PART II: Cleaning Up Our Approach to Public Health Interventions: How a Proposed Alternative Intervention Focuses on the Social and Ecological Framework and Social Network Theory to Effect Nutrition and Exercise Behavior Change—Megan Waterman

In my previous paper, I used social science theories and scientific literature about nutrition and exercise promotion to criticize the U.S. Department of Health and Human Services’ SmallStep Adult and Teen Program, arguing that it takes a flawed approach in three important ways (1). These flaws include: (1) its individual level focus that disregards the social context; (2) the centrality of rational choice in the intervention model, and; (3) the use of stigmatizing Public Service Announcements (PSAs) to advertise for the program. Here, I will continue this discussion, proposing a three-pronged alternative intervention called “Clean Up Our Act” that will address the flaws found in the SmallStep program. First, I will demonstrate how this intervention addresses the social context of physical exercise and nutrition, providing increased access to healthy foods and exercise options via tailored community mobilization approaches. Second, this intervention will rely on the Social Network Theory in using group networks to address problems of irrational decision-making in regard to nutrition and physical activity. Third, I offer a new proposed approach to public service announcements that avoids stigmatization of obese and overweight individuals and shifts the focus of PSAs onto social and ecological causes of obesity. Combined, these three prongs of the proposed intervention not only address the flaws of SmallStep, but they offer a framework for future public health practice in the area of obesity prevention and reduction.

Changing the Built Environment through Community Mobilization
SmallStep is based heavily on the Health Belief Model (2-5). This health behavior change theory focuses on the individual level of behavior change and largely disregards the social context of behavior. It has been criticized in a general sense (6), as a central tenet of research and epidemiology (7), and specifically in relation to attempts to impact nutrition and physical exercise behaviors (8-13). There is a growing body of literature that calls for a social, environmental, and ecological approach to nutrition and exercise interventions (8-13); thus, the proposed intervention here will incorporate some of this literature.
What might a social, environmental, ecological approach look like? The existing literature addresses two components that are necessary for success (8, 10, 12-13). First, changes in the built environment must occur to enhance access to healthy food options and exercise. Second, these changes must be accomplished through tailored community mobilization efforts. Community mobilization is based in the concept of empowerment, where communities take charge of an issue, set the goals, and take action to achieve those goals (22-23). Any intervention that hopes to be effective at the level of local environmental changes must mobilize and engage communities to agree on the priorities of that intervention.
Considering these two components, my proposed intervention will occur at the community level, tailoring its programs to the community’s needs and using existing community organizations and groups to support the following environmental changes. Turrell and colleagues have argued that more supermarkets must be brought into low income areas and transportation to otherwise inaccessible supermarkets should be improved (8). Browson and others have called for local funding for the improvement of areas for outdoor physical activity—what Giles-Corti and Donovan have called “supportive neighborhood environments” (10; 12, p. 610). My proposed intervention, which I have named Clean Up Our Act, will assist communities in mobilizing these environmental changes through several programs. It would involve a transportation program with a “grocery shuttle” that brings individuals in “Food Deserts” (9) to large supermarkets, such as Whole Foods, at peak hours of the evening or weekends. It would also hold weekend “clean-up” days in which community members come together to revitalize vacant lots, littered areas, and overgrown trails to become safer, more attractive locations for physical exercise. Clean Up Our Act would fundraise to provide the necessary resources to aid in revitalization efforts. Clean Up Our Act could also use community mobilization to advocate to supermarket chains to bring quality food retailers into these areas.
It is important to note that the success of Clean Up Our Act relies on the engagement of individual members and organizations to partner together to create physical change and political advocacy. While a perhaps challenging endeavor, the ultimate effects of such a model are potentially great. Clean Up Our Act truly addresses the first flaw of the SmallStep program. SmallStep attempted to impact individuals’ health behaviors via a broad-based website in which individuals were viewed as living in a vacuum. Clean Up Our Act, on the other hand, has recognized the idea that social context—specifically the local social context—matters. It proposes to engage with specific communities and tailors approaches based on those community needs. Further, it addresses the environmental context of health behavior, addressing that access plays a key role in mediating nutrition and exercise behaviors.

