Tactful Approach to Childhood Overweight and Obesity Prevention: Implementation of School-Based Programs- Samantha Roy

Suggested Approach to Childhood Overweight and Obesity
A number of childhood obesity prevention programs, promoting healthy weight and lifestyle in children, have been enacted. However, recent statistical analysis on childhood overweight and obesity reveals an increasing trend, indicating the lack of a successful intervention and leaving public health practitioners ardent for a solution (11). One example of an ineffective initiative is the “Fat chance” billboard, endorsed by the MetroWest Community Health Care Foundation in Framingham, Massachusetts.
Firstly, the ad negatively labels and stigmatizes overweight and obese children. Society’s mockery and negative view of obesity exacerbate obese-related behaviors; children eternalize the stigma and adopt the label, augmenting the severe condition of childhood overweight and obesity. Secondly, it fails to consider group-level factors, which contextualize the fundamental factors of obesity. An emphasis on individual-level factors assumes that all individuals behave the same, which is highly inaccurate. Finally, it disregards the influence of social networks. The behavior of overweight and obese children may be greatly influenced by the behavior of their social networks, which may predominantly be obese. The billboard is daunting and humiliating; it hinders its target audience of overweight and obese children from modifying behavior to acquire a healthier lifestyle.
A more practical intervention involves the implementation of school-based programs that, when combined, successfully approach childhood overweight and obesity. Currently, more than 95% of children and adolescents are enrolled in school, demonstrating the potential success of a school-based intervention. According to the Continuing Survey of Food Intakes by Individuals (CSFII) 1994-1996, 1998, 31% of boys aged 6-11 years and 34% of girls aged 6-11 years meet the fat-intake guideline of the U.S. Dietary Guidelines (14). Such findings indicate that the majority of children aged 6-11 years have a fat-intake greater than 35% of total calories from fat (28). Establishing healthy behaviors, such as physical activity and eating habits, at a young age increases the likelihood of proper child growth and development, as well as the possibility that healthy behavior and habits continue in adulthood (12). Implementation of nutrition standards and education, physical activity requirements, and Body Mass Index (BMI) screenings in schools would expose children to nutritious foods and healthy behaviors, and it would inform parents of their child’s likelihood of obesity, a more tactful approach to preventing childhood overweight and obesity
Implementation of Nutrition Standards and Education in Schools
Nutrition standards and education in primary and secondary schools would give to every child the opportunity to develop an understanding of proper eating habits and conscious, healthy behavior. Although the overall upbringing of a child is the parents’ responsibility, schools can utilize the time in class and during lunch period to introduce children to healthy behaviors and foods, which may or may not be present or available at home.
School cafeteria foods should be regulated under the Dietary Guidelines of Americans, jointly published by the United States Department of Agriculture (USDA) and Department of Health and Human Services (HHS) (42). The Dietary Guidelines “provide science-based advice to promote health and to reduce risk for major chronic diseases through diet and physical activity,” (42). During early school hours, cafeterias should provide breakfast options that fulfill “one-fourth of the Recommended Dietary Allowance (RDA) for protein, calcium, iron, Vitamin A, Vitamin C, and calories;” actual food items for all meals are chosen by individual schools, but should include multi-grain/whole-grain breads and cereals, fresh fruit and eggs, non-fat or low-fat milk, and additive free juices (39). Lunch menus must also incorporate USDA guidelines and serve foods that provide one-third of the RDA, such as bread and grains, fresh fruits and vegetables, lean meats and poultry, non-fat or low-fat milk, and additive free juices (35). After school snacks, following USDA guidelines, may also be provided to children in after school programs or extracurricular activities. Most importantly, schools should adhere to appropriate serving sizes and keep prices affordable for all children.
In addition to standardized cafeteria foods, on-campus vending machines must also be regulated to sell healthier options. According to a report by the Government Accountability Office, 83% of elementary schools and 97% of middle schools sell foods out of vending machines, which is why vending machine regulations are in dire need (18). Instead of selling ice cream, candy bars, cookies, fruit cups with syrup, chips, and pop, school vending machines should sell frozen fruit juice bars (with no sugar or high fructose corn syrup), granola bars, peanut butter crackers, low-sodium soups, low-fat yogurts, rice cakes, and 100% fruit juices (40). Changing vending options in schools prevents children from purchasing the unhealthy foods that may contribute to overweight and obesity. Outside of school, children may encounter vending machines that do not follow healthy vending guidelines, established by the USDA; thus, it is ultimately the child’s decision to carryout conscious, healthy behaviors and to consume nutritious foods, which is why an emphasis on healthy foods and nutrition education is imperative.
Nutrition education informs children of the relationship between diet, physical activity, and health, which is necessary to realize at an early age (30). A course on nutrition is as important as the core subjects of reading, math, and science; what a child eats affects his/her health, growth, and ability to learn (33). Children should be taught age-appropriate nutrition concepts, varying from identifying healthy foods, understanding the food pyramid, discussing healthy behaviors, and reading nutritional labels, to identifying USDA guidelines and applying knowledge for a healthier lifestyle (43). Interactive lessons, puzzles, and games can make learning nutrition exciting for children. Classrooms should have fun, colorful posters, diagrams, and images conducive to learning the foods to eat and avoid, the types of physical activities that can be performed, and the benefits of a healthy lifestyle. Teachers should be trained in nutrition to ensure that accurate nutrition information is communicated to children and positive, healthy behaviors are encouraged.
Early involvement in nutrition education and exposure to nutritious foods can instill attitudes and behaviors in children that may continue in adulthood. Requiring nutrition standards and education in schools enables every child the opportunity to eat healthy, fresh foods and acquire healthy behaviors. Most importantly, this approach considers the group-level factor of institutional menus, an improvement from the “Fat chance” billboard, which focuses on individual-level factors. Nutrition standards in schools are a contextual variable; the foods served in schools may be a fundamental cause of childhood overweight and obesity. Wholesome foods and nutrition education should not be a privilege; every child should have the same advantage in accessing fresh foods and learning the role of diet and health in school.
Implementation of Physical Activity Requirements in Schools
Children should be required to participate in physical education and activity to establish an awareness and understanding of the association between healthy diet and exercise. The Office of the Surgeon General (OSG) recommends children to engage in 60 minutes of moderate activity most days of the week; currently, less than 25% of children get at least 30 minutes of any type of physical activity each day (39). Physical education standards, established by the National Association for Sport and Physical Education (NASPE), require that a physically educated individual: demonstrates motor skills, understands movement concepts, principles, and skills, participates in regular physical activity, exhibits responsible, respectful behavior, and “values physical activity for health, enjoyment, challenge, self-expression, and/or social interaction,” (29). Designating time in schools for physical education and activity can increase the rate of physical activity children obtain on a daily basis.
Recently, schools have reduced or eliminated physical education in response to budget concerns and pressures to improve academic test scores (1). Results from the 2006 School Health Policies and Programs Study indicate the need for elementary school improvements: 3.8% of schools offered daily physical education, which entails 150 minutes a week for 36 weeks (as recommended by NAESP), 74% of schools provided regularly scheduled recess, and about 50% of schools offered intramural or physical activity clubs (24). Physical activity requirements, including gym class, recess, and intramural sports, not only positively affect musculoskeletal and cardiovascular health and cholesterol and triglyceride levels, but also reduce anxiety and stress levels, increase self-esteem, and even lay the foundation for regular activity in adulthood (22). Interestingly, children that participate in physical activity show improvements in the classroom (1). A national study conducted in 2006 examined the relationship between physical activity and academic performance: those children who reported participation in physical activity were 20% more likely than their peers to earn an “A” in math or English (1). If children reveal better academic performance in schools with physical education and activity requirements, school systems must consider incorporating physical activity requirements into the school day.
It is crucial to create an environment that prevents negative labeling and the degradation of children. Teachers and school monitors must advocate against peer bullying to ensure that no mocking or humiliation of overweight and obese children occurs. Children should not feel threatened or insecure when participating in physical education or activity. Results, based on Canadian records from the 2001/2002 World Health Organization (WHO) Health Behavior in School-Aged Children Survey, reveal a strong and significant association between relational and overt victimization and overweight and obese children. In addition, some overweight and obese children were more likely to perpetrate bullying than their normal-weight peers (6). Children should not be exposed to negative criticisms at such a young age; bullying behaviors may “hinder the short- and long-term social and psychological development of overweight and obese youth,” (6).
The implementation of physical education and activity in schools is an improvement to the “Fat chance” billboard: children enrolled in schools are given the opportunity to fulfill the recommended physical activity requirements for an improved, healthy life. Regardless of the child’s socio-economic status (SES), school gymnasiums, playgrounds, and athletic fields can offer a safer location to participate in physical activity, which may not be the case for a child in a lower SES (4). Overall, schools must create a positive and supportive learning environment and incorporate academics and physical activity, an approach to reduce the rate of childhood overweight and obesity.


