The workshop’s final session included opening remarks and a panel discussion that reflected on the workshop’s prior three sessions to identify themes and future directions. April Oh, program director in the Health Communication and Informatics Research Branch at the National Cancer Institute, moderated the session.
Oh began the session with a brief presentation of her reflections. She offered four key points for bridging from problems to solutions.
The first was to challenge traditional assumptions that characterize much of the research on health- and obesity-related behaviors. She listed six such assumptions that she said are barriers to the successful implementation and the potential impact of evidence-based messages:
- The assumption that communications and messages are static. Oh pointed out that the current communication environment operates on a 24-hour news cycle and includes vast amounts of content; therefore, the relevance of a given topic and the public’s attention can be ephemeral.
- The assumption that obesity is a choice and a moral failing. Oh observed that this assumption does not align with the reality that obesity is a chronic disease that is highly influenced by obesogenic environments.
- The assumption on the part of many stakeholders that obesity-related messages are the best or the only messages. According to Oh, this is not true because health is not a top priority or value for everyone. As an example, she noted that it is difficult for health
messages to compete with messages about finding happiness and love.
- The assumption that people will trust science-driven messages. Oh stated that this assumption runs counter to the phenomenon of diminishing trust in government and institutions, and reiterated that people already know what to do.
- Therefore, the assumption that knowledge is enough to change behavior is false.
- The assumption that consumers, patients, and communities are homogeneous. Oh countered that these groups are all diverse.
Oh’s second point was the importance of addressing communication inequalities. She referenced disparities in the prevalence of obesity and its risk factors across the United States, listing several social determinants of health that drive these disparities: racism and discrimination, income, education, health literacy, neighborhood environments that are unsafe and targeted by junk food marketing amid low access to healthy foods, and health care access limitations and bias. These determinants contribute to the inequitable distribution of information, she maintained, in the forms of access, distribution of information channels, and capacity and resources to act on information that is received. Oh called for addressing these inequalities by embedding cross-sector partnerships within messaging efforts. Messages about obesity solutions interact across socioecological levels and systems, she argued, and are more effective if they are adapted for different audiences, distributed using the right channels, and delivered by influencers of the target audience. She urged consideration of the “stickiness” of messages across levels by engaging and identifying trusted influencers within levels.
Oh’s third point was to shape the narrative using community-driven co-design, which she said engages and empowers all stakeholders in communities to develop messages that reflect their goals and values. Co-design can also engage partners and other stakeholders, she proposed, to think collectively about solutions. It also allows for agile, responsive thinking and iteration of messages, she noted, which is well suited for the 24-hour news cycle and its continuous introduction of new messages.
Lastly, Oh described differences among diffusion, dissemination, and implementation of information. She explained that diffusion is “letting it happen”—the passive, untargeted spread of information, such as traditional public health campaigns; dissemination is “helping it happen”—the targeted distribution of information and intervention materials to a specific audience to drive behavior change; and implementation is “making it happen”—the use of strategies to integrate interventions and change practices and policies in specific settings. Oh urged a focus on implementation of communications about obesity solutions, explaining that even the best interventions can
impact population health only to the extent that they are adopted, delivered properly by trained providers, and received by the intended audience. She described the RE-AIM model’s five dimensions of evaluation of implementation: reach, effectiveness, adoption, implementation, and maintenance, and corresponding questions to help stakeholders plan these implementation steps (Glasgow et al., 1999; see Figure 5-1).
Oh concluded her remarks by challenging participants to think about their end goals and solutions and how to progress toward those outcomes. Implementation is critical for that progress, she maintained, urging participants to identify strategies for incorporating key intervention components into practices and environments.
Following Oh’s remarks, four panelists shared brief reflections on their lessons learned and thoughts about future directions: Kevin Ronneberg, vice president and associate medical director at HealthPartners; Vish Viswanath, Lee Kum Kee Professor of Health Communication in the Department of
Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health and in the McGraw-Patterson Center for Population Sciences at the Dana-Farber Cancer Institute; Dietram Scheufele, Taylor-Bascom Chair in Science Communication and Vilas Distinguished Achievement Professor at the University of Wisconsin–Madison and in the Morgridge Institute for Research; and Patty Nece, vice chair of the Obesity Action Coalition and chair of its Weight Bias Task Force.
Ronneberg highlighted the dilemma of normalizing healthy versus unhealthy weight, suggesting that the field dedicate time to determining where to position itself to achieve desired outcomes and avoid unintended consequences. The right positioning—and corresponding imagery—is critical to establishing solutions that will resonate and be acted upon by stakeholders, he elaborated, given the emotion around the topic of obesity and the balance between individual responsibility and social determinants or social drivers. He recalled several participants’ remarks about avoiding use of the words “obesity” or “overweight,” and cautioned not to allow this practice to result in creating solutions that focus on interim outcomes, such as nutrition or physical activity, but do not impact weight. Lastly, he encouraged the identification of process measures and milestones to indicate success in communicating about overweight and obesity so as to maintain focus while working toward end goals.
