Commentaries
nature publishing group
Childhood Obesity
Social Marketing as a Childhood Obesity Prevention Strategy W. Douglas Evans1, Katherine K. Christoffel2, Jonathan W. Necheles2 and Adam B. Becker2 In recent years, an ecological approach to nutrition and physical activity promotion has become widespread in community-based obesity prevention programs (1). One aspect of such approaches has been incorporation of social marketing messages. The relationship between ecological approaches to obesity prevention and social marketing has not yet been systematically explored. In this commentary, we discuss this relationship and offer a model for research and action at the interface. Because our team works specifically on childhood obesity, this is our focus, but the perspective that we offer may be more broadly applicable. Ecological approaches to childhood obesity prevention
The ecological approach to health promotion treats the social and physical environments surrounding individuals as primary determinants of health status (1). As discussed extensively elsewhere, ecological theory conceptualizes the individual as surrounded by “layers” or “levels” of environment including family and friends, community, school or workplace, media, and policy factors that impact health (2). Obesity prevention programs utilizing an ecological approach seek to enhance the family, social, and physical environments to reduce obesity risk factors (2,3). Their primary strategies are to enhance social capital (community participation, social agency, and feelings of trust and safety), mobilize communities, remove physical and functional barriers to adopting healthy eating and active lifestyles, and deliver health information to promote behavior change (4,5). Social marketing related to childhood obesity prevention
Social marketing has been used in the context of community-based obesity prevention programs to promote behaviors such as increased parent–child communication and improved family health. Many social marketing efforts—such as nutrition and physical activity messages promoted by the 1% milk campaign in California, the Centers for Disease Control and Prevention (CDC) VERB: It’s What You Do campaign, and the 5-4-3-2-1 Go! campaign in Chicago—have targeted parents in order to encourage them to change the home health environment, and talk to their children about health behaviors (6–8). Many such programs use community outreach as well as mass media components for a multichannel message strategy (1). In that context, marketing efforts may address multiple risk
factors in the social and physical environment, such as the effects of community environments, food and physical activity resource availability, and food advertising on children’s health behavior. Particular approaches are useful when children are the focus. Parents of children and adolescents can be reached with targeted social marketing campaigns aimed at changing social norms about food preference and choice, social desirability of exercise, and healthy weight. Risk factors such as excessive media use (e.g., TV watching, video game playing) can be targeted with messages aimed at both parents (to encourage their involvement) and children (to change their preferences) varying by children’s stage of development (9). Some examples of such efforts provide useful illustrations of possible approaches. In Chicago, 5-4-3-2-1 Go! targets adults, and particularly parents, for intervention within the larger community and social environment (7). The campaign delivers health messages aimed at affecting parental nutrition and physical activity, as well as their management of the family nutrition and physical activity environment. The strategy of treating parents as agents of change in childhood obesity is supported by recent studies. Parental obesity has been associated with lower odds of success in childhood obesity prevention and weight reduction programs (10). Also, BMI (kg/m2) tracks closely in families based on meta-analysis of family-based studies of obese parents and children (11). In South Africa, where childhood obesity estimates exceed those of the United States, Evans and colleagues studied the family, school, community and media nutrition and physical activity environments in the diverse Western Cape region (12). The investigators identified environmental barriers and opportunities to market healthy eating and active living. Parents reported safety concerns, lack of organized markets, or other sources of healthy foods in rural and township areas, and lack of resources for physical activity. But they also demonstrated strong preferences for print (including outdoor) and radio as channels of health information and for use of social role models and depictions of alternative, healthy lifestyle choices. These preferred message strategies were in many ways similar to some HIV/AIDS social marketing campaigns in Africa, offering opportunities to transfer strategy into obesity prevention.
The George Washington University, Washington, DC, USA; 2Consortium to Lower Obesity in Chicago Children, Children’s Memorial Hospital, Chicago, Illinois, USA. Correspondence: W. Douglas Evans (
[email protected])
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Social marketing as part of ecological approaches
Social marketing may be broadly defined as the application of commercial marketing principles (i.e., the 4 “Ps” of place, price, product, and promotion) to benefit society and the intended audience rather than the marketer (5). In public health, social marketing can be integrated into multilevel ecological approaches, using multiple “P” intervention strategies to support changing the environment around the audience, fostering change in community norms by delivering health messages, as well as encouraging individual behavior change. Social marketing goes beyond individual-focused health communication and uses multiple “P” interventions at the various ecological levels (13). Family. Parents serve as important nutrition and physical activity role models. Their behavior fosters child emulation of eating, exercise, and leisure habits, such as media use (8,14). Parental modeling can serve as either a risk or protective factor for childhood obesity. To foster beneficial modeling, social marketing can encourage parents to adopt protective behaviors by depicting positive parental role models creating a healthy home environment (13). Parents who model healthy rather than unhealthy behaviors, such as keeping fruits and vegetables foods in the household instead of junk foods, can lay the foundation for their children to incorporate healthy habits at home and in school and community environments. Community. Social marketing can be used to promote engage-
ment and positive role modeling of residents, community leaders in the faith and not-for-profit sectors, and local health and health-care organizations. Community mobilization has long been a major component of social marketing, including coalition building and empowerment of youth to tackle public health challenges such as tobacco control (9). Youth empowerment at the community level was used as an intervention component of the 5-4-3-2-1 Go! childhood obesity prevention initiative, mentioned earlier (7).