Implementation of BMI Screenings in Schools
Annual school-based BMI screenings would inform parents of their child’s risk for weight-related health problems and notify schools of the health status of its students. BMI is a relatively easy number to calculate from an individual’s height and weight; it is a reliable indicator of body fat and for risk of weight-related health conditions (12). Currently, 10 states have BMI report requirements in effect; some may be state required aggregate reports while others may be individual reports sent to parents (31). A study, which examined recent BMI trends for U.S. children and adolescents from 2003-2006, found that 11.3% of children and adolescents were at or above the 97th percentile, 16.3% were at or above the 95th percentile, and 31.9% were at or above the 85th percentile (9). A child is considered overweight with a BMI between the 85th to less than 95th percentile and obese with a BMI equal to or greater than the 95th percentile (12). With the current rate of childhood overweight and obesity, school-based BMI screening reports address the need for conscious, healthy behavior in children.
BMI reports are not intended to offend children or parents; the goals of BMI reports are to increase awareness of the severity of overweight and obese-related health problems and suggest appropriate, healthy solutions to live a healthier life. It is vital that school-based BMI reports provide parents “a clear and respectful explanation of the BMI results and appropriate follow-up actions” so that parents understand the purpose of BMI reports (22). Parents may not perceive their child as overweight or obese, so providing a clinically standardized children’s BMI scale assures parents of the accuracy of the report. Reports should be mailed to parents to prevent children from feeling stigmatized; most BMI reports are handed to children in class, which creates fear and embarrassment, a current complaint with BMI reports. BMI screenings are similar to additional screenings conducted in schools, such as hearing, vision, and speech tests, so it should not be correlated with an overweight or obese label or stigma (19).
School-based BMI screenings allow schools to gather a general consensus of the health of its student body and apply findings to improve nutrition and physical activity requirements. Every child receives a BMI screening, regardless of weight, so schools do not explicitly differentiate between students. School-based BMI screenings is a better approach to the “Fat chance” billboard: instead of solely informing a child and his/her parents that he/she is overweight or obese, BMI reports provide advice on how to improve health.
Conclusion
A more logical approach to preventing childhood overweight and obesity is the implementation of school-based programs. A successful intervention cannot rely on one single implementation; a multi-based approach is crucial. Nutrition education and standards in schools gives children enrolled in school the opportunity to learn healthy behaviors and to eat nutritious foods. Children from families in a lower SES may not be able to afford fresh foods, so making nutritious foods available in schools increases the likelihood of those children consuming healthy foods. Physical education and activity give children the opportunity to be active, self-expressive, and social, which enhance health and academic performance. Children may not live in a safe neighborhood with recreational parks nearby; providing children a safe location to play can encourage physical activity. Importantly, schools must advocate against peer-bullying so that negative labeling or stigmatization does not occur; peer-bullying victimizes overweight and obese children more than their normal-weight peers. Finally, school-based BMI screenings would inform parents of their child’s current weight-related health; it also would provide straightforward information and advice on BMI results and improving health.
Although parents are responsible for a child’s upbringing and likelihood of acquiring a healthy lifestyle, school systems can play a major role in preventing childhood overweight and obesity. Schools that adhere to this intervention would provide an environment where children can learn healthy attitudes and behaviors from their teachers and peers. It is important to emphasize health and nutrition at a young age so that healthy behaviors become habit in adulthood.
















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Dole Food Company’s Five a Day Campaign: A Critique and a Cure – Jason Itzkowitz

