Challenging Dogma

Tuesday, May 15, 2012

Same Old Song and Dance with CDC’s “Salt Matters” Effort – Doug Cowles

Dietary salt consumption is out of control in the United States and other developed nations around the globe primarily because of the proliferation of the processed foods industry over the last 40 years.  In the average persons diet within the United States, 77% of sodium intake comes from processed and restaurant foods.  Many processed foods contain 1000 mg of sodium or more per serving while typical restaurant meals contain 2300-4600 mg of sodium.  (1)   Compare these values with the fact that in 2005 the National Academy of Sciences established adequate dietary intake levels for sodium ranging between 1200-1500 mg/day and you are left with the sobering reality of the sodium consumption public health issue.  (2)   As a generality, processed food manufacturers use salt, among other food additives, to enhance the taste of and extend the shelf life of their products.  This practice is virtually ubiquitous amongst all processed food manufacturers and has led to our present day circumstances of having a population consuming, on average, upwards of two to three times the recommended as safe amounts of salt in their diets as the convenience and availability of processed foods is more the norm than the exception for meal options in developed countries.     The primary medical issue with salt intake is that it is directly related to hypertension, or more familiarly “high blood pressure”.   Hypertension is a leading cause of cardiovascular disease and is attributable for 8 million deaths per year worldwide.
As a part of a multi-faceted campaign to reduce sodium consumption in the US, the Centers for Disease Control  and Prevention (CDCP) released an educational  video entitled “Salt Matters: Preserving Choice, Protecting Health”.  The CDCP describes the video as “aiming to educate viewers on the staggering facts about the sodium in our food: where it comes from, how it affects our health, and what we can do about it”.  (1)   The video was made available in three version of varying length:  public service announcement (PSA) version (~2 minutes), a short version (~4 minutes) and finally, an extended version (~15 minutes).   To be fair, these videos were well produced and provided concise and accurate information about the issues involved with and causing the US dietary sodium consumption crisis we find ourselves faced with today.  The video provided several commentary segments from experienced national health policy leaders such as New York City Department of Health and Mental Hygiene Director Sonia Angell, MD, MPH, CDCP Director Thomas R. Frieden, MD, MPH, and Johns Hopkins University Assistant Professor Cheryl Anderson, PhD, MPH, MS who all lent credibility and a level of gravity to the issue and helped to communicate more effectively then the anonymous narrator used for the majority of the video.  Also, many graphical representations of statistical health data and dietary sodium contents in an average American’s diet were also effectively used to communicate the videos primary message areas. 
From an educational video perspective the CDCP hit all of their targets and really produced a well crafted video that is very informative to viewers.  From a social and behavioral sciences perspective however, the video really fell flat.  It is apparent that the production firm the CDCP used to produce the string of videos was not familiar with basic principles, theories, and techniques of social and behavioral sciences.  I will illustrate the three most glaring shortcomings of the CDCP video effort with this regard.   

