The Coalition for Healthy Children’s Reliance on Individual Behavior Change and Social Marketing to Combat Childhood Obesity - Virginia Lijewski

The Coalition for Healthy Children is an Ad Council initiative whose goal is to “help address the obesity crisis that confronts our nation and its children” with a mission to “provide clear, consistent, research-based messages to children and parents on the importance of practicing a healthier lifestyle and offer them the means to do it” (1). They feel fighting the childhood obesity epidemic can be achieved by communicating directly to children, and their parents, about the importance of physical activity and healthy eating. They have crafted five main messages to promote healthy lifestyles: 1) physical activity; 2) food choice; 3) food portions; 4) balance between food and activity; and 5) role modeling.

The five basic messages are broken down into messages tailored to kids and to parents. Messages to kids are 1) Physical activity: Be a player. Get up and play and hour a day; 2) Balance: Eat well. Play hard. Make it balance; 3) Food choices: Are you eating a home run or a strikeout?; 4) Food portions: The amount counts. Keep portions under control. Messages to parents are 1) Encourage your kid to be a player. Get up and play an hour a day; 2) food choice: Tell your kids to eat well, play hard, and make it balance; 3) Food choices: is your kid eating a home run or a strikeout? 4) food portions: The amount counts. Keep portions under control; and 5) Set the example: When it comes to activity and eating right kids take their lead from you.

Organizations and companies have the options to become members of the Coalition for Healthy Children and help in the promotion of the campaign’s health messages. By becoming a member of the Coalition, these groups have made a commitment to incorporate the “strategic messages” into their marketing materials including advertisements, packaging, websites, and in-store promotions (1).

The Ad Council’s Coalition for Healthy Children is using social marketing strategies to deliver their health messages to children and adults. Social marketing has been defined as “the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group” (2) Social marketing tactics persuade an individual to change their behavior in order to improve their own health and often work to alter an individual’s perceptions and attitudes about their health (3).

Traditional social marketing campaigns, like that of the Coalition for Healthy Children, develop a short-lived mass advertising campaigns to encourage individuals to exercise more and eat more fruits and vegetables. The Coalition for Healthy Children focuses on the individual as being in complete control of his or her health and ignores the social, environmental, and economic causes of childhood obesity. The campaign recognizes the important role parents play in the health of their children but it fails to provide parents with the tools they need to make a positive change in their child’s health. Obesity disproportionately effects minority populations who have limited access to healthy foods and places to engage in physical activity. The campaign fails to acknowledge the racial and ethnic health disparities that exist and does not target a particular population nor does it try to reduce disparities in health and access to health promoting activities.

Critique 1: Providing parents with the tools needed to promote healthy behaviors in their children

Parents play a vital role in the health of their children and are critical to the success of any intervention to combat childhood obesity. The Coalition understands the important role parents play in the health of their child and through their targeted messages advise them to be a role model for healthy behavior, to play with their children and hour a day, encourage their kids to eat smaller portions and healthy foods, and convince them that being healthier now will pay off in the end. The Coalition however, does not provide parents with the tools they need to make a positive change in their child’s health.

Research has been done to determine the barriers parents face in helping their child eat healthy and be more physically active. The main barriers that have been identified are family schedules, lack of money/transportation, safety, and availability and desirability of healthy foods. Hectic family and work schedules and the convenience and accessibility to unhealthy foods lead parents to make unhealthy food choices for their families. There is a lack of desirability among children for healthy foods, which also makes it hard for parents to encourage healthy eating in their children (4).

A study by Tyler and Horner (5) analyzed an intervention aimed at collaboration between parents, children, and medical providers. Through discussions with parents and children, the medical providers created individualized health plans for each family. The most frequent barriers parents reported were a lack time and safe recreational facilities for their children to play. Most parents understood that their children needed to become more physically active and eat healthier foods but did not know how to implement a healthier lifestyle into their family’s routine. The intervention’s focus was on helping parents make positive changes in their children’s health by providing them with ideas and strategies to improve their families’ health.

Interventions designed to increase physical activity may be more effective if they are designed to accommodate the multiple competing demands of a family and provide affordable and diverse activities that families can do together (6). Parental involvement in obesity prevention programs has been proven to be effective in reducing the rates of childhood obesity (7) but telling parents what to do through health messages isn’t enough. Parents already know the importance of physical activity and healthy food choices but need to be provided with the tools required to accommodate lifestyle change. Effective interventions should provide parents with the ability to work around the barriers they face by encouraging families to work together to improve their health and come up with create ways to be active together.