Managing Irrational Behavior through Social Networks
In my second critique of the SmallStep program, I argued that SmallStep's reliance on the Health Belief Model resulted in its flawed assumption of rational behavior. Dan Ariely’s book, Predictably Irrational, provided useful theories to demonstrate that human behavior is irrational (15). One of Ariely’s concepts used in the critique of SmallStep was that of anchors and self-herding. Ariely argues that people act irrationally in choosing things because they remember the first encounter with a product or experience—the anchor—and then continue to choose that product or perform that behavior, herding themselves into this repeated (irrational) choice. My previous example of anchoring with food choice is how an unhealthy, cheaply priced food item can act as an anchor, discouraging individuals from purchasing higher priced, healthier foods. Similar self-herding occurs when individuals develop habits of physical inactivity. In his section on anchoring and herding, Ariely does offer insight as to how to break the cycle of anchoring and herding with the example of Starbucks. “If anchoring is based on our initial decisions, how did Starbucks manage to become an initial decision in the first place?” Ariely asks (15, p.38). The answer, Ariely explains, is separation. Starbucks made the entire experience of getting coffee at Starbucks feel different than the experience at existing coffee shops, creating a new anchor rather than failing to compete with the old one. Thus, if Clean Up Our Act hopes to create a new anchor for food choice or exercise behavior, it must make the entire experiences of eating, cooking, shopping, and exercising feel different than what is currently accepted.
To create a new anchor, Clean Up Our Act will utilize the Social Network Theory, which holds that relationships between people in networks are important determinants of health behavior (24-29). As an intervention program situated within communities, Clean Up Our Act will hold education sessions for groups of friends and neighbors to attend together. This education will be qualitatively different than the “Tips” provided on the SmallStep website, because it seeks to educate groups via discussion and interaction, rather than by dictation of information to individuals. After learning and discussing information about healthy food options and exercise, groups will be encouraged to schedule weekly shopping trips, cooking get-togethers, and exercise dates. These activities will serve as a new anchor for food shopping, cooking, and exercise experiences. For example, the experience of walking around a grocery store as a group and choosing food items that have been recently been an important topic of discussion between members of the group is a much different experience than one an individual might have had previously in the supermarket. Importantly, this component of the intervention does not rid the participants of their irrational behavior (that would be nearly impossible!); rather, it embraces the irrationality of anchor creation, using it to influence newly created behaviors of shopping, cooking, and exercising.
Second, the use of networks as facilitators for group-level change is relevant to the management of irrational behaviors of momentary arousal and procrastination. Clean Up Our Act groups would enter into agreements with one another about nutrition and exercise, agreeing that they will avoid unhealthy foods (like McDonalds, in the critique’s example) and will show up to exercise dates. Dan Ariely himself uses exercise as an example in suggesting a management strategy for procrastination: “if we don’t have the will to exercise regularly alone, we can make an appointment to exercise in the company of our friends,” he writes (15, p.117). Because the Clean Up Our Act groups will be composed of already socially connected friends and neighbors, the members of the groups will feel responsible and accountable to one another. Thus, the use of networks as coercive managers for nutrition and exercise behaviors is a good one that addresses the irrational flaws of momentary arousal and procrastination.
Finally, the irrational behaviors of “ownership” of ideas and choice overload can be addressed by Clean Up Our Act group work. Ariely is less optimistic about the elimination of the irrational, unyielding ownership of ideas. He writes, “There is no known cure for the ills of ownership….But being aware of it might help” (15, p.138). Considering this less than hopeful advice to combat ideological ownership, Clean Up Our Act might attempt to mitigate its effects by incorporating a discussion of group members’ strongly held points of view about nutrition and exercise into group meetings. By encouraging discussion about where different individuals in the groups are coming from, Clean Up Our Act can increase awareness and make people think twice about why they think what they think regarding food and exercise. Lastly, Clean Up Our Act should strive to clearly communicate information about nutrition and exercise to group members. One of SmallStep’s flaws was its overloading of resources and information on the website. Ariely has discussed how overabundance of choices can be overwhelming and counterproductive to decision-making. Clean Up Our Act will take this finding into account, providing clear, digestible health information to participants to aid in their decision-making processes.