Problem With the Use of the Health Belief Model
My first criticism of the video is that it rather rigidly follows the “Health Belief Model” (HBM) theory of influencing a behavior change in its viewership.  The HBM is a conceptual framework with which to follow in order to influence a particular behavior in an individual.  It originated in the design of public health programs developed in the 1950’s by the U.S. Public Health Service to screen citizens for tuberculosis.  It has a foundation upon the assumption that people will engage in healthy behavior if 1) they value the outcome (being healthy) related to the behavior, and 2) they think that the behavior is likely to result in that outcome.  (3)  The theory argues that a targeted population will be ready to make a health behavior change if the HBM based intervention hits upon these six theory constructs -
1.      Belief that they are susceptible to the condition (e.g. hypertension, cardiovascular disease)
2.      Belief that the condition has serious consequences
3.      Belief that taking action (adopting a low sodium diet) would reduce their susceptibility to the condition or its severity
4.      Belief that the costs (decreased enjoyment of meals / foods, time and energy spent analyzing food labels for low sodium options) of taking action are outweighed by the benefits
5.      They are exposed to factors that prompt action (the CDCP video)
6.      They are confident in their ability to successfully perform an action (self-efficacy)
Despite its popularity among public health practitioners, the HBM theory is flawed for a number of reasons.  The available evidence indicates that the HBM has only a weak predictive power in most areas of health related behavior.  This is in part a result of poor construct definition, a lack of combinatorial rules and weaknesses in the predictive validity of the HBM’s core psychological components.  (4)  The primary psychological weaknesses of the HBM is that human behavior is predicated by intentions and that we predominantly act rationally by deliberately balancing benefits against costs when electing to adopt or continue a particular behavior.  Dan Ariely, Professor of Psychology and Behavioral Economics at Duke University writes in his New York Times Best Seller, Predictably Irrational, “We are just pawns in a game whose forces we largely fail to comprehend.  We usually think of ourselves as sitting in the driver’s seat, with ultimate control over the decisions we make and the direction our life takes; but, alas, this perception has more to do with our desires – with how we want to view ourselves-than with reality”.  (5)  Arielly asserts in this book through the illustration of numerous psychological experiments involving human behavior and decision making that human behavior is not planned or reasoned but is automatic and responsive based upon numerous external and internal forces and engrained responsive human behaviors that are explicitly irrational. 

 Problem with the Message Framing
Throughout the video the viewer is bombarded with commentary, statistics, data, video imagery, graphical representations, and other forms of evidence supporting the videos core value of long term health promotion.  All of these elements contribute to the overall message frame being cast to compel a person to reject a high in sodium diet and the reason the video offers is “long term health”.   Message frames, or simply frames are the conceptual bedrocks for understanding anything.  People are only able to interpret words, images, actions, or text of any kind because their brains fit those texts into an existing conceptual system that gives them order and meaning.  Just a few cues, a word or an image, trigger whole frames that inspire certain interpretations in audiences.  (6)  Conceptually any message frame should consist of 5 component parts: a core position, a metaphor, a catch phrase, images or symbols, and finally an over arching core value which resonates with the target population the message is being developed for.  The central problem with the Salt Matters video was that the CDCP elected to use long term health as their core value in their message frame.  Long term health promotion is generally considered to be a poor core value to portray as a message frame to motivate a behavior change.  In terms of Maslow’s Hierarchy of Needs, long term health would generally rank as a higher level self-actualization need thus people generally hold it as important and idealistic yet are driven to act by lower level needs such as family, sexual intimacy, and personal security. (7)  An example of a frame using a personal security frame, a lower level need in Maslow’s hierarchy, would be to refer to a particular piece of legislation as a “job killer”.  Here “job killer” is being used as a metaphor, the catch phrase, and provides some symbolism for the frame.  Killer implies that someone is coming after you and that the situation is threatening, even dire.  Killers must be stopped.  They must be punished.  Their targets need immediate protection and defensive maneuvers.  The frame evokes these ideas before we have even an inkling of what the specific legislation is about. (6)            