Critique 2: Failure to consider social determinants of health

The Coalition for Healthy Children’s campaign fails to acknowledge the lack of resources available to certain subsets of the population. They encourage individual behavior change without recognizing that minorities groups, and people in disadvantaged populations, disproportionately lack access to the resources they need to create personal change.

The highest rates of obesity occur in the most disadvantaged populations, including minority groups, and populations with the highest poverty rates and least education (8). Socioeconomic status has been viewed as one possible explanation for the disproportionate rates of obesity among these populations (9). Studies evaluating the effects of socioeconomic status and health have found that poor health is directly correlated to low socioeconomic status. Improvement in health of disadvantaged people includes providing material conditions for good health and a control of life circumstances or empowerment. In the United States material conditions for good health include things like the availability of healthy foods and opportunities for exercise. Empowerment is both an individual and community level phenomenon and at the community level involves securing resources for health (10).

Some research suggests that racial and ethnic disparities in obesity rates can be explained by a lack of access to activity- friendly environments. Rates of physical activity among youth are higher in communities where there are sidewalks, parks, and indoor recreation facilities (11). Access to supermarkets is associated with improved dietary quality, higher intake of fruits and vegetables, and lower rates of obesity. There is a disparity in access to these resources among predominantly white neighborhoods and those of minority populations. High income and white communities tend to have more access to sources of healthy foods and places to engage in physical activity. Low-income communities, and communities with a high percentage of racial and ethnic minorities, tend to have less access to supermarkets and a higher availability of corner convenience stores and inexpensive high-calorie foods (12). The Coalition for Healthy Children fails to recognize that people may have a hard time making a positive health change because they lack access to the resources they need to improve their health. The Coalition is not addressing the larger social issues that may be part of the cause of childhood obesity rates. Instead, the Coalition is sending health messages to children and parents encouraging them to make a change without addressing the specific needs or the barriers to health.

Critique 3: Individual approach

The Coalition’s strategy for achieving its goals is through sending messages to children and parents about health behaviors and physical activity. By creating targeted messages the Coalition is fostering the notion that eating healthy and being more physically active is all within an individual’s control. The Coalition is ignoring the social, economic, and environmental factors that also contribute to obesity and lack of physical activity in children.

Historically, obesity as been blamed on the individual and it is still the case today that a failure of personal responsibility is thought to be the its cause (13). The concept of personal responsibility, especially for one’s health, is highly ingrained in American society and can even be seen in the political structure of the United States (14). While taking personal responsibility for one’s health can lead to positive changes in behavior and heath, emphasizing this as the only way to achieve optimal health can foster victim blaming. Victim blaming occurs when someone is blamed for his or her ill health and negative characteristics are ascribed to the person because they did not make the positive health behavior changes expected by society (14). Societal focus on the individual diverts attention from the social influences that affect health.

Individual level approaches to health behavior change have been criticized in recent years and the field of public health has begun to shift its focus from the individual to the group level. Group level approaches to behavior change emphasize that an individual’s behavior is the result of one’s intentions and abilities to act on those intentions. Factors acting on the individual level like self-efficacy, confidence, and personal beliefs, determine an individual’s intention. Factors acting in the wider environment like access to healthy food and socioeconomic status, determine whether a person acts on their intentions (15). Focusing on group level interventions requires creating environments that will foster behavior change.

People seek good health and the ability to pursue it; however, traditional individual level approaches to behavior change do not capture the importance of both needs. Rugar (16), in an attempt to shift the focus from the individual to the group, defined the concept of health capability. Health capability incorporates the conditions that affect one’s health as well as the person’s ability to make healthy choices; it is the ability to be healthy. Individual health capability is dependent on how someone’s external environment enhances or detracts from his or her health.

Intervention

The Coalition for Healthy Children uses a social marketing approach in an attempt to communicate health messages to parents and children about the importance of eating healthy and exercising. Their goal is to reduce obesity on the individual level; however, by doing so they neglect the environmental causes of childhood obesity. Current social science research has shown “diet and physical activity interventions that build knowledge, motivation, and behavior change skills in individuals without changing the environments in which they live are unlikely to be effective” (17). An individual can make the choice to be more physically active and eat healthier foods but they cannot act on these decisions if their wider environment is preventing them from living a healthy lifestyle. An intervention designed to address an individual’s barriers to health behaviors would be a more effective approach to reducing the rates of childhood obesity. In designing an intervention it is important to understand the population being targeted and the specific needs of the communities within that population to enable the individual to make personal changes in his or her health. I propose an intervention that corrects the shortcomings of the Coalition for Healthy Children’s campaign to combat childhood obesity by using the combined concepts of social marketing, community organization, and policy change. By incorporating these approaches, the intervention can address the environmental and societal barriers that children and their parents face, sustain a level of personal accomplishment, and address the disparities in health that are the underlying cause of childhood obesity.

