Sunday, May 9, 2010

Adolescent Girls are Irrational, Even When it comes to Their Bones: A Critique of the Best Bones Forever Campaign – Lauren Ferraro

Calcium and Vitamin D are vital in adolescence to form strong bones for the remainder of a person’s life (1). A person also needs to perform weight-bearing exercise in order to strengthen and thicken the bone (2). The essentiality of this process is portrayed to the American public in many ways through the media and various public health campaigns. This process is especially important during childhood and adolescence because peak bone mass is generally reached by a person’s early 20’s (1). Adolescent girls are more vulnerable to low bone mineral density because of the menstrual cycle, which increases the need for Calcium and Vitamin D (3). This is the likely the reason that a program was developed by the U.S. Department of Health and Human Services that targets adolescent girls. The website calls the program “Best Bones Forever: A bone health campaign for girls and their BFFs to ‘grow strong together and stay strong forever’”.

Though this campaign is a valid idea for a public health intervention it is flawed in many ways. There are certain aspects of the campaign that were composed without stepping into the mind of an adolescent girl. The first reason the campaign is flawed is because it assumes that adolescent girls think rationally. Anyone who has interacted with or observed an adolescent girl knows this is not accurate. Secondly, the campaign does not capitalize on the fact that adolescent girls are highly influenced by what others around them are doing. Lastly, the campaign does not give the girls an immediate promise or benefit from practicing what the program asks. Like so many other campaigns the Best Bones Forever campaign has a promising future if it can change its perspective on the health behavior and group it is targeting.

The Issue of Irrationality

The Best Bones Forever campaign is largely based on the Health Belief Model. The creators of this campaign believed that young girls would see that they are susceptible to poor bone health and that it could become severe with time. They also believed that adolescent girls would take into account the benefits of altering the choices that influence their bone health and that there are few barriers for them to take action. The fact that the campaign developers thought that adolescent girls’ thought process was this rational shows the irrationality of the human race. Anyone who interacts with an adolescent girl knows that her main concern is when the next High School Musical is going to be released, not that she may have a hip fracture in her sixties.

The Health Belief Model is a poor choice to base the Best Bones Forever campaign upon. There is little evidence of how the Health Belief Model works as a whole (4). The majority of the research on the Health Belief Model focuses on the individual parts of the model and not their sum in entirety. Andrew Baum notes this fact in his book and questions if researchers can say the Health Belief Model is effective when they are not examining the combination of health beliefs leading to a change in health behavior (4). This issue allows one to criticize the Health Belief Model because it does not account for a person’s irrationality, especially an adolescent girl’s. Many studies focus on one or two facets of the Health Belief Model as the reason people change their health behaviors (5-7). However, many people may perceive a risk and his or her susceptibility to it but still partake in a high-risk behavior. This is especially true for adolescents. This is why the Best Bones Forever Campaign cannot be effective.

It is false for one to assume that adolescent girls are rational decision makers because the majority of adolescents focus on what will bring them immediate pleasure. Adolescents would argue that their decision-making is rational because they are looking for immediate stimulation (8). However, these decisions are not see as rational by adults. Unfortunately, it is also adults who are developing campaigns such as Best Bones Forever. Many adults are also misguided and believe that adolescents perceive themselves as non-vulnerable or invincible. Certain studies have found this is not true and that adolescent know they are not invincible (8). When decisions that may result in negative outcomes are presented to them, adolescents say they engage in the activity because they feel their fate is inevitable (8). The Best Bones Forever campaign does not specifically provide the girls with horror stories about bone fractures and breaks; it also does not give any positive reinforcement testimonials. It can be inferred from this study that adolescent thoughts are perceived to be irrational by adults because adolescents are trying to optimize their immediate pleasure and avoid their impending vulnerability. The Best Bones Forever campaign does not provide the girls with a way to find pleasure and a way to decrease their feelings of vulnerability.