 Ineffective Use of Social cognitive theory
Social cognitive theory posits that people gain knowledge by observing others within the context of social interactions and experiences as well as by outside media influences.  People do not learn new behaviors solely by trying them and either succeeding or failing, but instead, are dependent upon repeating the actions of others. (8)   The core determinants include knowledge of health risks and benefits of different health practices, perceived self-efficacy that one can exercise control over one’s health habits, outcome expectations about the expected costs and benefits for different health habits, the health goals people set for themselves and the concrete plans and strategies for realizing them, and the perceived facilitators and social and structural impediments to the changes they seek.  (9)  In this regard, one area where the Salt Matters video went wrong was with its selection of statistics and imagery that was depicted and the likelihood of them having the unintended consequence of reducing the viewership’s feeling of self efficacy.   
“The average American consumes twice the amount of salt then the recommended amount” – video narrator
“Very few people, if any at all, eat a low sodium diet” – Jeremiah Stamler, MD, Northwestern University
“I know what I’m supposed to do and yet I find it very challenging and difficult despite all the information that I have” – Sonia Angell, MD, MPH, New York City Department of Health and Mental Hygiene
“Better public health equals bland food can be a difficult message for consumers to accept.  You really do notice the difference.”  - Cheryl Anderson, PhD, MPH, MS, Johns Hopkins University
Listening to these quotes taken from the video makes a person feel that the idea of adopting a low sodium diet behavior change is too difficult and too undesirable to even attempt and the result will likely be that people won’t.   The second example I have of poor awareness to social expectations theory is in how the video described what the societal norms were toward sodium consumption.  Just looking at the same quotes I have provided above, gives  you a sense that you would be more an outlier than a conformer if you were to actually follow the advice of the video and adopt the behavior change being proposed.  In addition to the messages verbalized orally the video also uses imagery of foods which are high in sodium such as pizza, french fries, and canned soup to bolster key message points however the video depicted everyday people at eateries enjoying a lunch with friends and family which is easily relatable and can be identified as the norm.  People may deduce from these images and video footage that by adopting a low sodium diet they will not be able to enjoy their food and their personal relationships as they once did and again, would fall outside of the norm. 

Solution Offered to the Problems Expected with the Use of the Health Belief Model & Social Cognitive Theory
I would propose a social expectations theory based intervention rather than the HBM approach.  Instead of developing a video that is largely educational and health risk oriented I would focus in on these key message points in an alternative video -
§         Provide information as to the abundance of low sodium product and food choices and their wide spread availability
§         Identify where the products and food choices can be purchased
§         Offer  comparability in consumer price to higher salt content food choices
§         Inform the public of the imminent  legislation of process food manufacturers which would require them to reduce the sodium content in their marketed products as well as a call to action from political notaries from both major political parties
§         Present limited data and statistical information but ensure the information that is provided is provided in such a way as to describe the publics main stream adoption and support of the low sodium diet
These message points are intended to reshape the descriptive norms for the public around adopting a low sodium diet.  In essence you are simply identifying what is right with adopting the behavior and the current climate for low sodium products rather than what is wrong so that people get their social cues from the perceived norms portrayed.  Humans are not exactly lemmings, but they are easily influenced by the statements and deeds of others.  (8)  Having representation from each of the two major political parties should widen the appeal of the message and increase its reception by individuals who affiliate with one party or the other.  This would also reduce cognitive dissonance which has the potential to occur in this situation because in essence a freedom is being threatened by asking people to abstain from high sodium products.    I would also make an attempt to change the affective norm associated with the taste of low sodium products being perceived as bland in comparison to high sodium products.   Potentially I would portray a blind taste test scenario in a super market or sporting event where people were asked which particular product variation they preferred: the high sodium product choice or the low sodium product choice.  These portrayals would depict people voluntarily opting for the low sodium product choice so more and more the different taste was associated with being pleasant and desirable rather than bland.   In the 1950’s Solomon Asch conducted a series of experiments to gauge how susceptible people are to outside social influences by asking people to take a particularly easy test and report back the answers in a number of different contexts.  When the study participants reported back their responses individually and in private nearly everyone received perfect scores to the test however when the participants reported aloud and in front of the other participants in the study and an incorrect answer was read aloud by a study investigator nearly 1/3 of the participants changed their responses to reflect the incorrect response posed by the investigator.  People were responding to the decisions of strangers, whom they would probably never see again.  Conformity experiments have been replicated and extended in more than 130 experiments from seventeen countries with people confirming between 20-40% of the time. (8)  I think that my blind taste test portrayal would yield similar results.