Socioeconomic status is a strongly correlated with health and interventions created to focus on changing disparities in health, especially those that disproportionately effect minorities and low-income populations, will have the greatest population benefit. Achieving social and economic change would require major societal change and interventions aimed at addressing social determinants of health need the support of the government and society. A successful intervention should include government and policy makers and should work to promote change in the social system in the United States.

The Health Impact Pyramid is one example of how public health is trying to shift its attention to the population and not the individual to make positive health changes. At the base of the pyramid are efforts to address socioeconomic factors (i.e. poverty and education levels), followed by public health interventions that change the context for health to make individuals’ default decisions healthy (i.e. clean water, safe roads), then long-lasting protective interventions (i.e. immunizations), clinical interventions, and at the top counseling interventions. Public health interventions at the base of the model require the least individual effort and have the greatest population impact. The focus of public health interventions should be at the first and second levels of the pyramid (18).

Parents play a vital role in the success of childhood obesity prevention interventions but they cannot help their child if they are not provided with the information necessary to assist them in making healthy decisions for their family. A good example of a current campaign that involves parents and provides them with the appropriate tools to make a positive change is the “Let’s Move” campaign (19) created by First Lady Michelle Obama. The campaign’s website provides links to services and resources parents can use to make a positive change in their child’s health (20). Part of the campaign’s website focuses on access to affordable healthy food which provides links to the National Policy and Legal Analysis Network to Prevent Childhood Obesity (21) where parents can learn how to increase the access to fresh fruits and vegetables in their particular neighborhood, the Farmer’s Market Coalition (22) where parents can learn how to start a farmer’s market in their community, and the Food Trust (23) where parents can learn what community and school-based access plans there are in their community. The intervention combines individual approaches with group level approaches by providing individuals with the tools they need improve not only their health, but also the health of their family their community. The “Let’s Move” campaign also focuses on making broader social changes through the use of policy changes and government initiatives. The campaign highlights the Healthy Food Financing Initiative, which as part of the president’s 2011 budget, will put $400 million dollars a year towards increasing access to healthy foods in underserved areas (20) By combining the efforts of individuals, communities, and the government, “Let’s Move” has the potential to reduce health disparities related to access to healthy food as well as reduce the rates of childhood obesity.

Several ecological models combining public health, health psychology, consumer psychology, and urban planning, have identified four types of food environments (community, consumer, organizational, and information) that should be understood when trying to reduce obesity in minority populations (17). Community food environments refer to places where food can be obtained (grocery stores, restaurants, etc). Consumer environments refer to what people are exposed to; more specifically the availability, prices, and promotions of certain foods. Information environments include places in the built environment (school and work) that directly and indirectly encourage unhealthy eating habits and sedentary lifestyles and do not encourage healthy eating behavior (24). Schools are one type of information environment that can easily be changed to promote positive health behaviors. Schools are a major setting in a child’s life and should become active in developing obesity prevention programs. Communities, schools, and governmental agencies should work together to design and implement obesity prevention programs (25).

By changing the environments in which children interact through a combination of efforts, positive health behaviors, like increased physical activity and healthy eating habits, can be formed. Interventions aimed at addressing the barriers individual’s face in access to healthy food and the health disparities that exist in the United States would be more effective in combating childhood obesity. A successful intervention should combine the concepts of social marketing, policy change, and community change that will allow the individual (both parents and children) to make the necessary steps to improve their health.

References

1. The Advertising Council Inc. (2008). Coalition for Healthy Children. http://www.healthychildrencoalition.org/

2. Goldberg, Marvin E. (1995). Social Marketing: Are we Fiddling while Rome Burns? Journal of Consumer Psychology 4(4), 347-370

3. Yancey, AK, Cole, BL., Brown, R, Williams, JD. Hillier, A, Randolph, KS, Ashe, M, Grier, SA, Backman, D, and McCarthy, WJ. (2009). A Cross-sectional Prevalence Study of Ethnically Targeted and General Audience Outdoor Obesity-Related Advertising. The Milbank Quarterly 87(1), 155-184.

