Challenging Dogma - Fall 2011

Monday, December 19, 2011

Using Social Marketing to Combat Childhood Obesity: A Critique of the VERBTM Campaign – Caroline Smith

Controlling obesity has become one of the highest priorities for public health practitioners. The prevalence of obesity among adolescents has increased 23% during the last three decades (1). In the United States, approximately 20% of children aged 6 to 11 years and 18% of youth aged 12 to 19 years are obese (1). The harmful effects of obesity are well documented throughout the literature. Obese children are more likely to have high blood pressure, high cholesterol, type 2 diabetes, as well as suffer from social and psychological problems such as discrimination and poor self-esteem (1). The prevalence and long-term effects of childhood obesity make it a serious public health concern.
In an effort to curb the growing problem of childhood obesity in the United States, social marketing campaigns have been created to influence behavior and improve personal health. One such social marketing campaign created by the Centers for Disease Control and Prevention (CDC) is the VERB campaign. Intended to target youth (ages 9-13), the mission of VERB was to increase and maintain physical activity among American youth (2). Using the tagline “VERB: It’s what you do”, VERB aimed to increase knowledge, improve attitudes about physical activity, and encourage young people to be physically active every day (2). Although initial studies found the campaign to be successful, it only ran from 2002 to 2006 (2).
When the VERB campaign started in 2002 it was a highly regarded public health intervention. Finally something was able to catch the attention of American youth and raise awareness about the importance of physical activity. Rather than focus specifically on exercise, VERB emphasized trying new activities, spending time with friends, and having fun (2). Yet, now it is 2011 and the prevalence of childhood obesity continues to rise. VERB was an innovative idea, but its focus was too narrow. Although VERB did incorporate some social and behavioral science principles, it mainly looked at individual level models. Failing to acknowledge to extent to which outside factors play a role in adolescent physical activity is what makes VERB flawed.
VERB and the Built Environment
One major factor VERB failed to acknowledge was the extent to which the environment affects physical activity. The built environment play a large role in the amount, type, and level of physical activity a child is involved in (3). Urban environments can often discourage physical activity. Data from the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health and Nutrition Examination Survey (NHANES) reveal that inner-city residents are more overweight, less physically active, and less healthy overall than the general population (3). Within urban areas, neighborhoods with low socioeconomic status (SES) usually have fewer physical activity resources such as parks or community centers than medium-to high-SES neighborhoods (3). This creates an environment that fosters sedentary lifestyles. Also, physical decay, litter, graffiti and unsafe conditions are common in low-SES neighborhoods, creating unappealing and even dangerous environments (3). The VERB campaign television advertisements regularly encouraged children to simply go outside and play. VERB failed to acknowledge that for some children regular outdoor activity is not accessible and other options should have been given.
In contrast to urban environments, rural environments pose their own set of challenges when trying to incorporate the VERB message. While rural environments have the unique strength of being able to incorporate the natural environment into physical activity, there are also many challenges. Long distances between home and school or play areas have been found to greatly hinder physical activity among children (4). In addition, limited availability of recreational facilities and programs has been identified as a primary barrier to children’s physical activity (4). The VERB campaign may have increased youth awareness of physical activity by encouraging children to try new activities, but it will have little impact if there is no way for children to incorporate the VERB ideas into their lifestyle.
What About the Parents?
It is no surprise that parents play a major role in the lifestyle behaviors of their children. Social cognitive theory (SCT) has been used to examine interpersonal influences on behavior by describing the relationships between cognitive, behavioral, and environmental factors. Using SCT to examine children’s physical activity suggests that parents can influence children by directly and indirectly influencing the physical, socio-economic, cultural, and social-cognitive aspects of the environment (5). Three primary mechanisms of influence on children’s physical activity are role modeling, social influence, and social support processes (5). Parental encouragement (an indicator of social influence) and parental facilitation (an indicator of social support) have been found to be strong predictors of a child’s interest and involvement in physical activity (5).