Breaking News: Adolescents Are Easily Influenced

Peer pressure is an issue that adolescent boys and girls deal with all the time. Peer pressure comes in many forms: clothing choice, music preference, drug experimentation, and alcohol use. It has been shown that adolescents can be influenced by their peers to engage in both proactive and detrimental behaviors (9). The same study showed that this varies by sex. The researchers concluded that males are more heavily influenced to participate in misconduct behaviors where as girls usually engaged in more neutral activities when urged by peers (9). This is an important aspect of the adolescent psyche that should be manipulated to benefit public health campaigns. Best Bones Forever does not use this research to their advatage. The closest the campaign comes to utilizing peer pressure is a discussion about volunteer work. Volunteering is not the main focus of the Best Bones Forever campaign. If the campaign developers wanted to reach out to girls they would need to have other girls of a varying ages and ethnicities participate in and show support for the campaign

Another reason that the Best Bones Forever campaign is not being as effective as it could is because there are not innovators to start the movement toward better bone health. The Diffusion of Innovations Theory is based on the concepts of innovation, communication channels, social systems, and time (10). The Best Bones Forever Campaign does not utilize any of these. As stated previously, adolescent girls are highly influenced to engage in neutral or proactive activities when pressured by their peers (9). The issue may arise of whether or not calcium intake is a new and innovative idea. However, for adolescent girls it very well may be. The Joint Committee on National Health Education Standards recommends that children in Pre-K through grade 2 receive a minimum of 40 hours of health education per year (11). They also recommend that grades 3-12 receive a minimum of 80 hours per year (11). A survey done by the National Center for Education Statistics found that most teachers spend an average of only 13 hours per year educating their students about nutrition (12). Based on the infinite topics that can be covered during a nutrition education lesson calcium consumption may not have been taught. This is why the Diffusion of Innovations theory could prove beneficial for the campaign. The campaign developers would have been able to produce a more successful campaign if they first worked with a group of girls who are ready to make changes and could be innovators. The topic of calcium consumption and bone health would be completely new to the adolescent girls and they would be able to follow the example set by their innovative peers.

Another important issue to consider in the influence of adolescents is the change related to social support. It was previously mentioned that adolescents, especially girls, could be pressured in to socially neutral behaviors (9). The word “pressure” gives a negative connotation to adolescent decision-making. “Support” on the other hand gives the impression of guiding, rather than forcing, adolescent girls into a behavior that they may not have performed previously. Special attention should be paid to important members of the girls’ lives. Kaplan et al., notes that support from important members of an individual’s life will provide a protective effect if the individual is feeling stressed (13). Social support can be provided to the adolescent through a number of groups: parents, friends, family, coaches, etc. Kaplan et al. emphasizes that social support is the “metness” of the individual’s needs (13). However, the Best Bones Forever campaign does not provide this “metness” or support for the girls it is targeting. There is a link on the page that is dedicated to parental knowledge; however, this is mostly facts and statistics about bone health. It characterizes the parents as a separate entity from the girls, making it harder for girls to relate and feel supported. Also, the tag line of the campaign is “ bone health campaign for girls and their BFFs to ‘grow strong together and stay strong forever’”. This gives the impression of encouraging social support with peers. However, there is nothing on the website that allows girls to utilize this support or provide it to their friends. No part of the Best Bones Forever campaign provides girls with reinforcement to continue. Reinforcement can come in different forms through tangible support or appraisal support (13). Tangible support is physical help getting the job done and appraisal support is help that redefines what the expectations of the individual are (13). Best Bones Forever defines what the expectations are, but after that there is little help provided to the girls. As previously mentioned, much of the information on the site is factual rather than applicable. Without concrete support for adolescent girls to follow, the Best Bones Forever campaign will continue to be average at best.

Where is the promise or goal?

It has been mentioned that adolescents behave based on what will provide them with the most immediate pleasure (8). Based on this assumption there should be something provided by the Best Bones Forever campaign that will provide the girls with immediate satisfaction for the changes they make. A study on Advertisement Theory in practice showed that simple health education was effective in increasing the intake of high fiber cereals by adults (14). However, this may not be effective on adolescent girls because it does not provide them with an immediate effect. This is another area where the Best Bones Forever campaign falls short. The Best Bones Forever campaign needs to provide the adolescent girls with calcium and vitamin D education through the principles of the Advertising Theory. Advertising Theory focuses on the social and symbolic uses of the products that are advertised (15). Although bone health is not a product, it is something that can be made more appealing to the adolescent girls. Another important aspect of the theory of advertising is the supposed “culture” that the product creates (15). Before being exposed to the Best Bones Forever campaign the adolescent girls are in a culture that is defined by inadequate calcium and vitamin D intake. In the current culture they may also be part of a group that will have osteoporosis later in life. The Best Bones Forever campaign wants the adolescent girls to reevaluate the culture they want to be apart of. However, they do not give the girls an incentive to become a part of this new and unfamiliar culture.