A CRITIQUE OF DOLE FOOD COMPANY’S FIVE A DAY CAMPAIGN
This is a critique in response to Dole’s Five a Day Campaign which is aimed to encourage all Americans to eat a minimum of five servings of fruits and vegetables a day. This intervention began in 1991 and ended in 2003 (2). This campaign was ineffective because throughout these years, America has witnessed an increase of diseases such as heart disease and obesity. These were diseases in which Dole aimed to reduce, through its main message to encourage America to eat five to nine servings of fruits and vegetables a day (2). Dole Food Company is a founding member of this national Five a Day Campaign for better health program. Through nutritional education programs, they simply encourage children and their families to eat five to nine servings of vegetables and fruits a day. Educational materials and programs include five a day supermarket tours, Dole’s five a day website, five a day friends e-mail, and a Fun with Fruits and Vegetables Kids Cookbook (2).
Although this public health intervention is an effort to encourage healthy eating habits and decrease America’s serious obesity epidemic, it is ineffective and is flawed in many ways. First, the intervention is strictly individually based as it advocates that everyone must proactively on their own, take the initiative to eat a total of at least five servings of vegetables and fruits a day. This is far too simplistic and ignores many of the problems with enacting an intervention that is solely individually based. Second, it does not take into consideration the role of social factors that inevitably influences eating behaviors. Issues like socio-economic factors and social norms both impact diet. This study fails to acknowledge these endeavors and their impact on health. Finally, this campaign is ineffective because it is culturally incompetent and fails to consider the role of culture on diet. This campaign is consequently flawed because of these three claims. It will become quite apparent as to why in this paper.
Dole’s public health effort advocates for the individual to make the decision to eat five servings of vegetables and fruit a day. It is positive that this company raised awareness about healthy eating habits by promoting that people consume a sufficient amount of daily fruits and vegetables. However, their approach is flawed as their campaign will consequently result in a great deal of wasted time and money. To tell someone to eat their fruits and vegetables a day is far too simplistic. Diet and eating behaviors are complex conceptions. There are many factors at play that impact healthy eating habits. Everyone has their own unique lives and obstacles that may prevent them from eating a healthy diet. For example, an individual may hold such a stressful job that causes him/her to seek unhealthy candies in order to alleviate his/her anxiety. Although this person may take Dole’s health campaign seriously and evaluate the benefits of eating a minimum of five servings of vegetables and fruits a day, he/she may still not conform to the campaign’s goals because of this stressful job. In this campaign, it is up to the individual to take the initiative to enroll in Dole’s educational programs like the five a day supermarket tours. The reality is that many families and children will not get themselves to do so due to a lack of time and motivation.
Another reason why Dole’s intervention effort is flawed, due to its sole focus on the individual, is because individuals can be predictably irrational. This campaign assumes that individuals will observe their message to eat five servings of fruits and vegetables a day and will consequently make the rational decision to take on these eating behaviors due to its benefits. An individual may intend to comply with this message after perceiving that fruits and vegetables lead to weight loss and reduces the risks of certain diseases like cancer and CHD. However, because people can be irrational, this does not mean that this person will rationally make the decision to take on this novel behavior. For example, even though a person may intend to attend a five a day supermarket tour with the hope that it will encourage them to eat healthier, they may not rationally make the decision to do so. Due to the complexity of human nature, people can be irrational in this fashion. Because this campaign assumes that people are rational and will intend to follow through with their decision to consume this sufficient amount of fruits and vegetables, it is consequently flawed.
My argument declaring the ineffectiveness of this campaign due to its sole focus on the individual, leads me to my next claim which suggests Dole’s failure to consider important social factors that inevitably influence such healthy eating behaviors. Its focus on the individual overlooks the fact that behaviors like diet are made in the context of a complex ecological social environment. Socio-economic status is a higher level factor that has an impact on health behaviors and health outcomes. According to Haan et al in their study, “Poverty and Health” (1987), “Socioeconomic position is one of the most persistent and ubiquitous risk factors known. Members of lower socioeconomic groups experience higher incidence and mortality rates and poorer survival rates for most major chronic diseases” (4). It is therefore safe to say that the higher one’s socioeconomic status, the more these individuals will take on healthy behaviors like healthy diet, and the less they will experience an adverse health outcome like obesity or CHD. If “John,” the CEO of Dole, has access and money for foods like fruits and vegetables (which can sometimes be expensive), it can conveniently wind up in his house refrigerators. On the other hand, there is “Joe” who holds a minimum wage job and struggles to eat three healthy meals a day. This impoverished individual may take Dole’s campaign extremely seriously, and he may desire to eat nine servings of fruits and vegetables a day. However, due to his job that barely pays him enough money for monthly rent, he just cannot afford to eat nine servings of vegetables and fruits a day. Joe may also not be able to afford a computer which is essential for Dole’s campaign since many of its educational materials are through email and on the internet.
Another external factor is geographic location. In lower socioeconomic communities, supermarkets like Trader Joes that promote healthy eating habits and mainly sell healthy foods like fresh fruits and vegetables are simply not present. People like Joe would love to go there, but he lives in a working class neighborhood. The closest Trader Joes to him is about an hour away from him. Joe could take public transportation to this location but it would require him to change train lines and would take up too much time because he has to work every day. Also, he just cannot afford to take the train back and forth because that is money he usually relies on for his lunch. Joe, who is an advocate for the Five a Day Campaign, and desires to follow through with its message, is simply deterred from doing so. Unfortunately, Joe cannot adhere to the campaign because society’s structural forces of money, access, and geography simply restrict him from doing so. What Joe does have are three fast food joints (comprised of foods with high sodium and trans fats) within his distance so it is convenient and inexpensive for him to eat his meals. Why would he therefore put in all of that effort, time, and money to go to Trader Joes? Our friend John on the other hand, has a five minute car ride from Trader Joes which resides a few miles from his mansion on the ocean. John who believes in the Five a Day Campaign can consequently meet the intervention’s daily goals because of his location next to a supermarket that sells healthy foods and advocates for healthy eating habits. He also has the money to afford an endless amount of fruits and vegetables a day. He can also afford all of the campaign’s materials like the cookbook and a computer which allows him to participate in Dole’s website and email offers.
Although many individuals perceive the benefits of Dole’s campaign and would follow through with their intention to eat up to nine servings of vegetables and fruits a day, there is that barrier of socio-economic status which can restrict one from doing so. In my opinion, this is unfortunate because the majority of America’s population is in this position. I believe that this is a main reason as to why America has an obesity and heart disease epidemic.
Socioeconomic status is an important factor that this campaign blatantly overlooks. Instead of mundanely stating that everyone ought to eat a minimum of five servings of vegetables and fruits a day, there needs to be a campaign that promotes healthy eating behaviors that takes into consideration many complex social factors like socioeconomic status. Perhaps there ought to be a campaign which advocates for lowering the prices of fruits and vegetables and one that raises the importance of placing stores like Trader Joes in unprivileged communities. Such an intervention ought to be accomplished so that those of lower socioeconomic status have access and can afford such healthy foods which prevent adverse disease outcomes and lead to happier, healthier lives.
In addition, under this “social factors argument,” the Five a Day Campaign fails to take into consideration social norms. In certain communities or networks, the perceived norm may not be to ingest a sufficient amount of fruits and vegetables day in and day out. Especially in underprivileged communities, this expectation to eat in such a healthy manner may not be taken as seriously as it should be. This could be due to issues mentioned earlier like access, money and geography. Nevertheless, if eating up to nine servings of vegetables and fruits a day is perceived as abnormal in a clique or community, individuals will most likely not violate this hidden rule even if there is a campaign that advocates this message. A group of so called macho roommates, for example, may create the norm that it is “uncool” to eat fruits and vegetables and link its consumption with being effeminate. With the fear of looking womanly or “untough,” not one man may even buy any fruits or vegetables to put in their common refrigerator. Although each of these men may have seen the Five a Day Campaign ad on billboard on their way to the bar and may take it seriously, they simply will not consume a sufficient amount of fruits and vegetables with the fear that they will be ostracized from their group of roommates/friends. Moreover, the Five a Day Campaign fails to be effective due to the Social Expectations Theory (1).
Perhaps if the campaign implemented an element that addresses social norms it could somewhat be effective. Through an advertising campaign for example, their five a day ad could link eating vegetables and fruits with being manly and tough. Through its promise that eating up to nine servings of vegetables and fruits a day will make a man tough and rugged, it could work to normalize healthy eating behaviors in the male population. Nevertheless, this campaign fails to address issues like social norms and socioeconomic status. This last section aims to critique this campaign effort and reveal its last flaw which fails to address the components of culture and stigmatization in contemporary American society.
In the United States, where this campaign had reigned, there are many diverse belief systems and cultures. Some cultures may view the notion of health differently from another and may place a low value on eating up to nine servings of fruits and vegetables and some may not. Different cultures have unique norms about eating habits and what constitutes a healthy diet (3). This Five a Day Campaign is strictly from the point of view of what Americans believe comprises a good diet. American institutions such as the Surgeon General of the United States and the U.S Public Health Service all support and advocate for this campaign (2). Its platform is strictly what they think is the best diet for all Americans. This United States population includes citizens that can place different meanings on health and diet due to their unique culture.
Moreover, this campaign is run by American public health authorities and experts. Thus, its message to eat up to nine servings of vegetables and fruits a day is what Americans perceive as a good and healthy diet. Another person from a different culture may not feel the same way. In fact, some cultures view a large body type as being a positive endeavor as it echoes high self-esteem (3). Therefore, this culture may not place a high emphasis on eating fruits and vegetables because eating them will result in lean body types.
Also, another culture may not understand this message because it is strictly from an American’s perspective. Due to deeply embedded norms about food, diet, and eating, one from a foreign culture living in the United States may not comprehend this message and its intentions because their own culture places different values on what constitutes a healthy diet. For example, in Marsh et al’s study (2007), “Childhood Obesity Gender Actual-Ideal Body Image Discrepancies and Physical Self-Concept in Hong Kong Children: Cultural Differences of Moderation,” reveals that the Chinese culture values eating in moderation and accepts the notion of obesity more than western cultures like the United States (5).
In addition, one from a different culture may view this campaign as oppressive and as a means to coerce minorities into conforming to the American culture’s way of healthy eating. In this light, this campaign could have an opposite effect on such individual. He/she may purposely not conform to their message as a way of rebelling to the mainstream values of a culture who is attempting to tell them what to do. An individual may go out of their way and purposely not eat any vegetables or fruits at all in order to preserve their cultural pride and to prove that this American approach of a healthy diet is not superior to their own. In this light, the Five a Day Campaign is culturally incompetent as its goals and messages are strictly from an American perspective and fails to consider the many unique belief systems which reside in the country where this intervention takes place. It is culturally insensitive because this is a campaign that is addressed solely to the typical American. Eating a sufficient amount of fruits and vegetables a day has been constructed and maintained as an American norm regarding healthy diet. It may not be the same case for many unique cultures in America’s “melting pot.” Although American public health officials may have thought that this one approach may fit the entire American community, it simply does not. Being in America, one would think that such a campaign would be sensitive to other cultures. In order to promote a higher consumption of fruits and vegetables a day which leads to a healthy diet, more research on culture and the many belief systems that dwell in America must be accomplished.
The last issue which falls under my culture argument is the notion of stigmatization. This Five a Day Campaign overlooks this fact totally. There are those in America who are obese and overweight who may be stigmatized and feel inferior. Although there s a large number of obese Americans, obese individuals are not looked highly upon and can be discriminated against in the United States (7). Some gain the stigma that they are lazy due to a lack of exercise or that they lack self-control in their eating habits. This stigma in American culture where this Five a Day Campaign resides could prevent such an obese individual from adhering to its message (7). The reason is because stigmatization usually produces a sense of low self-esteem and hopelessness (7). Even though an obese individual may perceive the benefits of eating up to nine servings of fruits and vegetables a day, he/she may feel that doing so won’t matter. He/she may feel that nothing will solve their problem and that they may as well keep eating unhealthy because putting in the effort to conform to interventions, like the Five a Day Campaign, simply will not help.
The study, “Stigma, Obesity, and The Health of Nation’s Children,” by Puhl and Latner (2007), reveals that stigmatization in American obese children tend to result in negative health outcomes (7). To tackle the problem of obesity in their opinion is to solve the problems of weight stigmatization. The authors review stigma-reduction efforts that have been proven to improve attitudes toward obese children. They suggest that abolishing weight stigma in youths and enhancing their positive attitude consequently increases their chances of overcoming obesity and leads to better physical outcomes (7).
