Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Failures Of The Jump Up & Go Campaign: What is Really Making Adolescents Unhealthy? – Diane Wheaton

Introduction: A rational-empirical approach to solving the nation’s obesity epidemic

The Jump Up & Go campaign is a multidimensional intervention campaign that aims to address some important health issues in today’s youth and adolescents. In recent years, the prevalence of overweight and obesity has reached epidemic proportions. Currently, approximately 66% of American adults aged twenty and above are overweight (BMI > 24.9), while approximately 32% are obese (BMI > 29.9) (1). Of even greater concern is the prevalence of overweight among children and adolescents. Approximately 19% of children aged 6-11 and 17% of adolescents aged 12-19 are overweight (1). All of these statistics have increased dramatically within the last decade (2). These numbers present an area of concern because individuals who are overweight as children or who have overweight parents have a significantly increased risk of being overweight or obese as adults. The comorbidities associated with overweight and obesity present an additional set of issues, which the US healthcare system struggles to address every day. Some of these include increased risks for hypertension, heart disease, diabetes, stroke, poor bone and muscle strength, some types of cancers, and social and emotional problems (3). The economic consequences of these conditions as they relate to overweight and obesity totaled approximately $92.6 billion in 2002 (3). A quick review of these statistics immediately reveals the urgent need to address the nation’s rising obesity epidemic, especially among children and adolescents.

The Jump Up & Go campaign has identified and targeted three factors that are currently contributing to the obesity epidemic among youths. These factors are physical inactivity, poor diet and nutrition, and an overabundance of “screen time” including time spent watching television, playing video games, or using a computer. The Jump Up & Go campaign takes a rational-empirical approach to addressing these issues by attempting to educate children, parents, teachers, and healthcare providers on the importance of establishing healthy lifestyle behaviors at a young age. The focus of the campaign is the ‘5-2-1 philosophy’, which advocates for five or more servings of fruits and vegetables, fewer than two hours of screen time, and one or more hours of activity every day (4). The campaign promotes these behaviors by educating and providing resources to children, parents, teachers, and physicians such as healthy recipe ideas and nutrition tips, activities for the classroom, daily logs, and other materials for evaluating and promoting healthy behaviors within school systems (4). However, this approach does not consider some important implications that are central to public health interventions among children. The Jump Up & Go campaign is inadequate in addressing the public health concerns associated with physical activity, poor nutrition, and excessive “screen time” in children and adolescents because it does not consider the underlying social contributors or behavioral models that are essential in youth development.

Issues associated with access to a healthy lifestyle

One of the most important factors to consider when developing a public health campaign is the availability of resources beyond the control of the target population. The Jump Up & Go campaign fails to address this. When a child or family does not have access to healthy food choices or venues for safe physical activity, these interventions are doomed to fail. Research shows that regardless of the level of knowledge one may have regarding appropriate health behaviors, the inability to access healthy foods and physical activity will remain a constant barrier to behavior interventions (5). These issues are exaggerated especially in low socioeconomic neighborhoods and populations (6).

Access to healthy foods is a key determinant in the success of a nutrition intervention program. The Jump Up & Go campaign encourages children to consume at least five servings of fruits and vegetables every day. The campaign assumes that such fruits and vegetables are readily available. However, increasing costs of fresh produce and increasing prevalence of fast food restaurants have contributed significantly to the decreasing levels of fruit and vegetable intake among children (6). In addition to the rising cost of fresh produce, families may find it difficult to buy fruits and vegetables due to inconvenient locations of grocery stores. The concept of built environment has recently become a topic of discussion among public health professionals due to its contributions to urban sprawl and to many families’ inability to shop at healthful grocery stores (5). In addition to the lack of access to healthy foods, many children and their families find that the plethora of fast food restaurants and unhealthy snack options available in schools and stores offer cheaper and more satisfying meal choices (5). In today’s capitalist society, fast food chains like McDonald’s, Taco Bell, Dunkin Donuts, Domino’s, and Dairy Queen can dominate the food market and offer a wide range of inexpensive food options that are high in fat and sugar, low in vitamins and minerals, and in portions that far exceed the caloric needs of adolescents, directly contributing to the rising rates of pediatric obesity. The Jump Up & Go campaign does not address these issues of access to nutritional food choices and therefore cannot possibly expect to obtain full compliance with their five-a-day recommendation for fruits and vegetables.