4. Power, TG, Bindler, RC., Goetz, S, and Daratha, KB. (2010). Obesity Prevention in Early Adolescence: Student, Parent, and Teacher Views. Journal of School Health 8(1), 13-19.

5. Tyler, Diane and Horner, Sharon. (2008). Collaborating with Low-Income Families and Their Overweight Children to Improve Weight-Related Behaviors: An Intervention Process Evaluation. Journal for Specialists in Pediatric Nursing 13(4), 263-274.

6. Thompson, J.L., Jago, R., Brockman, R., Cartwright, K., Page, A.S., Fox, K.R. Physically Active Families- de-bunking the myth? A Qualitative Study of Family Participation in Physical Activity. Child: Care, Health, and Development 36(2), 265-274.

7. Kitzmann, KM, Dalton, WT, Stanley, CM, Beech, CM, Reeves, TP, Buscemi, J, Egli, CJ, Gamble, HL, Midgett, EL. (2010). Lifestyle Interventions for Youth Who are Overweight: A Meta-Analytic Review. Health Psychology 29(1), 91-101.

8. Flegal, Katherine M., Margaret D. Carroll, Cynthia L. Ogden and Clifford L. Johnson. 2002. "Prevalence and Trends in Obesity Among US Adults, 1999-2000." Journal of the American Medical Association 288(14): 1723-1727.

9. LaVeist, Thomas, A. (2005). Minority Populations and Health: An Introduction to Health Disparities in the United States. Preventing Chronic Disease: Public Health Research, Practice, and Policy 2(4).

10. Marmot, Michael. (2006). Health in an Unequal World. The Lancet 368.

11. Whitt-Glover, Melicia C, Taylor, Wendell C, Floyd, Myrone F, Yore, Michelle M, Yancey, Antronette K, and Matthews, Charles E. (2009). Disparities in Physical Activity and Sedentary Behaviors Among US Children and Adolescents: Prevalence, Correlations, and Intervention Implications. Journal of Public Health Policy 30, 309-334.

12. Odoms-Young, AM, Zenk, Shannon and Mason, M. (2009). Measuring Food Availability and Access in African-American Communities. Implications for Intervention and Policy. American Journal of Preventative Medicine 36, 145-149.

13. Schwartz, Marlene and Brownwell, Kelly D. (2007). Actions Necessary to Prevent Childhood Obesity: Creating the Climate for Change. Journal of Law, Medicine, and Ethics 35(1).

14. Brownwell, Kelly D. (1991). Personal Responsibly and Control Over Our Bodies: When Expectation Exceeds Reality. Health Psychology 105(5), 303-310.

15. Maziak, Wasim and Ward, Kenneth. (2009). From Health as a Rational Choice to Health as an Affordable Choice. American Journal of Public Health 99(12), 2134-2139.

16. Ruger, Jennifer Prah. (2010). Health Capability: Conceptualization and Operationalization. American Journal of Public Health 100(1), 41-49.

17.Sallis, James F. and Glanz, Karen. Physical Activity and Food Environments: Solutions to the Obesity Epidemic. The Milbank Quarterly 87(1), 123-154.

18. Frieden, Thomas R. (2010). A Framework for Public Health Action: The Health Impact Pyramid. The American Journal of Public Health 100(4), 590-595.

19. U.S. Department of Health and Human Services. “Let’s Move” (January 2009). http://www.letsmove.gov/

20. U.S. Department of Health and Human Services. (2009).“Access to Affordable Healthy Food.” http://www.letsmove.gov/accessing/index.html

21. National Policy and Legal Analysis Network to Prevent Childhood Obesity. (2010). http://www.nplanonline.org/nplan/products/8-steps-more-fruits-vegetables

22. Farmer’s Market Coalition. (2008). http://www.farmersmarketcoalition.org/resources/

23. USDA Supplemental Assistance Nutrition Program. The Food Trust (2004). http://www.thefoodtrust.org/php/about/OurMission.php

24. Wechsler, H., Devereaux, RS, Davis, M, and Collins, J. (2000). Using the School Environment to Promote Physical Activity and Healthy Eating. Preventative Medicine 31, 122-134.

25. Li, Ji and Hooker, Neal. (2010). Childhood Obesity and Schools: Evidence from the National Survey of Children’s Health. Journal of School Health 8(2), 96-103.