Similarly, the main issue here is not the simple consumption of fruits and vegetables, but rather augmenting these obese individuals self esteem and giving them hope that they can lose weight and become healthy by adhering to such a healthy diet. Dole’s Five a Day Campaign does not mention anything that could possibly increase self-efficacy and confidence within such individuals in order to get them to consume up to nine servings of vegetables and fruits a day. In fact, the campaign is pretty boring in my opinion and lacks any type of motivational factor to get the American population (never mind obese individuals) to conform to this healthy diet. If this Five a Day Campaign had any type of “jolt” or any interesting techniques to motivate individuals who may feel hopeless in their attempts to eat up to nine servings of vegetables and fruits a day, they would increase self-efficacy and confidence for those who desire to adhere to their intervention. This would consequently abolish the negative effects that stigmatization could have on their health campaign.
These three prior arguments reveal that Dole’s Five a Day Campaign is flawed and ineffective. The intervention’s sole focus on the individual, its lack of attention to social factors, and its ignorance to culture are three major reasons as to why this campaign has been unsuccessful in solving serious American health problems like heart disease and obesity. In 1991, when this campaign began, 10-14% of individuals in most states were considered obese, or in other words, they had a BMI of greater than or equal to 30 (6). In 2003, when this campaign ended, 20-24% of individuals in most states met the criterion of being obese. In fact, in 2003, there were four states in which over 25% of the people were obese (6). Moreover, while this intervention took effect, America actually grew fatter. In my opinion, those behind this campaign put no effort into researching how they could make their cause effective. Instead of investigating certain cultural and social factors, for example, all the campaign designers really did was simplistically and mundanely state, “eat a minimum of five servings of vegetables and fruits a day.”
In my opinion, Dole really did not care about making America healthier with their message. Instead, they sought to advertise their product “Dole.” Instead of a health campaign, it was more like an advertising campaign for their own selfish interests to sell their products like pineapples. By linking their company with a health campaign and revealing that they were connected to agencies like the American Board of Public Health, they believed that the American public would view their company as health conscious and as benevolent. Also, their campaign for individuals “to eat up to nine servings of fruits and vegetables a day” was designed so that people simply buy products that Dole sells which are unsurprisingly fruits and vegetables. Although they may be viewed in the public eye as one who advocates for better health and has products which will ameliorate America’s well-being, they’re intention is to solely sell a product.
This company could have put more time, effort, and money into researching important issues like social and cultural factors in order to make their campaign effective. However, they probably felt that they did not need to. They simply did what was good enough to help their own corporate cause and profits. This is so because their goal is not to improve the public’s health but rather to sell a product.
Moreover, I believe that corporations like Dole should not promote such health campaigns. Precious institutions like schools and universities ought to design campaigns as they have the research tools, they will put in the time and effort, and they also have the heart to truly improve America’s public health. Such institutions like Boston University, uncontaminated by American consumer culture, have designed effective interventions that focus not only on the individual, but also on social and cultural factors. These campaigns usually prove to be successful and therefore ought to be implemented in order to solve many of America’s important public health problems like obesity.
A CURE FOR DOLE FOOD COMPANY’S FIVE A DAY CAMPAIGN
As we have examined, Dole’s Five a Day Campaign was extremely flawed because it was based solely at the individual level and it neglects many important social and cultural factors. This paper focuses on addressing these problems in order to make this campaign effective. Here, I will fill in the holes of the Five a Day Campaign by considering the Social Networking Theory, Social Expectations Theory, socio-economic status, cultural competence and awareness, and stigmatization.
As assessed, Dole’s campaign’s sole focus on the individual results in an ineffective and unsuccessful intervention. To merely tell someone to eat a minimum of five servings of fruits and vegetables is too simplistic and mundane. Being strictly at the individual level, Dole’s campaign effort assumes that people will rationally decide to take on these eating behaviors because of its benefits. Although an individual may intend to eat up to nine servings of vegetables and fruits a day, this does not mean that a person will rationally make the decision to do so.
To address this issue, the Five a Day Campaign ought to implement the Social Networking Theory (3). The researchers of this intervention ought to identify people in certain networks like employees in a restaurant. For example, this campaign ought to be targeted to specific groups like workers at a Burger King. Responsibility should be placed on the manager who is someone these employees look up to and obey. These employees can make the effort to abide by the rules of Dole’s Five a Day Campaign in a communal effort. Perhaps the boss will command her workforce to come in with at least five servings of vegetables and fruits to eat throughout the day. Here, the individuals of this network are working towards the same goal which is to eat a sufficient amount of fruits and vegetables a day. Doing this only increases confidence within the group and augments their self-efficacy that they can adhere to this intervention. They will all gain a sense of accomplishment, they will feel healthier, and grow more connected as a group while being apart of a communal effort. Also, in this fashion, this campaign will work to be successful on a greater number of people at the same time.
In addition, Dole’s five a day campaign ignores many important social factors. First, this intervention takes place in a complex ecological social environment. It is therefore essential, that we consider social factors like socio-economic status and social norms. This campaign overlooks the fact that many Americans cannot afford such healthy foods and cannot travel to certain supermarkets comprised of healthy foods like Trader Joes. Individuals in impoverished neighborhoods are located far from such stores and simply do not have access to healthy foods. Traveling a far distance to a Trader Joe’s for many can be time consuming and expensive. Even if one wanted to abide by the Five a Day Campaign, they may not be able to due society’s many structural barriers.
Thus, within this campaign, there ought to be a strong element of advocacy in regards to socioeconomic status. The intervention should advocate lowering the prices of fruits and vegetables in general, and it ought to raise awareness about building stores like a Trader Joes in underprivileged communities. They ought to promote the fact that fruits and vegetables are extremely important due to their health benefits and thus ought to be affordable to everyone. In addition, perhaps Dole as a corporation could open up small stores in all communities where fruits and vegetables are cheap and conveniently accessible. This could not only work to make Americans healthier, but also it would certainly contribute to Dole’s advertising efforts and profits.
Also, in some communities the perceived norm may not be to consume a sufficient amount of fruits and vegetables. In underprivileged communities, for example, where fast food joints like Macdonald’s and Burger King reside, the expectation to eat up to nine servings of fruits and vegetables a day may not be taken as serious as it should be. If eating this amount of fruits and vegetables a day is viewed as abnormal in a community, these individuals will most likely not violate this concealed norm even if there is the Five a Day Campaign that supports this message.
Moreover, in order to make this intervention successful, Dole must consider the notion of social norms and implement the Social Expectation Theory (1). Through an advertisement, for example, Dole could link eating up to nine fruits and vegetables a day with success, love, and happiness. They could have many advertisements promising these endeavors that targets all social classes. For example, they could have an advertisement where a handsome man and a beautiful woman in a working class community are on their lunch break smiling and eating a meal comprised of rich, colorful vegetables. Of course, the couple is in love and appears extremely happy. Such an ad would promise that anyone who eats a minimum of five servings of fruits and vegetables a day will encounter love and happiness. Here, Dole could advertise their fruits and vegetables products in their commercials and also advocate their positive health message. Through these promises embedded within their advertisements, the campaign could work to normalize healthy eating behaviors in any given population. Once again, it would not only work to make America a healthier country, but it would also work to strengthen the profits of Dole Corporation.
The next issue that Dole’s campaign fails to address is culture. This intervention dwells in America where there are many diverse belief systems and cultures. Different cultures have distinct norms about what constitutes a healthy diet. As we have assessed, this campaign is strictly from the perspective of what Americans believe makes up a good diet. Thus, one from another culture in America may not understand Dole’s message, because of deeply ingrained norms regarding diet, food, and eating behaviors.
In order to fix this problem, Dole must employ researchers working on this campaign from different cultures, and hire those who are culturally competent and sensitive to others’ belief systems. Many cultures may view eating vegetables and fruits as important but may perceive the way Dole advocates the consumption of them as wrong and strange. Those designing this intervention must incorporate the main cultures that reside in the United States. In the campaign’s programs and materials, researchers must develop techniques that address these cultures. In order to accomplish this, extensive research should be done on the many cultures that comprise America’s “melting pot.” For example, the designers could implement recipes comprised of a sufficient amount of fruits and vegetables in accordance with specific cultures way of cooking and eating. For example, the Five a Day Campaign could be culturally sensitive to an Indian style of cooking and offer recipes that implements a variety of vegetables mixed with Indian spices like curry.
Also, because this intervention is strictly from an American point of view, some minorities may feel that this campaign is a means of coercing them into conforming to the American’s way of diet. One from a different culture may purposely not adhere to such an intervention because they do not want to be told what to do by the mainstream culture. They may also refuse to follow this effort in order to maintain their cultural pride and to prove that this American approach of eating healthy is not superior to their own. This is simply a matter of oppression. In order to address this potential problem, Dole should hire researchers working on this campaign from all different cultures and backgrounds. In addition, they should make light of the fact that they have employed a diverse group of experts, and emphasize the fact that it has been constructed by individuals from a variety of unique cultures. By revealing that this campaign is from the viewpoint of an array of different belief systems, their efforts to be culturally competent and sensitive would show. Moreover, the campaign should be designed in a way that is non-intimidating to cultures who may not be able to comprehend its messages, and who may feel that the campaign designers are attempting to acculturate them to America’s belief system. In this light, individuals from all backgrounds in America could abide by this campaign which advocates for the beneficial pursuit of a healthy diet.
The last issue that needs to be addressed is stigmatization. The Five a Day Campaign completely overlooks this fact. Especially in America, where the obesity epidemic is prevalent, those who are overweight or obese may feel inferior. Many are stigmatized as being lazy or as lacking self control in their eating habits. Such a stigma produces a sense of hopelessness and low self-esteem (7). This only works to hinder an obese person from adhering to this five a day campaign message which must be heard. As Puhl and Latner (2007), suggest, enhancing a positive attitude and increasing hope within children who are obese is the only way to eliminate stigmatization and thus augment self-efficacy to lose weight (7).
Similarly, this campaign must implement a sense of motivation or a “jolt” to those who may feel hopeless in their attempts to eat up to nine vegetables and fruits a day. For example, they should construct operant conditioning techniques. If an obese person eats up to nine servings of fruits and vegetables everyday for four months and then loses weight, Dole should give them free gift certificates to their food products. (Of course, the individual would have to come into a clinic and weigh themselves and then come in four months afterwards to monitor and evaluate their progress.)
In addition, the campaign ought to have language within it that encourages everyone, especially overweight and obese individuals in order to achieve its goals. It must stress the fact that it is never too late to change one’s diet and to eat healthy. This would only increase hope and confidence within obese individuals and eliminate stigma. Even if the person is not obese, such motivational efforts would work to increase the confidence for those who desire to comply with this intervention.
As Michael Siegel suggests in his work, “The Importance of Formative Research in Public Health Campaigns: An Example From the Area of HIV Prevention Among Gay Men (Appendix 3-A),” the campaign to encourage gay men to wear condoms was ineffective because gay men and their homosexual relationships (especially sexual relationships) are looked down upon in society and are viewed as abnormal (8). This stigma causes hopelessness for them to change their risky behaviors. He suggests that if gay men’s relationships were tolerated and appreciated, such stigmatization would be abolished.
Similarly, if Dole worked to eliminate such stigmas like laziness in obese individuals in American culture, their campaign would be successful and useful. If Dole increased the hope of such individuals in their campaign and encouraged them to have a positive attitude, such stigmatization would be eliminated and the acquirement of healthy eating behaviors would result. This could only work to make America a healthier society and curb its epidemic of obesity.
After criticizing Dole’s Five a Day Campaign was essential, the next task was to go back and mend its holes. Criticizing and commenting on such a campaign is essential but it is extremely necessary to go back and to cure its flaws. These prior solutions to the unsuccessful Five a Day Campaign will work to make this intervention successful and useful in any community. By addressing the problem of being solely at the individual with the Social Networking Theory and by considering social and cultural factors, this campaign would work to make America a healthier place to live.
REFERENCES:
1. DeFleur, M.L (1989). “Chapter 8: Socialization and Theories of Indirect Influence.” Theories of Mass Communication. New York: Longman Inc.
2. “Dole 5 A Day” (2004). Dole Food Company, Inc. .
3. Edberg, M (2007). Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers.
4. Haan, M et al (1987). Poverty and health. American Journal of Epidemiology, Vol. 125(6), pp.989-998.
5. Marsh, H. et al (2007). Childhood obesity, gender, actual-ideal body image discrepancies, and the physical self-concept in Hong Kong children: Cultural differences in the value of moderation. Developmental Psychology, Vol. 43(3), pp.647-662.
6. “Obesity in America.org.” .
7. Puhl, R.M and Latner, J.D (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, Vol. 133(4), pp. 557-580.
8. Siegel M. The importance of formative research in public health campaigns: An example from the area of HIV prevention among gay men (appendix 3-A), pp. 66-69. In: Siegel M, Dover L. Marketing Public Health: Strategies to Promote Social Change.