Policy/society. Social marketing has demonstrated its ability to
influence health policy, as exemplified by programs such as the National Cancer Institute’s American Stop Smoking Intervention Study (ASSIST) (13). Social marketing can change policy makers’ frame of reference for social issues, such as the social acceptability of smoking, contributing to legislation and policy that change the environment. Such approaches can be integrated with behavior change messaging to individual consumers and need to be strategically applied in obesity prevention as in fields such as smoking (9).
Social marketing, social modeling, and obesity prevention
Social marketing frequently relies on social cognitive theory (SCT), and thus often uses social modeling as a behavior change strategy (15). The concept of social modeling has long been understood by psychologists and commercial marketers. In SCT, social modeling plays a central role in social learning and cognition (16). Social models may embody the ideals promised by an advertisement or larger marketing campaign. S24
Idealized imagery can be a powerful marketing tool to create a social model. Brand marketing often creates an external ideal (i.e., a figure, image or symbol that embodies socially desirable, idealized brand characteristics). Consider the Marlboro Man riding out on the range, the BMW driver cornering nimbly, or a VERB tween creating new active games. Research on “social imagery”—on the process and effects of image formation due to social stimuli such as media and peer influences—shows that formation of social imagery can promote aspiration to obtain or realize an external ideal (i.e., be rugged like the Marlboro Man, or sexy and sporty like the BMW driver) (17). Social modeling has been used to market products and behaviors by making them more appealing than competing products or behaviors (13). By creating and promoting positive social images of healthy behaviors aimed at countering unhealthy imagery, social marketing efforts can compete for a children and adolescents’ time, attention, and behavioral choices. This approach—analysis of the competition and design of competing messages—is the stock and trade of commercial marketers, and is the basis of brand development and promotion. In marketing terminology, social marketing can compete with commercial messages by identifying the “frame of reference” (i.e., the behavioral options in a given social context, such as whether to play or watch TV) and the “point of difference” between behaviors (i.e., how to portray one behavioral option, such as eating fruits and vegetables as superior to another, like eating junk food) (18). Social marketing campaigns have been developed to compete with commercial marketing and social norms that promote behaviors such as smoking, excessive media use and other sedentary behavior, or consumption of junk and fast foods. For example, the CDC’s VERB: It’s What You Do campaign branded children’s play as fun, cool, and socially desirable behavior (19). This branded social marketing campaign portrayed excessive sedentary behavior as dull and boring for the audience of tweens (9–13 year olds). The VERB brand’s vision was to “free children to play out their dreams” (8). Social marketing brands like 5-4-3-2-1 Go! or the British Broadcasting Corporation’s 1999 Fighting Fat, Fighting Fit compete with in the marketplace of nutrition and physical activity behavioral options, not necessarily with a particular branded product or product line, but with the categories of nutrition and physical activity (or inactivity) behaviors (13). Such brands seek to take away “market share” away from the poor nutritional or physically inactive behavioral options. In traditional product marketing and branding, this would represent one product (e.g., Pepsi) increasing its share of a population (e.g., soda drinkers in a market like Chicago) at the expense of a competitor (e.g., Coca-Cola) (20). Social marketing efforts in a health domain like physical activity compete with commercial marketing by pitting one set of behavioral choices (or lifestyle) against another. For example, the BBC Fighting Fat, Fighting Fit series depicted characters representing a range of lifestyle alternatives (e.g., health conscious, active, or sedentary). It tried to brand a healthy, active lifestyle as having social and functional benefits greater than VOLUME 18 SUPPLEMENT 1 | FEBRUARY 2010 | www.obesityjournal.org
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those of competing choices such as eating a high-fat diet and being inactive. In essence, the Fighting Fat, Fighting Fit lifestyle was trying to take “market share” away from the behavioral alternatives by providing a more beneficial product (i.e., set of behaviors) (13). Implications for ecologically focused obesity prevention programs
These examples suggest strategies for ecologically focused obesity prevention programs to integrate social marketing. For example, there are opportunities to prevent childhood obesity at the family, school, and community levels (12). At the individual-level, promotion and product strategies can directly reach individuals and nudge them to change nutrition and physical activity habits for the better (e.g., reduce processed and low-nutrient density, high-fat foods promote convenient ways to increase energy expenditure such as neighborhood walking or household activities). Advertising to individuals can depict socially desirable role models realizing social benefits (e.g., more friends, better appearance) and functional benefits from a healthy active lifestyle. The product is the package of these behaviors and their benefits. At the family level, programs can reduce childhood obesity risk factors by changing parental behavior. The price of getting children active can be reduced through community sports and recreation programs in local neighborhoods (integrating place) at times convenient for busy working parents. Promotions aimed at individual parents can suggest small changes in food choice, such as buying one less package of processed snack foods and one more fruit or vegetable item (e.g., grapes) each shopping trip. Social marketing can also operate at the school level of ecology, and there are many examples of successful school-based campaigns to change student’s nutrition and exercise patterns through environmental changes such as cafeteria and vending interventions as well as promotional advertising (2). These Model approach