Access to physical activity opportunities presents another significant barrier to healthy behaviors, which the Jump Up & Go campaign does not address. The campaign advocates for children to engage in physical activity for at least one hour every day. However, in order to fulfill this requirement, children must have access to safe parks, playgrounds, recreational facilities, and neighborhood streets. These venues are often not available for children on a daily basis. Oftentimes public parks and playgrounds are too far away for children to access by walking or biking. Working parents may not be available to drive their children to such activity centers. Neighborhood streets may be unsafe due to traffic, poor lighting, or crime rates (5). All of these barriers combined result in many children remaining indoors, entertaining themselves with television and video games (5). A study conducted by the Department of Kinesiology and Physical Education at the Wilfrid Laurier University in Canada proved that the leading causes of resistance to behavioral change as it relates to physical activity among adolescents are infrastructural in nature and include low access to proper physical fitness centers (7). In addition to the physical barriers to activity, there exist mental barriers as well. Numerous studies have demonstrated correlations between an individual’s perceptions of their surrounding environments and the levels of physical activity (8). When a child or parent feels that their community is not “activity-friendly” or dangerous, they will often fail to engage in regular physical activity. Contributors to a community’s “activity-friendliness” include crime rates, street lighting, distances between residential and commercial areas (also known as ‘land use’), aesthetics, modes of transportation, traffic, and building and land maintenance (8). The Jump Up & Go campaign does not consider theses barriers to physical activity when they try to promote one hour of physical activity. When a child or parent cannot gain access to physical activity centers, exercise levels cannot increase, regardless of educational and promotional interventions.

The Jump Up & Go campaign attempts to educate children, parents, teachers, and physicians on the necessity of adequate nutrition and activity. However, by simply attempting to educate and inform, the campaign fails to consider issues of access to good nutrition and physical activity. Barriers such as these require more than just a rational-empirical intervention. They require policy change and government involvement. The Jump Up & Go campaign cannot possibly expect children to change their dietary and activity patterns while these barriers remain in place.

The Theory of Self-Efficacy: When is it too much?

Another negative reflection of the Jump Up & Go campaign is its failure to consider the Theory of Self-Efficacy. The Theory of Self-Efficacy centers on the idea that an individual’s personal expectations and perceptions regarding their ability to change will determine how effectively they will make that change (9). If an individual believes with conviction that he or she can successfully execute the necessary processes to make a behavioral change and to obtain the perceived outcomes and benefits, the person is more likely to be successful (9). Many public health interventions have employed the Theory of Self-Efficacy due to its widely applicable standards to almost any population and any behavioral change (10). However, the Jump Up & Go campaign does not utilize the messages of this theory and therefore cannot truly be successful.

The Jump Up & Go campaign establishes the 5-2-1 goal: five servings of fruits and vegetables, two or fewer hours of screen time, and one or more hours of physical activity every day. These changes could indeed contribute to an overall improvement in a child’s lifestyle, however, executing so many changes may be difficult if not impossible for most children and their families to make at the same time. Telling a child to make these changes is not sufficient to make them see the potential benefits, which may deter him or her from trying to make any changes at all (11). Additionally, attempting to enforce so many changes all at once, may overwhelm the child and their family, making them feel that they cannot achieve such lofty goals. This could in turn cause the family to abandon the suggestions entirely (11). In cases such as this, or in cases where the child does attempt to make the changes and fails, the campaign does not offer any suggestions for alternative methods of behavioral change. This could cause the family to relapse into old behaviors rather quickly. By challenging the target population to make so many changes, the campaign may in fact deter children and families from making any positive adjustments (11).

The Jump Up & Go campaign further violates the Theory of Self-Efficacy by involving too many stakeholders in the change process. The campaign provides educational and promotional materials for children, parents, teachers, school administrators, and medical care personnel. All of these materials offer suggestions that pertain to each stakeholder’s role in the child’s life, however, they do not integrate well with each other, nor are there sufficient opportunities for the stakeholders to engage in group decision making. As a result, the child may receive slightly different suggestions from each role model, which can cause conflict (12). A school administrator and a parent may want different things for the child or have different motivations and resources available to them. As a result, conflict and confusion may result within the child causing him or her to ignore the suggestions altogether (7). An example of what happens when too many authority figures are involved in an intervention, will be provided later in this paper. If the campaign took a more active approach to engaging all stakeholders in a group decision process, the result could be a more clear and thorough message for the child, which could enable the child to feel more confident in his or her ability to make the suggested behavioral changes.

The Theory of Self-Efficacy is a widely accepted and utilized behavioral theory in public health. Its implications in a program such as the Jump Up & Go campaign are important to the success of the intervention. This campaign fails to consider the central concepts of the theory by forcing too many changes at once and involving too many individual stakeholders. These factors combined may decrease the child’s self-efficacy resulting in a failure to make a change.

Social Learning Theory: The importance of understanding how children really learn

A second theory that has great implications on public health interventions is the Social Learning Theory. The Social Learning Theory maintains that individuals learn behaviors through their observations of others (10). This theory is especially important among children, who are very impressionable and quickly observe and imitate the habits that parents, siblings, teachers and friends exhibit (12). When public health officials try to promote behavioral change in youth and adolescents, they must consider the ways in which children really learn. The Jump Up & Go campaign contends that the best way to impart a behavioral change is through education and knowledge. This is inconsistent with the messages of the Social Learning Theory. The use of knowledge and education is ineffective by itself in implementing any significant behavioral change because it lacks a modeling component that is essential in youth development (12).