Hand Hygiene Interventions Need Some Cleaning Up: A Critique of Current Hand Hygiene Program’s in Hospitals Nationwide - Emily Scheer

Hospital acquired infections (also known as nosocomial infections) are a well documented cause of increased morbidity and mortality among hospitalized patients in the United States. Nearly 2 million patients are affected and almost 80,000 individuals die each year as a result of acquiring such infections making this a serious public health issue in the United States (4). Given the severity of this issue, successful public health interventions are necessary to halt the spread of disease.
Hand hygiene has been identified as an essential evidence based infection control measure to prevent the occurrence of hospital acquired infections, “Hand hygiene by hand washing or hand disinfection remains the single most important measure to prevent nosocomial infections” (9). Nonetheless, hand hygiene policies are not always followed by health care workers and poor compliance is repeatedly documented throughout entire hospitals and hospital systems nationwide. Some interventions have proven successful. However, success has been short lived. Hand hygiene programs in the United States have had difficulty achieving lasting improvement (4). If hand hygiene interventions fail to incorporate a multidimensional approach to behavior change, social norms and self efficacy, and continue to be unsuccessful in effectively educating health care workers, successful hand hygiene programs cannot be sustained.
Lack of an Interconnected Approach to Behavior Change

What many widespread hand hygiene interventions are missing is a multi faceted and creative design to change health behavior (4). Interventions aimed at improving compliance with hand hygiene must be based on the various levels of behavior interaction including the interdependence of individual factors, environmental constraints such as access to hand washing supplies at point of care, knowledge and values that are inherent to the many medical specialties, and institutional culture. Noncompliance with hand hygiene interventions may not only relate to the individual health care worker but to the group or specialty he/ she belongs to.
The complex dynamic of behavioral change involves a combination of education, motivation, and system change that acknowledges social norms and self efficacy. Hand hygiene interventions have traditionally followed the framework of the popular and frequently utilized model of health behavior, the Health Belief Model (3). This model focuses on behavior change at the individual level. It is limited in that it does not look at change in a group context nor does it account for social and environmental factors. Time after time, hand hygiene guidelines focus on the individual and fail to incorporate aspects of the complicated environment that the typical health care worker is in. Many risk factors for non-compliance with hand washing among health care workers are continuously faced including increased workload, stress, lack of time, psychology, the culture of the environment or unit of the hospital, individual values as well as values inherent to certain medical specialties, availability and access to hand washing materials, type and intensity of patient care required, nurse to patients ratios, and education as to what the correct hand-hygiene techniques are (9). Compliance with recommended instructions is commonly poor because hand hygiene models have failed to consider and account for these complex risk factors. Hand hygiene interventions have primarily focused on the individual which is not enough to result in sustainable change (7).
Failure to Establish a Culture of Safety that Incorporates Social Norms and Self Efficacy
Traditional hand hygiene interventions have failed to consider social norms in development of policies. In health care, as in many other environments, behavior will be influenced according to whether or not a person will meet approval or disapproval by his/her social groups, or in this case among the various medical specialties (nursing, physicians, respiratory, etc) (3). For example, if the intervention is driven by the nursing department, a physician may be less likely to comply because his/her group did not “buy in” to the program. The physician-in-chief did not support the program or feel that it was necessary and this attitude and belief trickled down to the rest of the physicians. Hand hygiene interventions must incorporate social norms and above all aim to make compliance the social norm among all medical specialties.
An additional limitation of current hand hygiene programs is the lack of incorporation of self efficacy. Staff must believe that they have the ability and power to make major improvements and that hand washing will lead to these big improvements. Health care workers must be empowered to remind other caregivers, regardless of rank, position, or specialty to practice hand hygiene and comply with all guidelines (4).