One of the VERB campaign’s biggest mistakes was failing to adequately involve parents in the campaign. Young children cannot be solely responsible for their levels of physical activity. Even if children responded favorably to VERB, without parental involvement the program would do no more than raise awareness. In an effort the keep the VERB brand “cool”, the brand was de-emphasized for parents (6). The campaign planners believed that parents would support their children’s physical activity because children would enlist support from them (6). Therefore VERB commercials ran only during television programs that were popular with children. After two years of implementation, an evaluation showed that 81% of US children ages 9-13 were aware of the VERB campaign (7). In contrast to the adolescent general-market strategy, the general-market strategy for parent-directed messages did not include television advertisements. Instead garnering parental interest focused on print advertisements most of which were found in magazines geared toward women (8). Two years after the campaign started, only 49% of parents were aware of the VERB campaign (8).
The VERB campaign was weakened by the lack of parental knowledge about the campaign. Parents remain one of the strongest socializing agents for young children and adolescents rely on their parents for guidance and support. The theory of planned behavior proposes that behavior can be predicted by personal attitude, subjective norms, and perceived control over the behavior (9). By creating VERB ads aimed at parents, VERB could have used the theory of planned behavior to shape parental views of their involvement with their children’s physical activity. Parents provide logistical support (transportation) and monetary support for their children’s activities. By using the theory of planned behavior in the VERB campaign parents may have been more likely to recognize the importance physical activity.
Lack of Community Partnerships
Social marketing campaigns are a great way to raise awareness to a cause; however, sometimes that can be the extent of their success. There is no doubt that the VERB campaign was successful in promoting the idea of physical activity among children, but it is hard to determine VERB’s lasting effect. Applying the social ecological model to the VERB campaign shows another one of VERB’s flaws. It failed to create lasting community partnerships. VERB shines at the individual level, by using the information processing theory to influence adolescent attitudes toward physical activity. The information processing theory proposes that the impact of persuasive communication is mediated by three stages of message processing: attention, comprehension, and acceptance (10). Attention depends on exposure and awareness; comprehension is based on understanding the message; and acceptance results in a change in behavior (10). Results from VERB’s year two evaluation make it clear that adolescents were exposed to the message and understood what it was saying, but the extent to which they accepted the communication is unclear (7).
Using the social ecological model to incorporate the relationship between the individual, the parents, and the social environment would have reinforced VERB’s message. The social ecological model recognizes that individual behavior is largely determined by social environment (11). Lasting behavior change is unlikely when the intervention in question does not address the social environment that produced the unwanted behavior (12). Schools should have been incorporated into the VERB campaign because children spend a large portion of their day there. Data from the 2006 School Health Policies and Practice Study (SHPPS) found that only 3.8% of elementary schools and 7.9% of middle schools provided daily physical education (13). This does not support the idea that physical activity is important.
Outside of the school environment, VERB lacked local community implementation strategies. In 2004, the Lexington Tweens Nutrition and Fitness Coalition of Lexington, KY implemented a local extension of the national VERB campaign called the VERB Summer Scorecard (VSS). VSS encouraged youth to try new and fun activities during summer and was designed to increase opportunities for vigorous physical activity (14). As part of the program, adolescents were given a “scorecard” that included various activities hosted by businesses, often with deals included (14). After completing 60 minutes of physical activity, either at an action outlet (or at home), an adult could stamp or sign one of the scorecard’s 24 spaces (14). When all squares had been filled the card could be redeemed for prizes donated by local merchants or other sponsoring organizations (14). Results of the study showed that VSS participants were 1.6 times as likely as the reference group to be vigorously active 2 or more days per week, 1.4 times as likely to be vigorously active 4 or more days per week, and 1.4 times as likely to be vigorously active 6 or more days per week (14). VSS shows that incorporating youth social environment into the VERB campaign encourages acceptance of VERB’s message.
A Step in the Right Direction
The VERB social marketing campaign showed much promise, but it did not offer a clear solution to fight the growing problem of child obesity. Lifestyle and behavioral changes such as increasing physical activity are difficult to achieve and even more difficult to sustain. Producing changes in individual attitudes and social norms is only the beginning. Subsequent changes must extend beyond the social marketing campaign and address issues like the physical environment and school policies regarding physical activity.