Recommended Message Framing
A solution offered to the issues identified with the message framing of the Salt Matters video is to simply reframe the message to associate the core position with a core value that actually motivates people to adopt the desired behavior of adopting a low sodium diet.  Health messages can be framed either in terms of potential gains (i.e., advantages or benefits) or in terms of potential losses (i.e. disadvantages or costs). (10)  An example of a gain-framed message is “If you reduce your sodium intake by half, you will increase your chances of living a long and happy life”.  In contrast the Salt Matters video uses a loss-framed message of “If you do not reduce your sodium intake by half, you will increase your chances of dying early”.  A loss-framed message creates psychological reactance in a person because a particular freedom that the person had enjoyed (i.e. consuming a high sodium diet) is being threatened and nothing is being offered in return except for “long term health”, which we identified earlier as a weak core value which does not motivate behavior change and is deemed as lesser to the freedom being taken away.  People are averse to loss which creates an irrational response in people when a behavior that they identify with is threatened, and they have an irrational response to restore the freedom regardless of the information presented against it.  By reframing the message as a gain we are not taking away a freedom and triggering reactance, we are offering a benefit to people.  In a 1999 study performed to investigate the efficacy of different types of message framing on sunscreen use behavior, gain-framed messages were responsible for a 32% increase in sunscreen use when compared to that of loss framed messages amongst individuals in the study who had no initial plan to use sunscreen. (11)
I identified earlier in the paper that a frame fundamentally consists of 5 component parts: a core position, a metaphor, a catch phrase, images and symbols, and a core value.  For the Salt Matters campaign I would suggest “revolution” as the core value of the messaging.  The term “revolution” excites people to take action and has successfully been used in a number of other healthy diet / physical fitness campaigns such as the celebrity chef and television personality Jamie Oliver and his “Food Revolution” television show and web based endeavors.  The phrase “revolution” invokes a national pride in people to take their health back much like the country’s “forefathers” fought for and achieved freedoms during the American Revolution.  I would suggest portraying processed food companies as oppressors to which people need to revolt against by rejecting their products.  Symbols which would support this frame would include images of revolution which people would connect with: a raised, clinched fist or perhaps the Gadsden flag.  The Gadsden flag is a historical American flag with a yellow field depicting a rattlesnake coiled and ready to strike.  Positioned below the snake is the legendary “DON’T TREAD ON ME”.  The flag get’s it’s name from it’s designer, American general Christopher Gadsden and was the first flag ever carried into battle by the United States Marine Corps during the American Revolution.  (12)  In summary in terms of my frame construction I would recommend the following elements –
Core position – reject the consumption of high sodium processed foods
Metaphor – Revolution, War, Fighting against oppression
Catch Phrase – Don’t Tread on Me
 Images & Symbols – Gadsden flag + Raised, clinched fist
Core Value – Revolution