Viswanath underscored that communications cannot solve all obesity problems, but that it is worth broadening the boundary of obesity solutions to consider their contribution. Highlighting issues of equity is central to anything communications can do, he asserted, pointing out that while efforts to draw attention to obesity over the past two to three decades have been successful, disparities in the prevalence of obesity persist. He reiterated that communication inequalities have contributed to these disparities, pointing out the differential effects of communications in diverse groups. Viswanath next urged clarification of goals, elucidating that different communication strategies are warranted in the pursuit of individual versus policy versus cultural outcomes. He added that continuous evaluation creates the agility to detect unintended effects and make midcourse corrections. Finally, he called for a social mobilization approach to demand public support for obesity solutions, lest other social and political issues continue to be more salient. He underscored the crucial role of communications in mobilizing the public to recognize obesity as a social problem and to demand change in the problem’s underlying social conditions.
Scheufele appealed for abandoning the knowledge deficit model of thinking, which he described as the idea that if people only knew the science, their behaviors would align with expert recommendations. Information-centered communication campaigns that are based on this model have null results at best, he pointed out, and polarizing or detrimental effects at worst.
Second, Scheufele observed that the theme of framing had recurred throughout the workshop; he warned against speculation about framing effects, stressing that the most successful communication campaigns were extremely well researched and tested. Framing works by resonating with an audience’s underlying schemas, Scheufele explained, using the example of “frankenfood” as a highly successful frame. He elaborated that though this term does not provide detailed information, it attaches the complex issue of genetically modified foods to the recognizable story of Dr. Frankenstein, leading audiences to interpret such foods as unnatural and troublesome. He called framing “a researchable problem” that warrants careful thought about how to target messages about obesity solutions to different audiences.
Third, Scheufele maintained that message discipline is crucial in a competitive message environment, particularly where other communicators have the money to greatly outspend obesity communicators. Well-organized campaigns have a clear message that is regularly amplified by partners, he explained, noting that this alignment helps consumers filter messages and extract consistent takeaways.
Scheufele’s final point was that storytelling and narrative, which he suggested have been put forward as a universal solution, may be risky because they are agnostic to truth. Unless an obesity narrative is a truth-telling tool for conveying the evidence base supporting a solution, he warned that competition for the best story may find narratives about obesity solutions at the losing end.
Nece proposed focusing on an initial audience for communications about obesity solutions, pointing to insufficient resources to target all audiences simultaneously. The next step, she continued, is to identify that audience’s values and a frame that will resonate with it, and to set goals. Nece endorsed other participants’ suggestions that stigma and bias are a cross-cutting, minimally controversial target, and highlighted the promise of using implicit messages to debias and provide a counternarrative. She expressed hope that her participation in the workshop had helped dispel unfavorable notions about people with obesity. She applauded a number of other strategies shared throughout the day: giving hope, highlighting a solution’s benefits to everyone, meeting people where they are, providing common-sense messages, and helping people with obesity cultivate self-compassion. According to Nece, her personal experience corroborates the principle that self-acceptance at the outset of a weight-loss journey leads to better outcomes.
Following the four panelists’ remarks, they (along with the speakers throughout the day) addressed participants’ questions on the topics of
message harmonization and discipline, persuasive communications, connectedness and mobilization, achievable outcomes for obesity communications, and clarification of goals for communications about obesity solutions.
Message Harmonization and Discipline
A participant referenced the crowded field of organizations that communicate about obesity and solicited input about potential strategies for convening stakeholders to develop and disseminate guidelines for harmonizing and simplifying messages. Scheufele recounted his experience on a National Academies consensus study committee that drew on stakeholder partnerships to conduct focus groups with target audiences for a specific messaging topic. Those conversations helped illuminate problems with current messages and inform more effective messages, he explained, which were then tested and disseminated in targeted channels. He also mentioned The Science & Entertainment Exchange of the National Academy of Sciences, which connects entertainment industry professionals with top scientists and engineers to create a synergy between accurate science and engaging storylines in film and television programming, noting that what is shown in the media also influences perceptions of behavioral norms.
Based on the principle that providing facts and figures does not equal behavior change, a participant asked what evidence supports the concept of listening to the other side and gathering information as a strategy for persuasive communication, particularly for policy makers. Scheufele suggested connecting issues with the values of policy makers and their constituencies, affirming that listening is required to identify those values. To illustrate this point, he summarized Mitt Romney’s presidential campaign strategy of shaping a climate change policy message to appeal to his followers’ values. Scheufele recounted that Romney communicated about the issue from the angles of investment in a clean energy portfolio and renewable energy technologies as strategies for economic growth, global competitiveness, and energy independence.