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.

Conclusion

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.

REFERENCES

1. Matkonc V, Fontana D, Tominac C, Goel P, & Chesnut CH. Factors that influence peak bone mass formation: a study of calcium balance and the inheritance of bone mass in adolescent females. The American Jounal of Clinical Nutrition 1990; 52: 878-888.

2. Duncan CS, Blimkie CJ, Coweel CT, Burke ST, Briody JN, & Howman-Giles R. Bone Mineral Density in adolescent female athletes: relationship to exercise type and muscle strength. Medicine and Science in Sports and Exercise 2002; 34: 286-294.

3. Nordin BE. Calcium and Osteoporosis. Nutrition 1997; 13: 664-686.

4. Baum A. Health Belief Model. Cambridge Handbook of Psychology, Health, and Medicine. New York, NY: Cambridge University Press, 1997.

5. Daddario DK. Areview of the use of the Health Belief Model for weight management. Academy if Medical Surgery Nurses Journal 2007; 16: 363-366.

6. Meron U, Champion V, Monahan PO, Daggy J, Hui S, & Skinner CS. Health Belief Model variables as predictors of progression in stage of mammography adoption. American Journal of Health Promotion 2007; 21: 255-261.

7. Austin LT, Ahmad F, Mcnally MS, & Stewart DE. Breast and Cervical Cancer Screening in Hispanic Women: a literature review using the Health belief Model. Women’s Health Issues 2002; 12: 122-128.

8. Reynn VF & Farley F. Risk and Rationality in Adolescent Decision Making: Implications for theory, practice, and public policy. Psychological Science in the Public Interest 2008; 7: 1-44.

9. Brown DB, Bradford B, Clasen DR, & ELcher SA. Perceptions of Peer Pressure, Peer Conformity Dispositions, and Self-Reported Behavior Among Adolescents. Developmental Psychology 1986; 22: 521-530.

10. Haider M & Kreps GL. 40 Years of Diffusion of Innovations: Utility and Value in Public Health. Journal of Health Communications 2004; 9:3-11.

11. American Cancer Society, American Diabetes Association, & American Heart Association. Health Education in Schools – the importance of establishing healthy behaviors in our nations youth. www.ncaahperd.org/pdf/health.pdf. Accessed April 15, 2010.

12. National Center for Education Statistics. Nutrition Education in Public Elementary School Classrooms, k-5. www.nces.ed.goc/surveys/frss/publications/2000040/. Accessed April 15, 2010.

13. Kaplan BH, Cassel JC, & Gore S. Social Support and Health. Medical Care 1977; 15:47-58.

14. Levy AS & Stokes. Effects of a Health Promotion Advertising Campaign on Sales of Ready-to-Eat Cereals. Public Health Reports 1987; 102: 398-403.

15. Haim J & Kellner D. Toward a Critical Theory of Advertising. Illuminations. www.uta.edu/huma/illuminations/kelele.htm. Accessed April 21,2010.

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17. Cory F, Biddle S, Famose JP, Goudas M, Sanazin P, & Durand M. Personal and Situational Factors Influencing Intrinsic Interest of Adolescent Girls in School Physical Education: a structural equation modeling analysis. Educational Psychology 1996; 16: 305-315.

18. Lattimore PJ & Halford JCG. Adolescence and the diet-dieting disparity: Healhty food choice or risky health behavior. British Journal of Health and Psychology 2003; 8: 451-463

19. Neumark-Sztainer D, Stong M, Perry C, & Casey Ma. Factors Influencing Food Choices in Adolescents: Findings from Focus Group Discussion with Adolescents. Journal of the American Dietetics Association 1999; 99: 929-937.

20. Story M & Resnick M. Adolescents’ View of Food and Nutrition. Adolescent Health Program, University of Minnesota. http://milk.mb.ca/teachers/Images_Docs/Adolescents'%20Views%20on%20Food%20and%20Nutrition.pdf. Accessed April 23, 2010.

21. Christakis NA & Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. The New England Jounral of Medicine 2008; 358: 2249-2258.

22. Christakis NA & Fowler JH. The Spread of Obesity in a Large Social Network Over 32 Years. The New England Jounral of Medicine 2007; 357: 370-379.

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26. Hunt KD. Truth in Marketing Theory and Research. Journal of Marketing 1990; 54: 1-15.