A Better Model: Using the Social Ecological Theory to Combat Childhood Obesity

Childhood obesity is a complex problem and lack of physical activity is only one component of the problem. At its most basic level, obesity is simply an energy imbalance (1). Too much energy is going in and not enough is being used. Therefore, incorporating more physical activity into the lives of adolescents represents one way to correct the energy imbalance.
In order to address the problem of sedentary behavior among adolescents, I will use the social ecological model to present an intervention that incorporates the many factors that influence physical activity levels. The social ecological model examines the multiple effects and relationships between social elements within an environment (15). The model integrates five distinct levels: individual, interpersonal, organizational, community, and policy (15). Studies conducted on the role of environments in shaping physical activity patterns have shown that the distribution and quality of recreational facilities have been shown to have an influence on physical activity (11). The general idea of the social ecological model is that environments and particular social factors enable or constrain behaviors by promoting certain actions and by discouraging other actions (15). Based on this, a social ecological approach would be suitable for addressing the childhood obesity epidemic by improving physical activity.
The main goal of my proposed intervention is to change adolescents’ attitude toward physical activity and to provide an environment that encourages sustained physical activity. To accomplish this the intervention will be composed of four major elements that incorporate various levels of the social ecological model. First, at the individual level, the VERB social marketing campaign will be revamped. Second, at the community and policy levels, research will be done to determine areas in which the environment significantly hinders physical activity. Once problem areas have been identified, the specific needs of each area can be addressed. Third, to address the interpersonal level, a spin-off of the VERB social marketing campaign will target parental involvement in their children’s physical activity. Lastly, incorporating the organizational level, a VERB sponsored physical activity program will be integrated at elementary and middle schools nationally. Successful accomplishment these goals will take a coordinated effort between federal, state, and local levels.
Revamping the VERB Social Marketing Campaign
The VERB campaign was not completely flawed. One area in which VERB excelled was in its use of a branding strategy. The VERB brand concept embraces more than 7000 verbs in the dictionary that can be used to describe physical activity. Building a brand relationship with consumers is important because it creates deep involvement and connectedness to a product (16). A person's attraction to a brand is not necessarily related to rational or functional needs. Brands can be symbolic, allowing consumers to project their self-image by association and by using certain brands consumers can communicate the type of person they are, or want to be (16). VERB succeeded in creating a brand that adolescents wanted to be a part of.
As a result of the branding success the VERB campaign achieved, for my intervention, I propose improving upon the VERB campaign. The social marketing campaign represents the individual level of the social ecological model and aims to increase the individual's knowledge and influence his or her attitudes toward physical activity. To bring the campaign back, I would start by running one national VERB advertisement on television networks geared toward children. This would expose a new cohort of children to the VERB message. Next, I would create advertisements to target specific regions and ethnicities around the country. So children in California would not be seeing the same advertisement as children in Georgia. The goal here is for children to be able to see themselves within the advertisements and ultimately want to be part of VERB.
Overcoming Physical Activity Barriers in the Environment
The built environment includes urban design factors, land use, and available public transportation for a region, as well as the available activity options for people within that space (3). The built environment can pose a major problem when it comes to physical activity. Even if people are motivated to exercise, the environment around them may hinder their ability to do so. In order to effectively tackle the problems that built environments pose, different intervention strategies must be employed based on the type of environment.
Assessing the environment represents the community and policy levels of the social ecological model. Actions taken on at these levels are intended to facilitate individual behavior change. For example, collaborating with local law enforcement to make sure neighborhoods are safe occurs at the community level. Whereas enacting new policies that facilitate behavior change through regulation occur at the policy level.
First, as mentioned earlier, urban environments can often discourage physical activity. To tackle this problem community planners would be employed to determine specific barriers that residents face that keep them from pursuing physical activity. A list of areas with a high prevalence of childhood obesity would be created and divided into neighborhoods. Each neighborhood would undergo a systematic review to determine its level of health. To start, a neighborhood’s walkability would be assessed. After it was determined that conditions of the neighborhood were appropriate for walking, further aspects of the area such as safety would be assessed. With specific problems in mind, public policy agendas could be created that remove physical activity barriers from neighborhoods.