Creating Dissonance
Cognitive dissonance theory states that the possession of inconsistent cognitions creates psychological discomfort which motivates people to alter their cognitions to produce greater consistency.  (13)  People desire continuity and agreement in their beliefs and when it is not present, a feeling of disagreement or hypocrisy is invoked within the person and the person is motivated to resolve the dissonance by adopting the new belief.  The more public and overt the issue which is that is creating the dissonance the greater the discomfort created therefore I would propose a dissonance based component to the CDCP’s sodium reduction effort.  I believe that once the video and the messaging involved with the campaign itself is rebranded to reflect the frame outlined above that we would be able to create dissonance in people by issuing trinkets, t-shirts, bumper stickers, and other types of paraphernalia with the branding developed by the symbols used in the frame (Gadsden Flag, Clinched Fist).  By distributing these types of Salt Matters brand associated objects at public events such as concerts or sporting events we’d be disseminating the information amongst a wide swath of our targeted population.  When those individuals wore the t-shirt or adorned the bumper sticker on their vehicle they should feel a greater amount of compulsion to abide by the core positions made by the Salt Matters video and supporting messaging.  Dissonance would be created in those individuals that chose to continue to consume high sodium foods and over time a certain percentage of individuals would be compelled to resolve the dissonance by adjusting their behaviors to be more in alignment with the Salt Matters core positions.  
To address the flaws presented by the original Salt Matters educational video effort and campaign based upon the Health Beliefs Model, I proposed a campaign focused on initiating a behavior change in the public.  My proposals were focused on changing the norms around the acceptability of eating processed foods and the perceived accessibility and barriers associated with consuming a low-sodium diet,    reframing the topic all together so that people will feel a part of a larger movement against processed food manufacturers and changing the messages to gain-framed messages to reduce the potential for psychological reactance, and lastly to create dissonance in people to minimize the potentiality of the public ignoring the messaging and returning to their “normal” high sodium diet.   Similar to the formative research performed by the Florida “Truth” anti-smoking campaign, I feel that the public is well aware of the human health hazards posed by sodium therefore the educational HBM approach is bound to in effective.  My focus was on changing the behavior first upon the assumption that the beliefs would naturally evolve to conform which is another dissonance based approach to behavior change that I feel would be effective. 
1.)   Centers for Disease Control and Prevention, Salt Subject Page,
2.)   Havas, Stephen, The Urgent Need to Reduce Sodium Consumption, Journal of the American Medical Association, September 26, 2007, Volume 298, No.12
3.)   Edberg, Mark, Social and Behavioral Theory in Public Health, Essentials of Health Behavior, Jones and Bartlett Publishers, 2007.
4.)   Armitage, Christopher, Efficacy of the Theory of Planned Behavior: A meta-analytic review, British Journal of Social Psychology, 40, 471-499, 2001.
5.)   Ariely, Dan, Predictably Irrational, The Hidden Forces That Shape Our Decisions, Harper Collins Publishers, 2008. 
6.)   Dorfman, Lori, More Than a Message: Framing Public Health Advocacy to Change Corporate Practices, Health Education and Behavior, 32, 320-336, June 2005. 
7.)   Maslow, Abraham, A Theory of Human Motivation, Psychological Review, 50, 1943, 370-396.
8.)   Thaler RH, Nudge: Improving Decisions About Health, Wealth, and Happiness, Yale University Press, 2008, 53-71.
9.)   Bandura, Albert, Health Promotion by Social Cognitive Means, Health Education and Behavior, April 2004, 143-164. 
10.)                      Gallagher, Kristel, Health Message Framing Effects on Attitudes, Intentions, and Behavior: A Meta-analytic Review, Annals of Behavioral Medicine, 43, 101-116, 2012.
11.)                       Detweiler, Jerusha, Message Framing and Sunscreen Use: Gain Framed Messages Motivate Beach-Goers, Health Psychology, 18, 189-196, 1999.
12.)                       Early American Flags with Snake Motif, webpage,
13.)                       Stice, E, Dissonance-based Interventions for the Prevention of Eating Disorders: Using Persuasion Principles to Promote Health, Prevention Science, 9, 114-128, (2008). 
14.)                       Siegel, Michael, Effect of local restaurant smoking regulations on progression to established smoking among youths, Tobacco Control, 14, 300-306, 2005.
15.)                       Havas, Stephen, Reducing the Public Health Burden from Elevated Blood Pressure Levels in the United States by Lowering Intake of Dietary Sodium, American Journal of Public Health, January 2004, 94, 19-22.
16.)                       Mohan, Sailesh, Effective population-wide public health interventions to promote sodium reduction, CMAJ, 2009.
17.)                       Shadel, William, Uncovering the most effective active ingredients of antismoking public service announcements: The role of actor and message characteristics, Nicotine & Tobacco Research, 11, May 2009, 547-552.
18.)                       Hornik R, Effects of the national youth anti-drug media campaign on youths, American Journal of Public Health, 2008, 98, 2229-2236.
19.)                       Hicks JJ, The strategy behind Florida’s “truth” campaign, Tobacco Control, 2001, 10, 3-5.


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