Social Learning Theory states that people will learn and perform behaviors based on rewards, punishments, or observational learning (16). This means that people are more likely to perform behaviors that provide them intrinsic and extrinsic rewards. These rewards may not be conscious. However, in order for the Best Bone Forever campaign to be successful they will need to provide extrinsic rewards to the girls who make positive changes. This would be something tangible they gain from bettering their bone health habits. This may in turn lead to self-pride and motivation to continue with these healthier habits, intrinsic rewards. Best Bones Forever does not provide any sort or reward or promise. Though some may argue that the reward is strong bones and bone health for life, this is not something that translates to adolescent girls because it is gained in the distant future.

Creators of the Best Bones Forever campaign should have researched what makes girls feel motivated. In a study published in Educational Psychology authors were looking to find what motivated adolescent girls to participate in physical education classes (17). Physical exercise, especially weight bearing, plays a critical role in the development of healthy bones (2). Best Bones Forever does not incorporate the possibility of physical education classes as a tool for the success of their campaign. The main purpose of the study was to find out what exactly influenced the goals of adolescent girls in regard to physical education participation (17). In other words, they wanted to see what the girls perceived as the reward of participation in these classes and what increased the likelihood of participation. The authors determined that there were two key factors that resulted in participation in the physical education classes: class climate and perceived competence (17). The study was based on the Theory of Goal Perspectives, which infers that goals pursued by students influence the levels of interest shown and personal motivation (17). Based on this experiment adolescent girls were most motivated by perceived ability. If the Best Bones Forever campaign could incorporate physical education instructors they would have better success. The instructors would have to be able to motivate the girls through mastery, rather than social comparison (17). Mastery allows the girls to set a goal for competence, rather than achievement or “being the best”. If girls work toward becoming more competent in physical activities it is a continuous goal. Social competition only allows girls to retain interest until they are the best and then the goal ends. Since weight-bearing activity is an essential component of bone health the Best Bones Forever campaign would benefit highly by presenting personal mastery as a reward for girls. The range of weight-bearing exercises is vast which allows girls to master and excel at the activity of their choosing. As stated before intrinsic motivation is a key component of success and the Best Bones Forever campaign should promote this.

Proposed Changes to Best Bones Forever

Best Bones Forever has the potential to be a campaign that has a positive effect on the bone health habits of adolescent girls. It is targeting an issue that has become more threatening as children continue toward obesity. Adolescents substitute many calcium rich foods with more convenient and less nutrient dense replacements. The combination of convenient foods with decreased exercise related to screen time is putting adolescents at risk for poor bone health later in life. The Best Bones Forever website has been trying to make changes to these habits. However, they cannot be successful with their current set up. Best Bones Forever needs to take a multi-media approach. Adolescents are not going to respond to a single website that contains facts, quizzes, and a few games. Utilizing multimedia and making revisions to the overall approach of Best Bones Forever will ensure a more successful campaign that can potentially have a large impact on the bone health of adolescent girls.

The first problem identified was how the Best Bones Forever campaign approaches adolescent decision-making. Adults see it as irrational because it is spontaneous and based on immediate pleasure. The Best Bones Forever campaign does not account for this “irrationality”. In order for the campaign to become successful the developers need to determine what will provide adolescents with immediate pleasure, but also still contribute to their bone health. This is going to be done through choices in recipes and physical activity. Adolescents cannot be forced to eat and act in ways that will strengthen his or her bones. By developing more choices in activities and recipes the Best Bones Forever campaign will account for adolescent impulsivity and compensate for their thoughts about personal vulnerability.