Children learn their behaviors from the individuals around them (12). Therefore, if children are expected to make changes, they must receive consistent signals from their role models. Role models must not only demonstrate the desired behavior, but also must demonstrate the benefits of performing the behavior. The child must see and understand why the desired behavior is important and how they can practice the behavior themselves (11). Additionally, parents, teachers, and friends, must portray the behavior as something that is attainable but also fun; children often do not respond well to harsh instructions. Telling a child that they must do something is inefficient for establishing a desired behavioral change (12).

Additionally, demonstration of behavioral changes must be consistent among all role models. It is essential that parents, teachers, physicians, and friends, exhibit and promote the same behaviors. This will increase the child’s feeling of self-efficacy as previously discussed as well as help to ensure that the desired action is more effectively engrained in the child’s mind. It is important that all role models send the same signals so that the child receives a consistent message that is easy to follow and understand (12). The Wilfrid University study found a striking association between lack of physical activity and mixed messages from authority figures. Many parents of adolescents were telling their children that sports were a waste of time, which detracted from their academic studies. Teacher and school administrators, however, supported athletes and encouraged further leisure time activity for all students. The result was a decrease in behavioral change (7). The Jump Up & Go campaign does not ensure consistencies among authority figures, which can allow for situations such as the one described in the Wilfrid study. There is limited interaction between the many stakeholders in this campaign, which may lead parents, teachers, and other involved members to take individual approaches. When too many stakeholders are involved, as in the Jump Up & Go campaign, it can be extremely difficult to keep everyone on the same page regarding the best course of action to promote behavioral change.

Social Learning Theory can have very important implications in behavioral interventions, especially among children. Until the Jump Up & Go campaign realizes and successfully implements the messages of this theory, the intervention can never reach its full potential. The campaign must go beyond an educative approach to behavioral change and incorporate important modeling theories as well.

Conclusion

Massachusetts’ Jump Up & Go campaign has the potential to impart some excellent behavioral changes in today’s youth, however the campaign comes up short in many aspects. The campaign attempts to promote healthier lifestyles in children at a young age so that they may retain those behaviors through life. These behaviors include increased fruit and vegetable consumption (along with general improved nutrition), decreased “screen time,” and increased physical activity. These three goals are legitimate and well founded however, the Jump Up & Go campaign will be unsuccessful in initiating and maintaining such changes. The campaign does not consider the issues surrounding access to proper nutrition and physical activity opportunities. The campaign also ignores the Theory of Self-Efficacy and the Social Learning Theory, both of which are essential in developing behavioral interventions, especially among children and adolescents.

Public health campaigns that aim to impart behavioral changes must look at the evidence supporting the real ways in which children learn and grow. Rational-empirical approaches will always fall short when they stand on their own, especially when children are involved. Behavioral interventions must go beyond education and move into the domain of teaching by example. They must recognize the inherent capabilities and cognitive limitations of children so as not to enforce too much change at once. Finally, behavioral interventions must recognize the factors affecting behavior that are beyond the control of the individual. Social factors such as built environment and access to proper nutrition require political and governmental resources as well. The Jump Up & Go Campaign has great potential to make changes however, there are serious flaws that the campaign must address if it expects to obtain all of the goals in their 5-2-1 philosophy.

REFERENCES

1. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Hyattsvile, MD: National Center for Health Statistics 2004.

2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Sysetem. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion 2005.

3. Center for Disease Control and Prevention. Overweight and Obesity. Atlanta, GA: Department of Health and Human Services 2007.

4. Blue Cross Massachusetts. Jump Up & Go!. Blue Cross Massachusetts. Bluecrossma.com.

5. Sallis JF, Glanz K. The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children 2006; 16(1): 89-108.

6. Burton NW, Turrell G, Oldenburg B. Participation in Recreational Physical Activity: Why do Socioeconomic Groups Differ?. Health Education & Behavior 2003; 30:225-240.

7. Berry T, Naylor PJ, Wharf-Higgins J. Stages of Change in adolescents: an examination of self-efficacy, decisional balance, and reasons for relapse. Journal of Adolescent Health 2005; 37:452-459.

8. Brennan Ramirez LK et al. Indicators of Activity-Friendly Communities: An Evidence-Based Consensus Process. American Journal of Preventive Medicine 2006; 31(6): 515-524.

9. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39(3): 128-135.

10. Choi KH, Yep GA, Kumekawa E. HIV Prevention Among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10: 19-30.

11. Bradley RH, Corwyn RF. Home Environment and Behavioral Development During Early Adolescences: The Mediating and Moderating Roles of Self-Efficacy Beliefs. Merrill-Palmer Quarterly 2001; 47(2): 165-187.

12. Hoelscher DM, Evans A, Parcel GS, Kelder SH. Designing effective nutrition interventions for adolescents. Journal of the American Dietetic Association 2002; 102(3): S52-S63.

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