The National Football League and Center for Disease Control and Prevention’s Public Service Announcement on Concussions:Missing the Mark– Jenna Carter

Introduction

According to the Centers for Disease Control and Prevention, an estimated 1.7 million traumatic brain, TBIs, of mild to moderate severity, most of which can be classified as concussions, (i.e., conditions of temporary altered mental status as a result of head trauma), occur in the United States each year. And, an estimated 135,000 sports related TBIs are treated in the emergency, among children five to eighteen years old. (1) Now, imagine if this happened to an athlete during a game or competition and they returned to that contest the same day without proper care? That has been the reality in many sports, but specifically in the National Football League until the end of 2009, when pressure was being placed on NFL commissioner, Roger Gooddell, by the House Judiciary Committee for their lack of action when it comes to head injuries to their players. In fact, during their hearing in October, the NFL’s concussion methods, or lack thereof, were being analogized to those of the tobacco industry’s methods when it came to tobacco causing cancer a few decades ago, by Representative Linda Sanchez (D-California). (2, 3) This hearing was called for following an internal study, announced by the NFL, which showed that NFL players who had suffered from head injuries are more susceptible to higher rates of dementia and cognitive decline than the rest of the population. (3) The NFL had been ultimately accused of ignoring the research linked to long term health problems caused by head injuries suffered by their players, but that is a different argument in itself. The news of this hearing arguably sent waves through the sport of football.

In an effort to combat the problem and finally take head injuries suffered by players seriously, the NFL, with the assistance of their newly formed “mild traumatic brain injury” committee, has come up with some proposed changes in its approach to make the sport safer. One effort was creating a public service announcement put together by both the NFL and the Centers for Disease Control and Prevention, released in December. (4,5,6) (You Tube) The intent was to debut this 30-second PSA during a Thursday night NFL game on the NFL Network and continue airing it during the commercial breaks of specific NFL games until the end of the 2009 season, including the Super Bowl (5).

There are several arguments that can be made as to why this effort will not be successful in its attempt to shed light on the issue of head injuries in sports due to several reasons. It is not persuasive, lacks the facts, and created a message of forceful change.

1.PSA frames message about concussions negatively and takes freedom to choose away

According to the Ad Council, who is a leading creator of PSAs in the United States, the most critical aspect of creating awareness in advertising is to “mobilize” the public and “make lasting positive social change”. (7) In this case, the NFL totally missed the mark. The PSA sounds like it should be an advertisement for a horror film, not a public health announcement. There is a man who speaks in a chilling voice about the problem of concussions and says, “Concussions and head injuries must be taken seriously”. He then states, “If you’re a player, protect yourself and your teammates. If you think you’re hurt, don’t hide it, report it, and take time to recover. If you’re a coach or parent, know concussion symptoms and warning signs and never let an athlete return to play before a health professional says it’s ok. Help take head injuries out of play.” At that point, it is mentioned that the CDC should be contacted for more information. (3) In addition to the terrifying voice, the music being played in the background could be associated with a horror movie soundtrack, such as “Jaws”.

To frame a message so that it has characteristics of persuasion, it is necessary for a message to grab the audience’s attention and it must be easy to understand so there is a sense that the audience would “get it”. The content must also be relevant to the receiver of the message and give them reason to think or talk about it. (8) It can certainly be argued that this message may have grabbed hold of some of its audience, but not enough to keep their attention.

In 1986, the elaboration likelihood model, which was outlined by Richard Petty and John Cacioppo, proposed that there are two routes a message can take to change a person’s attitude or behavior, the central route and the peripheral route. The central route requires careful scrutiny of an argument presented in a message that appeases to people who enjoy thinking through the logic of statements. (8) In other words, the message needs to be presented by a source that is credible and forms a compelling logical argument. The peripheral route focuses on the overall feeling that one would get from the message, rather than thinking critically. For example, the basis of this would be whether or not the character in the message is likeable or having a catchy slogan. (8) Obviously, the CDC is a very credible source and it was smart for the NFL to partner with them in this message. However, there is nothing likeable about how the message is delivered and doesn’t even offer a reasonable argument. In addition, this short announcement doesn’t offer any motivation or reason to support it’s plead. Why should the athlete report that they’re hurt? What is going to happen to them? What are the warning signs that a player needs to be treated by a health care professional? There is no information given that cites the dangers of concussions or any possible long-term effects. The implication of the announcement is clear, that concussions and brain injuries need to be taken seriously, but there is no evidence that gives viewers a reason to buy into the message and therefore, know which symptoms to report. (5)

Another point to add to this argument lies in Psychological Reactance Theory, where a person is not going to change just because they are told to do so. By approaching it in this way, the target audience may feel threatened that are losing their freedom to choose (“you must take concussions and head injuries seriously”) and in turn, try to find a way to restore that freedom. . (9) A large part of the target audience are teenagers and they like to rebel. This is a large reason why many anti-smoking campaigns were not successful, which will be covered later. (10) Also, with the message lacking support to back up the claim that symptoms must be reported and lacking attractiveness to the advertisement, there would be no reason for anyone in the target audience to follow through.