Failure to Educate and Communicate
A key element in implementing a successful hand hygiene program is educating and motivating the staff. Unfortunately, hand hygiene interventions based on the Health Belief Model assume that all health care workers have enough education and knowledge to make a rational decision surrounding hand washing. In reality, there is an overall lack of knowledge among health care workers regarding how hands are easily contaminated, how infection is spread, the efficacy of hand hygiene in reducing this spread, and lack of awareness of the recommended and most effective hand-washing techniques (8). The Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee published Guideline for Hand Hygiene in Health-Care Settings in 2002. Within these guidelines, it strongly recommended that alcohol-based hand rubs are the preferred method of hand hygiene because they are easy and quick to use and are extremely effective in killing bacteria and viruses that cause nosocomial infections. Introduction of alcohol-based hand rubs and education materials must be introduced as a part of hand hygiene programs and spread at a group level. Hospital employees need to be able to express knowledge and understanding that alcohol based hand rubs are extremely effective, are accessible, and are very quick and easy to use. Current hand hygiene programs have failed to ensure that staff entirely comprehend the rationale behind implementing hand hygiene programs. They are not designed in a way that results in high levels of staff “buy in” and high staff comprehension of the danger of not complying with the policies, not only to their patients but to themselves (2).
When asked, health care workers report the following reasons that they believe make it difficult to comply with hand hygiene programs: skin irritation caused by constant washing or use of the disinfectant rubs, “being too busy”, and “not thinking about it” (9). Health care workers must be educated that alcohol-based hand rubs have advantages to traditional hand washing because they require less time, are extremely fast acting and effective in preventing transmission of infection, and are less irritating to the skin. Studies have found that alcohol based hand rubs do contribute to the sustainability of high program compliance rates and are associated with decreased infection rates (7).
The Future of Hand Hygiene
Traditional hand hygiene programs may be successful short –term in some hospitals as an effective way to reduce hospital acquired infection rates but this intervention is not likely to be both effective and sustained for long periods of time. A more appropriate hand hygiene intervention would focus on health care worker’s behavior at the group level. Hand hygiene programs must be further developed to move beyond a model that focuses on individual behavior and include more psychosocial elements that will influence intention, attitude toward the behavior, perceived social norms, perceived risk of infection for self and patient, habits of hand hygiene practices, knowledge, and motivation at both the individual and group level. (7) Interventions must grow to incorporate a multidimensional approach to behavior change, social norms and self efficacy, and figure out how to effectively educate health care worker. Until then, morbidity and mortality due to hospital acquired infections will remain high in hospitals across the United States. Hand hygiene interventions must be changed so that quality of life can be improved for millions of patients in this nation’s health care system.
Hand Hygiene Programs in the United States: All Cleaned Up!
An unfortunate reality for the current health care system in the United States is that the prevalence of drug-resistant organisms in nosocomial infections is high and continues to be on the rise. The impact that this has on patient outcomes is incredibly severe. In light of all of this, it is well documented that prevention is possible. The key intervention suggested and supported by endless evidence is surprising in that it seems so simple. It is something that many of us were taught to do regularly since we were fairly young – wash our hands (7)! Although evidence based, proven important, and simple sounding, “hand hygiene by hand washing or hand disinfection remains the single most important measure to prevent nosocomial infections,” (9) hand hygiene interventions have been complicated and difficult to implement and sustain. Experts estimate that health care workers comply with recommended hand hygiene procedures less than 50 percent of the time — contributing to some terrible consequences (7).
Due to increased morbidity, mortality, and health costs that can result from health care workers failing to comply with hand hygiene protocols, this has become a major public health problem in the United States. Clearly, it is an issue that is worth working on and devoting substantial resources to. An alternative program must be implemented nationwide that moves away from policies based on the traditional health behavior models. A new program should incorporate an interconnected approach (specifically dealing with the health care environment and access issues), social norms, messages of empowerment and self efficacy, and improved education and communication of vital information.
Incorporating an Interconnected Approach to Behavior Change
An improved hand hygiene model should concentrate on taking an interconnected approach to improving compliance with hand hygiene programs. Unfortunately, many current hand hygiene programs currently take an “x causes y” approach to forming new policies and dealing with the issue. This type of approach does not deal with the “messiness of life.” Major risk factors for poor compliance with standard policies include lack of time or opportunity and poor access to hand washing facilities (7). These risk factors move beyond individual behavior and indicate that there are many external factors that can make behavior and life “messy” at times. This indicates that to implement a sustainable program these factors in the environment of the health care worker must be acknowledged.
In an ICU setting there is high workload and high demand of care. To improve access, opportunity, and deal with time constraints, the main hand hygiene agent promoted should be an alcohol based hand rub because it is quick to use, easy to access, and highly effective. Here, a focus study should be done with staff that examines various locations of the gel dispensers to ensure best possible access. The dispensers should be trialed at different locations at the bedside to determine where they are most easily accessed and most often remembered and used. Another proposal to improve access is to look at where health practitioners already keep items and information they want to have immediate access to. For example, many physicians keep tools the need to use in their white coat pockets such as patient notes, calculators, blackberries, etc. Leading alcohol based hand rub manufacturers have developed smaller and slightly flatter bottles. These could easily be stored in physician’s pockets without getting in the way. This would make hand hygiene available right at his/her hip in a location that is easy to remember and already part of their culture and behavior.
Establishing a Culture of Safety that Incorporates Social Norms and Self Efficacy
One major critique of current hand hygiene interventions is that they have traditionally followed the framework of the popular Health Belief Model (3). As mentioned previously, this model focuses on behavior change at the individual level instead of in a group context. It does not account for social and environmental factors. A hand hygiene program that changes focus to an alternative health behavior model that values and emphasizes social norms, such as Social Norms Theory, would prove to be a more successful and sustainable intervention. Social norms theory states that the behavior of an individual is greatly influenced by the way they perceive behavior of his/her social group (1). In the health care environment, if the worker views his/her medical specialty as being non-compliant with hand hygiene interventions, the urge that individual may feel to conform to that idea will negatively impact the compliance behavior of that entire group or specialty. However, if the various health care groups are educated effectively and hand hygiene is framed in ways that portray it as the norm and supported practice of the group, there may be more overall “buy in” to the program which would result in an overall higher compliance rate for the specialty group as well as the entire unit. Parallel to that, nosocomial infection rates and associated health costs would hopefully decrease.
Developing a culture of empowerment would help to foster compliance and change the social norm. There is an inherent hierarchy in the medical setting among the various specialties. Work should be done to eliminate this hierarchal structure and ensure that, for examples doctors and nurses feel that they are on the same level and have the same worth in influencing care of their patient. The feeling of empowerment developed by each group would trickle down to the individual and help him/her to be an advocate for a patient’s safety by kindly reminding his/her colleague to comply with hand hygiene policies. Hand hygiene is something that has to be practiced at every opportunity in order to get positive results. Therefore, self efficacy is an important component to any hand hygiene program. If health care workers believe that they have the ability and power to make major improvements by completing the simple task of washing hands per policy, compliance rates may rise. The action must be promoted as one small piece of a giant puzzle that makes up this major improvement.
Implementing Widespread Education and Communication
Many current hand hygiene programs have incorporated some type of education about hand hygiene through poster display or leaving pamphlets in staff mailboxes. However, merely making the poster is not an improvement and it is not adequate education and information. Instead, all efforts must be focused on placement and use of the poster. Posters should be informative, captivating, and placed in locations where they will not be missed (on the door to the unit, at the front desk, in the bathrooms, etc). Focus group should be formed by quality improvement staff and surveyed to assess whether or not people report noticing it, whether staff can answer questions about the material on the poster, and to ask people directly whether they believe it worked or not. The poster can be tested in various locations of visibility on the unit. Once the most ideal location is decided upon based on focus group feedback, information should be changed in and out on a regular basis to update, inform, and reeducate staff. To enhance communication, improvement leaders should make sure that data and audit results are disseminated to staff and posted where it can be seen. In many widespread surveys, health care workers report that they don’t see the numbers or results they just get the order to “do better” and this does not make them happy. Health care workers need to be made aware that hands need washing in certain situations. They should be educated on the specific definitions of hand hygiene “opportunities”, what supplies are available to them, and the location of such supplies. A hand hygiene program should identify and educate a few “champions” from each medical specialty who will go through training and evidence based education sessions. Each champion would be responsible for educating his/her appropriate group and advocating for change (5).
Education and communication also goes beyond the health care practitioners. A successful hand hygiene program should have a patient and visitor component, as well. A patient/visitor educational brochure and program should be developed that includes an orientation to the unit’s policies on hand hygiene and the negative outcomes that can occur as a result of failed compliance by health care workers. This will ensure that patients and families are aware and empower and encourage them to remind health care workers to wash their hands when caring for the patient (5).
Future
It is clear that a hand hygiene intervention that focuses on health care worker’s behavior at the group level will be successful and sustainable. Hand hygiene programs must move beyond a model that focuses on individual behavior and acknowledge that noncompliance with hand hygiene interventions may not only relate to the individual health care worker but to the environment and group or specialty he/ she belongs to. Therefore, a proposal to improve hand hygiene must incorporate the main attributes of social norms theory in order to make effective and sustainable change within hospital systems in the United States. It must also focus on access and environmental issues and utilize innovative education techniques. Overall, hand hygiene program designers and implementation managers must truly try to understand what really motivates people, specifically the medical staff in question, and work to gain better understanding of human behavior.
References:
1. Best Practices; Social Norms. http://wch.uhs.wisc.edu/13Eval/Tools/Resources/Social%20Norms.pdf
2. Boyce JM, Pittet D, et al. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity Mortality Weekly Report, 2002.

3. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

4. How-to Guide: Improving Hand Hygiene. Institute for Healthcare Improvement. 2006. http://www.ihi.org/NR/rdonlyres/E12206F9-6A81-4520-B92F-4BCB844133C2/3266/HandHygieneHowtoGuide1.pdf

5. Institute of Health Care Improvement. Improving Hand Hygiene Practice with Six Sigma. St. Paul, MN: HealthEast Care System. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/ImprovingHandHygienePracticewithSixSigma.htm
6. Institute of Health Care Improvement. The Sound of Two Hands Washing: Improving Hand Hygiene. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/FSSoundofTwoHandsWashing.htm
7. Pittet, D. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases 2001.

8. Pittet D, Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. Lancet Infect Dis 2001.

9. Pittet D, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet 2000.
10. WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. World Health Organization, 2005. http://www.who.int/patientsafety/events/05/HH_en.pdf

Critique of the BMI Report Card – Jenna Tonet

Obesity has been a continued concern in the United States, especially as it has risen dramatically in a relatively short period of time. One age group that is of great concern is children. Public health practitioners and health care professionals have worked to decrease obesity rates among adolescent using school-based interventions. One example of a public health intervention at the school level is the Body Mass Index (BMI) report card. Teachers issue students this card if the child is found to be at risk for becoming obese. This intervention is not effective for reasons that include labeling the child as overweight, framing the issue in a negative way, and preventing the child from believing they can change their behavior.
The intention of the BMI report card is to prevent obesity early enough in an individual’s life to make a difference. However, the approach is highly problematic because of its affect on an individual. Adolescence is a time in when children are very impressionable. Even though the intervention’s focus is to target the problem before it starts, the report card has more repercussions than good outcomes. The aim to prevent obesity becomes overshadowed by the harm caused to the child for a number of reasons. O’Dea (9) and Garner (4) both discuss the areas of concern regarding obesity prevention programs that are school-based, such as “stigmatization of pupils whose body weight are outside the “normal” range,” and “labeling of pupils as “overweight,” “obese,” “lazy” (1).
Stigmata Theory
The first and foremost reason is that the report card places a label on the child. This derives from the social science theory called the stigmata theory. When an individual is labeled a certain way, they develop a self-fulfilling prophecy (3). When the teacher gives the child this report card, they will often believe that they are and always will be overweight. Since the adolescent has this label, they will assume that this label is true. Therefore, they will not take understand how to interpret the original goal of the report card. The purpose of the card will not matter because the child and the parents will only focus on the label. According to the self-fulfilling prophecy, rather than trying to change the behavior, the child will assume the identity.
Since only the children who are found to be at risk for obesity receives this report card, they are singled out from the rest of the students. The stigma from this card affects how the individual views themselves and how they feel the other children look at them. If the report card has a negative connotation, the child will feel stigmatized. Also, they will feel isolated from the other children. When an individual is still developing their identity, they are vulnerable to impression, including what others think about them.
In a study of boys’ and girls’ perceptions of “fatness, thinness, social pressures and health” using focus groups, one of the conclusions was that the children believed that while being fat should not matter, they really did believe it does matter because those children were teased, bullied and had few friends (2). One such comment in the boys’ focus group was that “…people would be laughing at him, saying, “Ha ha, you’re fat, we’re strong” (2). With this label, the child’s stigmatization shows if other children tease them about the report card. The other children look at them differently because of the label given to the particular child with the report card.
Since not all children receive the report card, it is considered out of the social norm and not acceptable. The child can become victimized; and they suffer from being treated and viewed differently. In the focus group study, one of the boys accused the others of hypocrisy because they believed that the boys would single out the overweight child – “They say that now but in real life they’ll make fun of you if you’re different” (2). He had been an example of why that was true because he had been made fun of by boys in the group for that reason (2). Since adolescents do not know how to handle and understand differences, the child who is singled out is subject to their ridicule.
Social Cognitive Theory
Furthermore, the social cognitive theory illustrates more of the social factors addressed above. While this theory used to be known as the social learning theory, it moved from behaviorist roots to a theory that addresses individuals consciously operating within an environment (3). According to social cognitive theory, changing behavior is a function of individual characteristics, external factors, and an interactive process (3). However, the BMI report card directly contradicts this approach to changing a behavior. The self-fulfilling prophecy that results from the card’s issue prevents the first function of social cognitive theory.
This function, the individual’s characteristics, begins with the concept of self-efficacy, which is when a person has a sense about the new behavior, their confidence that they can do it and overcome obstacles (3). However, these components become questioned if the child does not believe that they can do it. The presentation of the report card can be viewed in a negative light. This does not allow the child to view a change in behavior as positive. Therefore, they will not want to change their behavior due to lack of confidence.
The child’s behavioral capability depends on their belief that they can make the behavioral change (3). Nonetheless, the report card is simply a piece of paper that warns the child and their parents that the child is at risk for becoming obese. In elementary school, an individual is still developing psychologically, so they will not completely understand the purpose of the card. Since they are singled out, the child only sees that and not the signal to make behavioral change. They also pick up cues from their classmates who bully them about their weight. In the focus group study, the boys felt pressure to tease others, and one comment in the focus group was “They’ll be miserable for the rest of their lives because they’ll get picked on” (2).
While it should be the parent’s role to deal with the card, they might see it as a problem and not accept it. For example, a teacher may notice a learning disability. In a number of cases, the parents do not want to believe that their child is “different.” The report card acts the same way because the parents may take it as a sign that their child is different from the other children. They do not want to see them as different or others to view them as different.
This leads to another component of the social cognitive theory, which is emotional coping (3). How the child and the parents handle the report card plays a significant part in the process. The child feels bad for getting the card and the parents do not like the label placed on their child. If no one can handle the situation in a beneficial way, then the intervention is ineffective. This result prevents the ability to handle change on a mental and emotional level (3).
The last two concepts within the first function of changing behavior, self-control and expectations, do not directly apply to this public health intervention. The report card deals more with the initiation of changing behavior and not the actual behavioral change. Self-control relates to the ability to carry out and change without returning to the original behavior. The fact that there the report card does not address these two factors contributes to the intervention’s ineffectiveness. The card just tells that there is a problem and does not provide information about what to do in the long term. In order to be effective, an intervention needs to follow through the progress of the behavioral change.
The next function of the social cognitive theory incorporates environmental factors. As stated before, the BMI report card does not address the environment. The external factors are the social and physical environment that surrounds individuals (3). Clearly, this intervention does not address the child’s peers – no one wants to be singled out of a group for something viewed as “bad.” It negatively influences the child’s social environment because they become susceptible to being teased by the other children in their class (2). Their self-esteem is lowered and they feel forced to make a change, which is not a healthy approach. For example, one girl in a focus group said: “When I was really chubby they all used to call me ‘fatty,’ so I had to stop tennis and so I went on a diet and nobody has called me ‘fatty’ since” (2).
The last function of the social cognitive theory is the “interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, acts again, and so on” (3). Again, due to its faults, the BMI report card does not even effectively achieve this function because the cues and individual factors do not produce positive results. If the child adjusts that behavior based on the social environment, it would not fit the intervention’s goals. Rather than change in order to lose weight, the child might hide from the children and focus on the embarrassment of the card. The problem shifts from obesity to avoidance. The intervention introduces another issue into the equation rather than dealing with the original issue.