Obesity prevention social marketing using multiple “P” strategies at multiple ecological levels: 1. Reactions to promotions 2. Price sensitivity 3. Product (brand) associations 4. Placement to fit audience lifestyle
strategies use varying combinations of place (i.e., where food is purchased in school), price (e.g., food prices in vending machines), and product (i.e., food availability) strategies and can be integrated with in-school posters aimed at students promoting healthy active lifestyles (21). At the community level, social marketing has shown evidence of effectiveness in promoting nutrition and physical activity among parents and children. Evans described the characteristics of effective community-based social marketing campaigns including source authenticity for the audience, use of relevant social models, and use of multiple outreach channels including co-branding with popular community events and venues (9). The VERB campaign used media and community outreach to reach youth (19) and was effective in increasing preadolescent physical activity (22). These strategies can be combined in integrated multilevel family, school, and community social marketing interventions. The 5-4-3-2-1 Go! campaign is an example of the multilevel approaches that we see as possible. It was designed to impact parental behaviors within the context “obesigenic” environments in low-income Chicago communities (23). As described in detail elsewhere, the campaign is designed to address five risk behaviors: eat five or more servings of fruits and vegetables, four servings of water, three servings of low-fat dairy, ≤2 hours of screen time, and ≥1 hour of physical activity daily (7,24). The campaign employs the full marketing mix (25), including price (e.g., making it easier to be active and eat well), place (reaching people where they live and shop), product (e.g., healthy behaviors they can do) and promotion (e.g., the 5-4-3-2-1 Go! message). Conceptual framework for community-based obesity prevention social marketing
Based on the common approaches we see across existing obesity prevention social marketing programs, we propose a
Actual implementation strategies one or more of following Policy level (e.g., advocacy campaign to promote trans fat ordnances) Media level (e.g., promotional campaigns like VERB to reach consumers) Community level (e.g., empowerment of youth in 5-4-3-2-1 Go! )
Note: Implementation strategies can work from higher levels down to change risk factors, or try to directly change risk factors depending on program context, resources, and other inputs
Outcomesfrom various strategic combinations
School level (e.g., change food products, adjust prices, in cafeterias/vending) Family level (e.g., community resources to make it easier for parents to promote healthy active lifestyles)
Reduced obesity risk factors Improved nutrition (e.g., parental food choice) Increased physical activity (e.g., children’s exercise)
Reduced obesity health impacts (e.g., long-term reductions in BMI)
Individual level (e.g., advertising or social networking)
Figure 1 Obesity prevention social marketing conceptual framework. obesity | VOLUME 18 SUPPLEMENT 1 | FEBRUARY 2010
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conceptual framework for consideration and future testing in ecologically focused obesity prevention programs. The basic approach is to utilize SCT as a foundation: modeling positive nutrition and physical activity behaviors and norms can encourage emulation. This is especially valuable and important in family settings, where parents can serve as role models for children, and in peer setting such as schools and communities where children and adolescents can model healthy eating and active lifestyles as “peer leaders” (e.g., as in VERB and 5-4-3-2-1 Go!). Social marketing campaigns can build strategy around this modeling approach, creating multiple “P” strategies that make healthy eating and active living appealing, convenient (low cost), available and achievable. The key to social marketing as an obesity prevention strategy is the concerted use of multiple “Ps” to address the multifaceted nature of the health risks at multiple ecological levels. Figure 1 provides a simple illustration of how this framework may be constructed. This model would be tested and refined in future research. In particular, the moderating variables, such as community resident factors and social environment, are highly complex and are only now being carefully studied in rigorous experimental trials. Additional factors are likely to be identified and would need to be incorporated into this kind of model. We present this as a working framework that builds on the evidence base in social marketing and suggests a research agenda. Conclusion
Where do we go from here? Social marketing is effective through use of multiple “P” strategies to change behaviors, just as commercial marketers build consumer relations through multiple channels. Given the behavioral and environmental complexity of the obesity epidemic, the field of obesity prevention needs to systematically apply multiple “P” strategies at multiple ecological levels. As researchers, we need to design multi-factorial studies to assess the effectiveness of different combinations (i.e., which combinations of Ps and ecological levels yield greatest effects). Following this agenda, we can build the evidence base and take advantage of the tremendous potential of social marketing to prevent obesity risk factors. DISCLOSURE
3. 4. 5.
6. 7. 8.
9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
21. 22.
The authors declared no conflict of interest. © 2010 The Obesity Society
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