2. Assumes that the athlete, parent, or coach will do the research by putting owness on them rather than giving the facts in a compelling way

Not once during the PSA, did it mention what the symptoms of a concussion or head injury are, nor does it advice potential consequences of not reporting this type of injury. Ultimately, this advertisement imposes the work of doing research on its audience by stating they should go to the CDC for more information. It is clear that the athlete, parent, and coach must know or find out what the symptoms of a head injury are and then take responsibility for reporting it and lastly, taking the necessary precautions. Based on Social Marketing, there is a related principal, which is to take complete responsibility for the customer’s (i.e. athlete, parent, coach) satisfaction with the product and to not take for granted that they will have the ability, knowledge, and skills to put that product to use. In this case, the product would be the dangers of concussion and head injuries. (11) This would have been a tremendous opportunity for the NFL to make clear as to why they are sending the message and it’s importance in order to compel their audience to take action.

It also poses another dangerous problem in that; there may be a lack of communication between the athlete, parent, and a coach. It is very possible that an athlete may believe that his or her parent/guardian will do the research and educate them on the issue or for the parent/guardian to guess the same about the coach’s responsibility. In essence, there is a lack of clear direction that could potentially continue the risk of an athlete going forward. There should be a separate targeted message to all three populations.

Furthermore, here is nothing stated about the health consequences of not reporting a head injury, such as cognitive decline, Chronic Traumatic Encephalopathy (CTE), or Second Impact Syndrome. Research has shown that the most cognitive impairments following a concussion are related to visual motor reaction time and information processing, memory, and attention. (12) CTE is a degenerative brain disease that is caused by head trauma and is neuropathologically related to Alzheimer’s disease. According to research from the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine, this had been a disease only linked to boxers, but more recently, in other athletes. (13) Lastly, Second Impact Syndrome is a condition that occurs from a second and recurring concussion, which causes vascular congestion and increased intracranial pressure, and can be very difficult, if not, impossible to control, and potentially be fatal. This is more likely to occur if there isn’t complete recovery from a previous concussion. (12)

If the NFL justly wants to be the leader on this issue, it should at the very least, disclose the facts, symptoms, precautions and risks of concussions in the actually PSA, rather than asking the players, parents, and coaches to do their own research.

3. Assumes the athlete will report symptoms of a head injury Football is a well known “hitting” sport and it seems the harder the hit, the tougher the play or player, and the more entertaining the sport. Football has a persona that you must be tough to play and because of that stigma and perception, athletes will most likely never divulge that they are hurt. This is the most obvious critique of NFL’s approach to get the message out about the importance of concussions and head injuries. Children who grown up playing sports are always taught to “suck it up and play” so why would this change now? In fact within the NFL itself, nearly one-fifth of the one hundred sixty players surveyed by The Associated Press from November 2-15 replied that they have hidden or played down the effects of a concussion. This survey was done to assess what the players are really revealing in association with the NFL’s new concussion policy that was launched in December stating that a player may return to game play if they don’t have persistent symptoms after passing a neurological exam. (14) While this policy has it’s own challenges (i.e. players not wanting to get sidelined, fear of losing their job/position ranking and not getting paid, etc…), the PSA assumes the same for younger athletes as well.