Pointing Fingers at the True Determinants: Effective, Non-Stigmatizing PSAs

My third critique of the SmallStep program focused on its stigmatizing public service announcements (PSAs) that condemned obese and overweight individuals as personally responsible for their fates. I argued that Becker’s labeling theory suggested that individuals who were labeled deviant—such as obese/overweight individuals in the PSAs—would actually live up to that label and continue their deviant behavior (19). Thus, obese individuals who were stigmatized by SmallStep’s PSAs might actually respond negatively to the ads, continuing their poor health behaviors that made them obese/overweight in the first place.
Like SmallStep, Clean Up Our Act will utilize PSAs to educate people about exercise and nutrition as it relates to obesity and to get people involved in our community environmental projects and group network discussions. However, the approach taken in the PSAs will be markedly different from that taken in SmallStep. In Clean Up Our Act’s PSAs, the focus will be taken off of the individuals as responsible for obesity and overweight and moved onto the community as the locus of change. The themes of the images and the text will be very different in this intervention’s PSAs. While the imagery in SmallStep of obese individuals’ hips and bellies was visually provoking, I argue that images of dilapidated neighborhoods, vacant overgrown lots, and unappealing fruits and vegetables in small corner stores can be equally stimulating. These latter images will be those used in Clean Up Our Act’s PSAs. The text of SmallStep’s PSAs discussed individual level behaviors, which encouraged the reader to assume that obesity and overweight were solely under the control of the obese person himself. Clean Up Our Act PSA’s text will strongly challenge these ideas, including information about how the built environment and access to foods and exercise impacts obesity. I have created one example PSA, entitled “Who You Callin’ Lazy?” to demonstrate this concept (see attached). This PSA’s background image is that of an overgrown vacant lot in a local low income Boston neighborhood (taken by author). The text reads: “Sometimes, it’s not just about will power. When our options for exercise look like this one, no wonder we’re not getting fit. Cleaning up our neighborhoods is the first step to happier, healthier lives. Join the movement at CleanUpOurAct.org [not a real website].” Clearly, the message of this PSA is much different than that of the example SmallStep PSA discussed in the critique paper, “Bikini” (20). Instead of stigmatizing obese individuals for not taking personal control over their lives, my PSA appeals to its readers to think more broadly about obesity and health and to get involved in improving the physical environment that is impacting these outcomes.
Additionally, as community environmental improvements occur, “before & after” images of community sites could be used as PSAs. This would be an ironic, but empowering, imitation of the “before & after” weight loss images that have been condemned as stigmatizing to obese and overweight individuals (21). Further, participants in community improvement projects or network groups could be interviewed on the effects of Clean Up Our Act and used in television and radio PSAs.
Conclusion
This paper has built upon my previous critique of the U.S. Department of Health and Human Services SmallStep program, offering a potential alternative intervention program that addresses the flaws of SmallStep. This alternative intervention, called Clean Up Our Act, involves community mobilization towards environmental community improvements in access to supermarkets, transportation to supermarkets, and the creation of supportive neighborhood environments for exercise. This aspect of the intervention conceives that the local social and environmental context is ultimately important; this conception improves upon SmallStep’s assumption that health behavior exists and can be changed at the individual level in a vacuum. Clean Up Our Act also involves social networks to enter group education sessions and schedule outings to food shopping, cooking, eating, and exercising. Its use of social networks to address some issues with human irrational behavior is an improvement upon SmallStep’s model that seeks to intervene based on rational “choice.” Finally, Clean Up Our Act uses a markedly altered schema in developing public service announcements. It focuses on imagery of poor built environments and addresses the social and environmental causes of poor health outcomes. It avoids the stigmatization of obese and overweight individuals that SmallStep may have caused in its juxtaposition of stark, exposed images of obese hips and abdomens with claims of personal autonomy in weight loss. For these three reasons, Clean Up Our Act may provide a useful and forward-thinking model of health behavior change regarding nutrition, exercise, and obesity. It avoids the common flaws of traditionally modeled public health interventions such as the SmallStep program and challenges public health practitioners to think and work locally with communities while always keeping the social and ecological context of health in mind.
