Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Global Strategy on Diet, Physical Activity and Health: A Failed WHO Program – Alice Lin

A profound shift in the balance of the major causes of death and disease has already occurred in developed countries and is under way in many developing countries. Globally, the burden of noncommunicable diseases has rapidly increased. In 2001 noncommunicable diseases accounted for almost 60% of the 56 million deaths worldwide annually and 47% of the global burden of disease (1). In view of these figures and their predicted continuous growth, the prevention of noncommunicable diseases presents a major challenge to global public health. Unhealthy diets and physical inactivity are among the leading causes of the major noncommunicable diseases, including cardiovascular disease, type 2 diabetes and certain types of cancer. Thus they contribute substantially to disease, premature death and disability. Other diseases related to diet and physical inactivity, such as dental caries and osteoporosis, are widespread causes of morbidity (1).
World Health Organization (WHO) recognized the unique opportunity that existed to formulate and implement an effective strategy for substantially reducing deaths and disease burden worldwide by improving diet and promoting physical activity. Therefore, in May 2004, WHO adopted the "Global Strategy on Diet, Physical Activity and Health" (2).The overall goal of the Global Strategy on Diet, Physical Activity and Health is to promote and protect health by guiding the development of an enabling environment for sustainable actions at individual, community, national and global levels that, when taken together, will lead to reduced disease and death rates related to unhealthy diet and physical inactivity (3). However, this global strategy falls short because it lacks consideration for self-efficacy, social and environmental barriers, and public values.
The worldwide program lacks consideration for self-efficacy and barriers
The Global Strategy on Diet, Physical Activity and Health did not recognize importance of self-efficacy. Based on Albert Bandura’s Social Cognitive Theory, self-efficacy is one of the keys to behavior change. Expectation of personal mastery and success determines whether or not an individual will engage in a particular behavior. One’s belief in the ability to perform a behavior is an important link between knowing what to do and actually doing it (4). People with high levels of self-efficacy are more likely to try new behaviors and keep up with them.
According to Social Cognitive Theory, people do not do things they think they can not do. So they simply do not think they can exercise on most days because there are so many social and environmental barriers. According to one research report, the four most commonly reported personal barriers were lack of time, feeling too tired, obtaining enough exercise at one’s job, and no motivation to exercise (5). Neighborhood characteristics, including the presence of sidewalks, enjoyable scenery, heavy traffic, and hills, were positively associated with physical activity. There was a high level of support for health policy–related measures. Up to one third of individuals who had used environmental supports reported an increase in physical activity (5).
If changes are made in the built environment, which remove barriers, it may for example, be more possible to walk or bike to destinations, to exercise on lunch breaks, and simply to take the stairs. Changing the built environment across different setting has an effect on behavior (6). In the strategy of this WHO program, it should consider people’s confidence that they can engage in the new behavior and overcome obstacles to doing it.
The strategy fails to incorporate the values of the public
The Global Strategy on Diet, Physical Activity and Health emphasizes increasing awareness and understanding of the influences of diet and physical activity on health and the positive impact of preventive interventions. According to the Health Belief Model, if people perceive the benefits and those benefits outweigh potential barriers, they will have the intention to do such behaviors. The strategy, however, is inadequate because it focuses on an individual behavior change theory. It does not consider what the public values.
For instance, we all know the benefits of eating healthy food, so why do so few of us cook for ourselves and eat as many vegetables and fruits as we can? It is because we value convenience more than health. We choose to eat out because it is easier and faster but less healthy. Interventions to reduce reliance on fast food restaurants may need to address perceived importance of healthy eating as well as time and convenience barriers (7). It is not really health itself we value. Rather, it is the freedom, independence, autonomy and control over our lives that come with being healthy for which people have the most fundamental need and desire (8).
In addition, the strategy does not account for self-control or self-autonomy, which we also value. A more appropriate approach for this type of intervention would incorporate something like Marketing Theory- which would take the wants/needs/values of the group into account, and make the choice of behavior change appear attractive. There are some successful stories based on Social Marketing Theory like Click it or Ticket in North Carolina and the “Truth” Campaign (9). In America, we have extensive marketing of unhealthy food products (including fast food), and we have the trend towards eating out. Perhaps we can think of some more attractive advertisement of healthy diet and exercise to compete with the food industry. We can also use the Four “Ps” of Social Marketing: Product, Price, Place and Promotion. For example, we can make a significant reduction for the price of healthy food and increase its availability (10).
The strategy cannot serve as a “one size fits all” campaign.