Rural areas also pose environmental problems concerning physical activity. The same systematic review that looked at urban environments would be used to assess rural environments. Lack of sidewalks is often a problem in rural communities and can discourage people from walking. To combat this, a national policy would be enacted that made it mandatory for sidewalks to be present one mile from schools in all directions. Placing sidewalks would remove one physical activity barrier that rural communities face. Next, rural communities would be encouraged to have at least one community center within the town, preferably close to a school so that children could walk to the community center after school.
Implementing changes to a built environment poses many challenges. Successful completion will require the collaboration of many groups. Federal, state, or local governments must approve of the plans in order to provide the necessary funding and policy changes. Systematic reviews of neighborhoods would take a lot of work and a long time. However, incorporating environmental changes is essential to changing social norms that exist in the way adolescents interact with their environments.
Making Parents Responsible for Youth Success
Parents play an integral role in their children’s health. A separate social marketing campaign would be used to target parents. This incorporates the interpersonal level of the social ecological model. A VERB social marketing campaign geared toward parents would facilitate adolescent physical activity change through interpersonal communication and support aimed at affecting social and cultural norms and overcoming individual-level barriers (15).
Instead of making physical activity look “cool”, a spin-off of the VERB campaign would stress the importance of physical activity in a child’s life. Keeping with the VERB theme, words like “encouragement” and “support” would be used to show that parents play an extremely important role in shaping their child’s behavior. Advertisements would depict various ways parents can support physical activity such as driving their child to a park, watching a kids football game from the stands, or taking a walk with their child. Focus groups from the original VERB campaign showed that a little guilt could be a powerful motivator for parents (17). Therefore advertisements would incorporate some guilt by depicting parents being inactive and have kids following their example. To differentiate from the VERB campaign targeted towards adolescents, the campaign targeted at parents would use the tagline “VERB: it’s what you do too”. This creates a sense of involvement for the parents affecting them at the individual level, thus making them more likely to have an interpersonal effect on their children.
Using VERB Programs to Further Promote Physical Activity
The final part of the intervention involves creating an after-school activity program that takes place at the school. Research shows that school-based exercise programs have demonstrated promising results in development of children’s health behaviors (18). In a randomized, controlled study, researchers found that children enrolled in a school-based fitness program showed greater loss of body fat, increase in cardiovascular fitness, and improvement in fasting insulin levels than control subjects (19). Adolescents are often sent to after-school childcare programs because their parents are still working when school ends. This provides a great opportunity for adolescents to take part in a physical activity program. Like the VERB campaign itself, the after-school program would emphasize fun and trying new activities. Examples of activities could include structured activities such as obstacle courses, or unstructured activities such as playing tag. In the interest of keeping things fun, unusual games like quidditch would also be used in the program.
In order for children to voluntarily participate in the after-school program, it must be viewed as cool. To create a buzz and gain support, a partnership would be formed with a television company such as Disney or Nickelodeon that would agree to depict the after-school program on one of their shows. Seeing the program on television would create a sense of belonging with adolescents and make them feel like they have the opportunity to be a part of something really cool.
At the end of each school year, VERB after school program participants would have the opportunity to compete in a sort of Olympic games type activity. Participants would work in teams and compete in various games and earn points along the way. At the end, the team with the most points would win. To make this seem important medals would be handed out and the names of the participants on the winning team would be prominently displayed somewhere in the school.
Providing an after-school VERB program would give adolescents an easy way to take part in physical activity. Using the time right after school is an important part of the program because it would not allow children to come into contact with other activities such as television that would discourage them from being physically active. The after-school program also allows physical activity to become a daily part of the participants’ lives. Optimistically, this would instill in adolescents the idea that physical activity is fun and important, thus making physical activity a necessary part of their lives.
Looking to the Future
Childhood obesity will remain a growing public health problem until an intervention can achieve sustained behavior changes in adolescents. While increasing the amounts of physical activity American youth partake in marks only part of the obesity challenge, it is nevertheless an important part. Controlling the problem of childhood obesity will require changing individual beliefs and social norms, as well as providing environments that encourage healthy lifestyles. In a world that seems to facilitate sedentary lifestyles, it remains to be seen whether public health interventions can really change behavior and create lasting health effects.


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