REFERENCES
. U.S. Department of Health & Human Services. Smallstep Adult and Teen. Washington, D.C.: U.S. Department of Health & Human Services. http://www.smallstep.gov.
2. Becker, MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire issue.
3. Janz, NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1-47.
4. Hochbaum GM. Public Participation in Medical Screening Programs: A Sociophysical Study. Public Health Service publication No. 572. Washington, DC: Government Printing Office; 1958.
5. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974;2:328-335.
6. Marks, D.F. Health psychology in context. Journal of Health Psychology 1996; 1:7-21.
7. Pearce, N. Traditional epidemiology, modern epidemiology, and public health. American Journal of Public Health 2006; 86:678-683.
8. Turrell, G., Hewitt, B., Patterson, C., Oldenberg, B., and Gould, T. Socioeconomic differences in food purchasing behaviour and suggested implications for diet-related health promotion. J Hum Nutr Dietet 2002; 15:355-364.
9. Whelan, A., Wrigley, N., Warm, D., and Cannings, E. Life in a ‘food desert.’ Urban Studies 2002; 39:2083-2100.
0. Browson, R.C., Baker, E.A., Housemann, R.A., Brennan, L.K., and Bacack, S.J. Environmental and policy determinants of physical activity in the United States. American Journal of Public Health 2001; 91: 1995-2003.
1 . Estabrooks, P.A., Lee, R.E., and Gyurcsik, N.C. Resources for physical activity participation: does availability and accessibility differ by neighborhood socioeconomic status? Ann Behav Med 2003; 25(2):100-104.
2. Giles-Corti, B. and Donovan, R.J. Socioeconomic status differences in recreational physical activity levels and real and perceived access to a supportive physical environment. Preventative Medicine 2002; 35:601-611.
3. Lee, C. and Moudon, A.V. Physical activity and environment research in the health field: implications for urban and transportation planning practice and research. Journal of Planning Literature 2004; 19:147-181.
4. Schwartz, S. and Carpenter, K.M. The right answer for the wrong question: consequences of type III error for public health research. American Journal of Public Health 1999; 89:1175-1180.
5. Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York: HarperCollins Publishers, 2008.
6. Osberg, T.M., Poland, D., Aguayo, G., and MacDougall, S. The irrational food beliefs scale: development and validation. Eating Behaviors 2008; 9(1):25-40.
7. U.S. Department of Health & Human Services. Ad Council: Obesity Prevention. Washington, D.C.: U.S. Department of Health & Human Services. http://www.adcouncil.org/default.aspx?id=54.
8. Link, B.G. and Phelan, J.C. Stigma and its public health implications. Lancet 2006; 367:528-529.
9. Becker, H.S. Outsiders: Studies in the Sociology of Deviance. New York: The Free Press, 1963.
20. U.S. Department of Health & Human Services, and Ad Council. “Bikini.” Washington, D.C.: U.S. Department of Health & Human Services and Ad Council. http://www.adcouncil.org/files/obesity_bikini_mag.jpg.
2 . Cohen, L., Perales, D.P. and Steadman, C. The O word: why focus on obesity is harmful to community health. Californian Journal of Health Promotion 2005; 3(3):154-161.
22. Alinsky, S.D. Rules for Radicals. New York: Random House; 1972.
23. Friere, P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
24. Barnes, J.A. Class and communities in a Norwegian island parish. Human Relations. 1954;7:39-58.
25. Wasserman, S., Faust, K. Social Network Analysis. Cambridge: Cambridge University Press; 1994.
26. Scott, J. Social Network Analysis: A Handbook, 2nd ed. London: Sage; 2000.
27. Monge, P.R., Contractor, N.S. Theories of Communication Networks. New York: Oxford University Press; 2003.
28. Rogers, E.M., Kincaid, D.L. Communications Networks: Toward a New Paradigm for Research. New York: Free Press; 1981.
29. Pescosolido, B.A., Levy, J.A., eds. Social Networks and Health, 8th ed. Elsevier, Inc.; 2002.