The WHO program stated that priority should be given to activities that have a positive impact on the poorest population groups and communities. Though we can carry out many good campaigns in poor communities or countries, the strategy fails to consider other aspects of limitations of healthy diet and physical activity.
One example is that it does not take into account the barriers that exist in low socioeconomic areas. Between 1992 and 1997, US government spent more than $40 million for the 5-A-Day campaign for Better Health Program, but failed to accomplish any significant improvement because it did not consider the basic geographic distribution of availability of healthy foods. In many inner-city neighborhoods, healthy foods are simply not easily available, or if they are, they are prohibitively costly. Fewer supermarkets, farmer markets in low-income areas (11-13).
Furthermore, mean quality of fresh produce was significantly lower in the predominately African-American, low- socioeconomic status (SES) community than in the racially heterogeneous, middle-SES community (14). Also, the most impoverished neighborhoods, where African Americans resided were, on an average, 1.1 miles more far away from the nearest supermarket than were White neighborhoods (15). Thus, increasing access to high-quality healthy foods in low-income communities is a critical first step toward improving health through better dietary practices.
People in lower SES experience more stressful life events and more subjective distress than their higher SES counterparts. It is also possible that SES may exert its effects on health through the performance or lack of performance of health-promoting or health-damaging behavior. For example, with decreasing SES, research has clearly documented a decrease in physical activity and an increased consumption of high-fat diets (16-18).
The Global Strategy on Diet, Physical Activity and Health was set up with a good intention to improve people’s health, but it is probably not so compelling. This program lacks consideration for self-efficacy and barriers, letting people feel they cannot accomplish what the strategy suggests, will result in people not following the recommendations. The strategy fails to incorporate the values of the public: freedom, independence, autonomy and control over our lives. Though we perceived the benefits of healthy diet and regular exercise, the strategy does not make them meet our demands. Finally, the strategy neglects the social or environmental differences among communities or countries.
An effective program would put more emphasis on self-efficacy, social and environmental barriers, what public would like, and the disparity of people in different areas. The public health practitioners of the global strategy should find out what we want and then package and frame the product to satisfy our demands. In addition, they should find ways to convince some of the people in the communities to adapt to healthy diet and frequent physical activity. Sooner or later, the behavior will get the chance to become a social norm and inspire the majority of the population to follow.
1. World Health Organization. Programmes and projects. Geneva, Switzerland: World Health Organization. May, 2004
2. World Health Organization. Programmes and projects. Geneva, Switzerland: World Health Organization. May, 2004
3. World Health Organization. Programmes and projects. Geneva, Switzerland: World Health Organization. May, 2004
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6. Saelens BE. Neighborhood-based differences in physical activity: An environment scale evaluation. American Journal of Public Health 2003; 93: 1552-1558
7. French SA. Fast food restaurant use among adolescents: associations with nutrient intake, food choices and behavioral and psychosocial variables. International Journal of Obesity 2001; 25: 1823-1833
8. Siegal M. Marketing Public Health: strategies to promote social change. Sudbury, MA: Jones & Bartlett Publisher, 2007.
9. Social Marketing Institute. Success Stories. Washington, DC: Social Marketing Institute.
10. French SA. Pricing and promotion effects on low-fat vending snack purchases: the CHIPS Study. American Journal of Public Health 2001; 91: 112-117
11. Weinberg Z. No Place to shop: food access lacking in the inner city. Race, Poverty Environ. 2000;7(2):22-24
12. Morland K. Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine 2001;22(1):23-29
13. Elizabeth E. In poor health: Supermarket redlining and urban nutrition. GeoJournal 2001; 53(2): 125-133
14. Shannon NZ. Fruit and Vegetable Access Differs by Community Racial Composition and Socioeconomic Position in Detroit, Michigan. Ethnicity & Disease 2006; 16(1):175-180
15. Shannon NZ. Neighborhood Racial Composition, Neighborhood Poverty, and the Spatial Accessibility of Supermarkets in Metropolitan Detroit. American Journal of Public Health 2005; 95(4):660-667
16. Ford E. Physical activity behaviors in lower and higher socioeconomic status populations. American Journal of Epidemiology 1991; 133:1246-1256
17. Cauley JA. Physical activity by socioeconomic status in two population based cohorts. Medicine & Science in Sports & Exercise 1991;23(3):343-352
18. Jeffrey R. Socioeconomic status differences in health behaviors related to obesity: The healthy worker project. International Journal of Obesity 1991;15:689-696

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