Framing Theory
The last overarching reason for why the BMI report card is an ineffective public health intervention stems from the framing theory. The way an issue is framed significantly determines how people will react to it. The real battle is to change people’s behaviors by framing the issue accordingly. People do not respond to the facts but how the issue is framed (7). When facts do not fit a person’s frame, then the fact is not internalized (7). However, if the fact does fit the frame, then it is internalized (Lakoff).
The BMI report card is an example of how a public health issue is framed. The frame acts as a way to prevent the problem of obesity before it happens. However, this frame shows that the child has a problem and portrays it in a negative way. It is beyond the child’s comprehension and not within their frame of thinking. Also, the parents will not fit into the frame correctly either because they will see that their child has a weight “problem” that requires behavioral change, which is a result of how the issue is framed. Frames lead to either more or less effective ways of addressing an issue, and in this case, the frame is less effective.
The development of the interpretative framework is to understand why people come to be exposed to certain risk or protective factors (8). This is an example of contextualizing risk factors, which the BMI report card fails to do. This intervention develops the card based on limited screening. Like many public health interventions, the report card assumes an individualistic approach to behavioral change rather than accounting for the whole picture. It fails to incorporate factors that include socio-economic status, access to healthy foods and safe parks, and cultural values.
Another component of the framing theory is Lakoff’s Levels of Analysis, which utilizes frames to achieve social change (7). The BMI report card applies to the third level; the card falls into the program category in this level and addresses the issue of health care. However, even though it incorporates this level, it is not a successful frame. While obesity is a health care concern, this particular intervention has an overly broad approach. The generalization indicates that the frame needs to be more specific. The card should be framed at level one, which involves values and principles, such as personal health value (12). While this is at a more individual level, the card should also include social factors. That is where contextualizing social factors play a role. The card should not tell the child and the parents that the child is at risk for becoming obese. Rather, it should frame the issue as valuing health overall – physical, emotional, and mental. The card should be directed toward the individual child’s situation, which depends on their risk or protective factors such as cultural/ethnic background.
The facts do not change at this point because the wording only shifts when framed toward a specific situation. The parents will be less hostile toward the card if the facts are presented differently. If the facts are presented in a way that the parents can understand, then they internalize the frame – it is a fact of how humans think (12). Parents are often sensitive when it comes to their children because they do not like to be told that they are not properly raising their children. The report card does not explicitly say this, but that is how parents internalize feedback that they view negatively. That is why the intervention should be more positive.
Although children may be too young to make health based decisions by themselves, it should not just come from the teacher issuing a piece of paper. There should be more health based education tailored to the child’s level of comprehension. While some might argue that the school system can only do so much and that is more of a responsibility of the parents, schools should still do something because they cannot control the parents. However, the intervention should consider the issues of labeling, framing, and environmental influence as more significant than the report card demonstrates in order to be more effective.
Counter-Proposal Intervention to the BMI Report Card – Jenna Tonet
The problem of childhood obesity has been on the rise in the United States for some time now. While public health practitioners and health care professionals have worked to decrease obesity rates among adolescents using school-based interventions, the example of the BMI report card poses more harm than good. It is ineffective for reasons that include stigmatizing the child, framing the issue negatively, and lowering the child’s self-esteem. The school is a good place to have a community level intervention, but the intervention might not be successful. More effective interventions at the school level require community involvement, including parents, teachers, and health educators. Also, the approach should be a positive view of the child’s overall well-being and health. There should be no card, which acts as a label and singles the child out from their peers.
The intervention should be portrayed positively so that the teacher, child, and their parents view the situation in a more positive light. One type of intervention could take an existing component of the school system – parent-teacher conferences – and integrate feedback on the child’s overall well-being as observed in the classroom. The purpose of parent-teacher conferences is for the teacher to let the parents know how the child is doing in the classroom; this should be an overall and comprehensive evaluation. However, the teacher alone cannot evaluate all the health factors of the child. This is where health educators would come in to help assess the child’s health. The conference would address flaws of the BMI report card, including labeling, framing, and environmental influence, as will be shown in this paper.
To get rid of the BMI report card entirely would be better for the child, parents, and the teacher. Due to its limited individualistic development, the BMI report card fails to show that many factors contribute to an individual’s health and well-being. Also, without the BMI report card, the child does not receive a “label” with the actual card, they are not singled out from their peers, and the parents would not look at the situation as negatively. All of these factors imply that there is a need for a new paradigm. In other words, the issue requires a new frame.
Framing Theory—Positive Paradigm
Reframing the issue would provide a better way for everyone to comprehend the issue and internalize the facts. For example, O’Dea (10) mentions the need for a new paradigm: one example cited was the ‘health at any size’ movement, which has been successful in part due to the focus on health improvement instead of weight status. O’Dea (10) argues that this broad focus, which incorporates and highlights several components of health, can result in positive outcomes in child obesity prevention. These factors include the physical, psychological, social, and spiritual (10). This frame is better to suit everyone involved so that no one thinks negatively of the situation.
The parents could better comprehend the issue at hand because their ultimate concern is their child’s well-being. The point of the conference is to communicate with the teacher and to receive feedback from the teacher about their child. However, they will not internalize facts that are considered negative because the parents want what is best for their child since they believe that their child is perfect. If the teacher’s feedback tells them otherwise, or that they are not as ‘good’ as the other children in the classroom, then the parents will not think favorably of the situation. Rather than framing it as a “problem,” the teacher could address it as overall health well-being. The use of positive language makes a significant difference.
The way to develop a frame is to understand why people become exposed to certain risk or protective factors (8). This is an example of contextualizing risk factors. An intervention should incorporate factors that go beyond the individual level. Many current public health interventions assume an individualistic approach to behavioral change rather than accounting for the whole picture. Instead, the focus should be to encourage children to engage in a healthy lifestyle (11). While it is difficult to find or develop an intervention that draws upon several factors, the parent-teacher conference brings in the family and community levels.
Additionally, this approach addresses the best level from Lakoff’s Level of Analyses, which is level one (7). This level involves values and principles, such as personal health care (7). Even though this seems to be more individualistically based, the parent-teacher conference incorporates social factors by the involvement of the family and school community. Both the parents and the teacher are significant to a child’s well-being and overall development due to their roles and relationship with the child. The social network theory exemplifies this because the theory highlights the importance of relationships between and among individuals, and the nature of these relationships influence beliefs and behavior (3). If they can work together, they can help the child together through a network; they can help the child to act in ways that is good for their health (3).

Stigmata Theory—Labeling the Child
Reframing the issue also helps to deal with the issue of stigmatization. One example that the child already faces in regard to social stigmatization is: “Prejudiced attitudes from other children and resulting peer rejection is one of the most common sources of stigmatization of obese children” (11). This shows that the child already deals with negative peer influence. The parent-teacher conference replaces the BMI report card and takes away some stigma by taking away the physical label. While it is still an issue, the child is not subject to teasing from being singled out in another way.
The teacher is also influential in how the children interact. If begun as early as preschool, the teacher could teach and encourage the children how to accept each other. However, this would need to continue throughout the child’s development because their psychological development continues throughout elementary and middle school. Peer influence continues through adolescence because social networks develop and continually change through a person’s life. These relationships have a nature that can influence beliefs and behaviors (3). The relationships between the child and the teacher and between the child and their parents are opportunity to encourage health promotion. Their relationships are vital to help the child since they are a significant part of the child’s life.
As long as they maintain an active role in the child’s life, their influence is greater. One example of influence is that parental behavior could influence their child by encouraging better nutritional habits and self-regulation. “One study demonstrates that young children are more willing to taste novel foods if their mother models tasting the food first compared to a condition in which children are offered food with no adult model” (5, 11). This also demonstrates that environmental and individual factors contribute to the child’s overall health, which is part of the social cognitive theory.
Social Cognitive Theory—Environmental Influence
A significant part of the social cognitive theory brings the individual characteristics and environmental factors together, whether it comes from the parents, teachers, or peers (3). The parent-teacher conference addresses the environmental role by introducing the teacher and parental influence into the situation. With parental support, the child has a better chance of changing the behavior. A good support system builds upon the child’s self-esteem and self-efficacy. If they believe that they can make the change, the child has a greater opportunity to actually go through with the change.
Additionally, environmental factors also show how children can learn from others through the situation and by reinforcement (3). The school acts as one venue where teachers influence children through role modeling. “In several related quasi-experimental studies, silent teacher modelling was found to be ineffective in encouraging food acceptance among pre-schoolers, but ‘enthusiastic’ verbal teacher modelling was found to increase food acceptance” (6, 11). While more studies need to be conducted in order to best utilize teacher role modeling to best suite the children in the classroom, such studies are a great starting point for this intervention.
Lastly, the social cognitive theory puts together the individual and external factors through an “interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, acts again, and so on” (3). The child acts upon environmental influence and their attitudes and beliefs about the behavior. If they receive community and social support, i.e., from their parents and the teacher, they are likely to change their behavior as long as their environment allows them to do so.
While the BMI report card poses more harm than good, parent-teacher conferences could take advantage of the fact that the child should not be singled out in their classroom environment. This exchange occurs outside the child’s environment where they are vulnerable to judgment. The frame and context of the situation should be positive so that everyone involved internalizes the issue. The parents and the teacher take the time to talk about and address the child’s overall well-being, both academic wise and health wise. Also, they provide support for the child so that the child believes that they can make the behavioral change and be less subjected to harassment from the other children.
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