Connectedness and Mobilization
A participant observed that the importance of connectedness and hope for the future had been apparent throughout the workshop, and asked how to connect with people living with overweight and obesity, particularly if internalization of bias and stigma is a barrier. Nece shared her belief that stigmatization of people at higher weights interferes with connectedness because
self-blame is difficult to overcome. As an example of how internalization of bias manifests, she cited how people who lose weight using medical help may be too embarrassed to return to their provider if they regain the weight. The Obesity Action Coalition’s annual patient-oriented convention draws repeat attendees, she added, because connecting with others who empathize with the daily struggles of living with obesity is overwhelmingly powerful.
Viswanath responded to a participant’s comment that bias and stigma persist despite most people’s personal connection to a person struggling with obesity. People will mobilize, he predicted, when they understand obesity as an unjust, unacceptable condition. A participant explained that common perception of a threat—which he said is key for every social movement—is lacking for obesity, partly because of the diversity of opinions about its causes. The participant implied that this gap makes it difficult to rally individuals around specific actions to address the problem. Garcia appealed for starting with the African American and Hispanic communities, where he characterized the high prevalence of obesity as an urgent matter. Oh agreed, noting that some of these communities are targeted by junk food marketing and lack access to healthy foods, suggesting that junk food is the norm, which she termed “reinforcing inequalities.”
Achievable Outcomes for Obesity Communications
A participant referenced the concept of starting with the end in mind, and asked panelists for examples of achievable outcomes for obesity communications. Viswanath advocated for an initial focus on the perceptions that individual lifestyle behavior is the sole driver of obesity and that obesity is the individual’s responsibility to solve. These beliefs lead people affected by obesity to internalize the problem, he continued, emphasizing that although personal agency for weight management is one aspect, the obesogenic environment is an important factor. Oh concurred, adding that an environmental or behavior change intervention without a communication campaign or a dissemination and implementation plan may fail to engage people. Ronneberg pointed out that facilitating conversations about obesity and its contributors is a low-cost strategy for cultivating the belief that it is an unjust condition. He proposed that healthy discourse on the topic can reveal how obesity impacts others, suggest how individuals can contribute to solutions, and increase willingness to discuss a difficult and often sensitive subject.
Puhl encouraged embracing and working through the tensions of communicating about obesity if mitigating stigma is a goal. She also questioned how communications can effectively address stigma and create an environment in which people of diverse body sizes are treated with dignity and respect, given that many current policies allow people to be treated unequally on the basis of weight.
A participant commented that a big win would be to make obesity treatment a health care priority so that greater numbers of people can access treatment modalities and receive respectful care as they would for other diseases. Ronneberg highlighted the opportunity to train health care providers and their support staff in discussing weight with patients and supporting patients who are ready to engage.
Clarification of Goals for Communications About Obesity Solutions
Gates emphasized that clarification of objectives and ultimate goals precedes communications. For obesity, she said, examples of goals are preventing obesity, reducing the prevalence of obesity among children or adults, or effecting environmental changes to facilitate behaviors that promote healthy weight. She acknowledged that all of those goals are desirable, but asked the panel where to start.
Ronneberg agreed that pinpointing objectives is critical, and suggested an initial focus on an area with the highest potential for return on investment. He observed that the public can often coalesce around helping children lead healthy lives as an investment for the future. Viswanath called out advertising as a potential key target. A tremendous financial investment is dedicated to marketing fast foods and sugar-sweetened beverages, he observed as an example, and cited an analysis indicating that elimination of tax deductions for such advertising aimed at children could have a profound impact on the risk factors for obesity. Scheufele encouraged resolution of the tension around how to address stigma. He recognized the merit of including a diversity of body sizes in marketing of fitness gear, for example, but suggested balancing this against several decades of research that associate unhealthy outcomes with modeling certain types of body images. Nece urged consideration of areas in which the roundtable can exert influence. A participant pointed to the difference between normalizing healthy weight and normalizing healthy behaviors, highlighting that the heterogeneity of people with obesity makes it challenging to convey what is normal or acceptable for one’s health and appearance. Promoting healthy behaviors may be more appropriate, he implied, because they are more mutable than weight.
Sylvia Rowe returned to deliver closing remarks following the panel discussion. She emphasized the importance of proactively and strategically aligning communications with the goals for obesity solutions. Rowe acknowledged that many questions and challenges persist, but took an optimistic view that the field has “an enormous amount of opportunity in this area.”
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