Another problem with the campaign is the autonomy of it. Though adolescents tend to seek independence from their parents they are seeking a connection with their peers. This is a tool that could be highly successful in improving the Best Bones Forever campaign. Research has shown that girls are more likely to be influenced to perform neutral or beneficial behaviors when pressured by peers. This is a fact that needs to be implemented into the development of videos using other adolescent girls to influences new visitors to the site. This can be used to induce better food choice habits as well as exercise habits. This is also an area that can improve on the support that the girls are receiving. It should provide activities that involve the family and close friends in order for the girls to continue with their positive behavior change.

The final problem with the Best bones campaign that needs to be addressed is that there is no reward or promise presented to the girls. Studies have shown that incentives and rewards increase compliance to health behavior changes. If the Best Bones Forever campaign creators set up a reward or incentive program more girls would be willing to attempt to make and maintain changes to their diet and exercise habits. Incentives can be created in abundance of ways and through a number of outlets. Best Bones Forever could benefit from the response that rewards would provide the site and the campaign.

The Power of Choice

Adolescents, as previously mentioned, base the majority of their decisions on what decisions are going to bring them the most instant gratification (8). This means that out of an array of high calcium choices, they are going to choose the snack or meal they think tastes the best. If an adolescent girl is presented with a choice between a glass of milk and a can of Coke, the Coke is going to be chosen the majority of the time. This is because it is accessible and tasty; it provides the girl with direct satisfaction. The Best Bones Forever campaign provides recipes that are not adolescent friendly or appealing for that matter. Most of the recipes include some form of tortillas and low fat cheese. Adolescent girls likely want cupcakes, pizza, and ice cream! As tempting as low fat yogurt sounds to the average adult who wants to consume more calcium it will not hold the same appeal for an adolescent. Also, studies have shown that promoting low-fat food options to adolescent girls may promote unhealthy dieting and food choices (18). The Best Bones Forever provides girls with 34 different recipes for snacks and meals. Out of those recipes 28 of them suggest using low-fat or fat-free dairy products. This may actually be having the opposite effect that Best Bones Forever is aiming for.

Best Bones Forever should incorporate an interactive recipe entry system. This would allow girls to input what they had consumed throughout the day or a meal they were going to have that night. As mentioned before promotion of low-fat and low calorie diets are detrimental to adolescent food choices (18). Therefore, the recipe input system should only provide girls with information of micronutrients such as vitamins and minerals. Using this system adolescent girls can see what nutrients they are lacking. The website could then provide them with helpful alternatives or new foods to incorporate into their meals and snacks. This allows for the “irrationality” of adolescent decisions. Providing them with information about their current choices gives them the power to make the changes. They can choose to have a bowl of ice cream one day and broccoli the next. This is beneficial because adolescent top reasons for choosing food are hunger and cravings (19). Providing them with this information will give them a concrete way to follow their intake and make changes.

The Health Belief Model focuses on the barriers to the suggested change. Adolescents feel that there are many barriers to being able to change their health behaviors (20). This likely contributes to why adults feel adolescents act irrationally since they do not realize that adolescent feel it is difficult to make the proposed changes. One of the barriers noted by adolescents is the fact that they are very busy and don’t feel they have enough time to make the proposed changes (20). This is something that the Best Bones Forever campaign should take note of. The recipes presented by the Best Bones Forever creators ask for a change in all eating habits overnight. It may be more beneficial, however, to celebrate small victories. Rather than urging a complete restructuring of the diet, start small. Suggestions should be made such as “try replacing the water you drink at dinner with a glass of milk”. This also will allow for adolescent impulsivity because they are focusing on one small change rather than many larger ones.

Using Peer Pressure Positively

Peer pressure is one of the most commonly talked about themes that occurs in adolescence. It is portrayed constantly on television, in the movies, and in magazines. Peer pressure is also generally shown as having a negative effect. Many times this can be the case, but peer pressure can also be used to influence positive behaviors. As noted before girls are more easily persuaded to perform neutral or positive behaviors when urged by peers (9). This is something that Best Bones Forever should use to their advantage. Once again, it would be through a media outlet. On the website and, with enough funding, through ads in magazines and on TV Best Bones Forever could further reach out to the girls. The simplest way is to reach out to girls who are already practicing food habits that promote bone health. There can be videos, testimonials, and chat rooms that show support for the desired food choices. It could also be beneficial to enlist celebrity adolescents that the girls would look up to and listen to. Since there has been evidence that supports the persuasion of adolescent girls through peer pressure on positive issues this could be extremely beneficial.

In order to stimulate change within a social group there needs to be a leader that decides the change is going to benefit the group. The Best Bones Forever campaign could target girls within a school or club that are most willing and ready to change. These girls could serve as innovators. Also, if the website were to incorporate videos of girls who have had success with and enjoy calcium-rich foods the girls in the videos could also serve as innovators. Studies with adolescent participants that looked at the effects of the Diffusion of Innovations Theory show that it is effective (23 & 24). It is important to note that these studies are based on negative behaviors, but girls are more likely to perform positive behaviors when pressured by other girls (9).

Peer Pressure could provide the effect that studies have shown using Social Network Theory. The New England Journal of Medicine has published two similar studies regarding the effects of Social Network Theory (21 & 22). These were both long term studies, but the point of Best Bones Forever is to develop good habits for life. Also, the studies focused on adults. This may infer that there will not be such a strong social influence on adolescents. However, adolescents are highly influenced by their peers. If a girl is a part of a social network and the peers in that network alter their calcium intake behaviors she will likely change her own behaviors. The problem this poses is finding a way to start the change within the social group. This is why the Diffusion of Innovations Theory also would benefit the Best Bones Forever campaign. This is also an area where support could be incorporated. Support from both peers and parents leads to a buffering effect and encourages the girls to continue with positive changes. The Best Bones Forever website should provide support through videos and chat rooms. This will provide the girls with support to continue their changes. Both the Social Network Theory and Diffusion of Innovations Theory could be used by the Best Bones Forever campaign in order to help influence girls to better bone health.

Make Bone Health Rewarding

Many adolescents may see healthy eating as a chore. Constant nagging from parents may make healthy choices a punishment rather than a choice. However, there are few things more motivating than a reward. It has been mentioned that adolescents make decisions based on impulse and pleasure. Therefore a reward will be able to provide that feeling. This is especially true when it comes to health behaviors. Students were part of a study that required them to rinse with fluoride and were rewarded for compliance. When the rewards were withdrawn, the behavior was slowly stopped (25). The Best Bones Forever Campaign can work through the same type of principle.

It has been proposed that Best Bones Forever develop an interactive data entry system that allows the girls to see where their calcium and vitamin D intake stack up compared to recommended intake. This can also be incorporated into a rewards system. This can be done a few different ways. One way could allow girls to earn points and choose from prizes. Also, they could be rewarded prizes after a number of days meeting their target intake for calcium and vitamin D. This is something that could really make the Best Bones Forever campaign a step above the rest.

Marketing Theory can also be loosely used to help make the Best Bones Forever campaign welcomed by adolescent girls. This can be done through the videos on the website and possible TV advertisements. Marketing Theory is effective because it provides its target group with a promise and a culture(26). Best Bones Forever can use this for both diet and exercise changes in adolescent girls. There are endless commercials and paper ads that show what an adolescent girl can be if she wears certain clothes, buys a certain perfume, or listens to a certain band. The same message can be portrayed when it comes to bone health. There is already the makings of a Best Bones Forever culture on the website. They have badges, but ownership should be established with t-shirts and other merchandise. This in turn can reinforce the ideas of Diffusion of Innovations and Social Learning Theories. With the right participants the videos and ads, as well as a branded culture Best Bones Forever could stir a desire for change within adolescent girls.


The Best Bones Forever Campaign has good intentions. It aims to change the diet and exercise habits of adolescent girls in order for them to have healthy bones later in life. However, the campaign is seriously flawed. The creators of this campaign did not put themselves in adolescent girls’ shoes when they developed Best Bones Forever. They do not allow for the impulsivity of adolescent decision amking. This can be revised by providing the girls with choices and a way to monitor her past behaviors. The campaign also does not utilize how shapeable these girls’ opinions are. If the campaign were to utilize influential peers and celebrities through a multimedia campaign the compliance to healthful food habits and weight-bearing exercise would increase. Lastly, this campaign does not provide the girls with a tangible reward. If an incentive program was created there were would higher rates of compliance.


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