To persuade athletes, parents, and coaches to change this engrained belief, and genuinely accept the message, there needs to be a connection to the audience or someone they can relate to. There is nothing for the target audience to connect with and in turn, urge individuals to genuinely accept the message and be persuaded to change this learned principal. To do this, the NFL must be keyed into the mindset of their target audience. (8) And attitudes such as Hines Ward from the Pittsburgh Steelers, when his teammate, Ben Roethlisberger had to sit out a game due to his recent concussion, when he said “I could see some players or teammates questioning, like, ‘It’s just a concussion. I’ve played with a concussion before.’ It’s almost like a 50-50 toss-up in the locker room. Should he play? Shouldn’t he play? It’s really hard to say. I’ve been out there dinged up. The following week, got right back out there”. is a great example of that stigma. (15)

The Proposed Intervention

In order to effectively prevent long-term health problems for athletes due to traumatic head injuries, players need to feel that they have the freedom to make decisions that will affect their lives. In the same sense, the parents and coaches need to have the correct information about signs, symptoms, and warning signs of concussions and what proper treatment needs to be given to the injured athlete so they can assist with proving education. As mentioned earlier, it is important that the message be relatable to the target audience, framed in a positive way so that it’s persuasive, and needs to be compelling to captures their attention. While the risks of concussion need to be known, it is important to portray the message of having the freedom to choose whether or not the consequence is worth it to the athlete. This can be done using an effective media campaign.

1.Message needs to be delivered to a more specific target audience to grab their attention in a compelling way

The “truth” campaign, that was launched in the year 2000 developed into one of the most successful and effective anti-smoking campaigns in U.S. history. Ads such as displaying 1,200 body bags laid out on the street, which covered two city blocks, as visual evidence as to how many people tobacco kills everyday was extremely eye catching. And, it was this sort of campaign message that inspired teenagers, the intended target audience, not to smoke. (10) It can be argued that the NFL is moving down the same road as tobacco industry giant Phillip Morris, when they made a failed attempt to release their own set of ads around the same time as the “truth” campaign. They’re slogan, “Think. Don’t Smoke.” was not so successful at changing the behaviors of teens. It portrayed a message of taking away a teenager’s freedom to choose. In fact, according to research published in the American Journal of Public Health in 2002, teens that were exposed to “truth” commercials were sixty six percent less inclined to smoke than those who saw the “Think. Don’t Smoke.” advertisements, which interestingly enough, had the opposite effect on a teen, who were more inclined to smoke by thirty six percent. (16)

To make this media campaign more effective, the target audience would need to be divided into three separate groups; athletes, parents, and coaches. Successful social marketing campaigns, similar to the media campaign used in Oklahoma County to combat one of their greatest public health problems, Syphilis, focused on delivering a specific message to a specific part of the population to change a specific behavior. Another approach using Social Marketing, allows the message and strategy to actually come from the target audience, increasing the effectiveness of the message instead of an expert view, who may have opinions and knowledge about the matter at hand, but are not actually part of the population that is affected. (17)

Formative research needs to be done to find out what makes each of the target audiences tick. This helps those planning a campaign produce messages that ring with the audience it is attempting to change their behavior. (10) One of the reasons why the “truth” campaign was so successful was due to the research done by those spearheading the campaign in order to directly relate to teens. They found that teenagers were looking for the facts and then wanted to be left to make their own decision. What they also learned in the investigation process was that a youth’s reasoning for tobacco use had nothing to do with making rational decisions, but rather everything to do with emotion. (10)

2. Encourage athletes, parents, and coaches to do more research based on evidence shown in the media campaign

Supporting what can happen from too many concussions or not taking proper care when they occur may be very powerful, so much that it would prompt additional research by the specified target audience. For example, a prevailing story is that of former San Francisco 49ers linesman George Visger. He now lives his life and has been for more than 20 years, using hundreds of small yellow notebooks. This is because of dementia, a condition he has acquired as a result of too many concussions, and he is forced to write down everything he does in a given day so he doesn’t forget. By him delivering the message that this is what his life has become and stating that he believes he had hundreds, maybe even thousands, of concussions from Pop Warner football all the way through his professional football career, there is no denying this would be an impactful message. (18) A case like George’s and showing his family and what they are left to cope with, could be targeted toward the parents to show how the potential of suffering from the consequences of repeated head trauma to their loved one.

For coaches, using a former NFL player who has suffered from concussions during his career and had a story about how a coach intervened or in some cases failed in this action, could serve as a strong spokesperson in targeting them, and compel them to be more involved in doing the same. Kurt Warner, the former St. Louis Rams, and most recently Arizona Cardinals quarterback, just retired from the NFL and is known for suffering from sustaining concussions. During a recent interview, he was quoted as saying; “I can tell you I wrestled with it when I was going down to that room to talk to them (before the game), saying, ‘Do I not want to tell them everything so I can play?’ But I had to go, ‘What are you thinking? This is bigger than that.’ The easy thing to do is play. The hard thing is to make that decision where you feel like you could be hurting your team, but you don’t know whether you’re putting yourself at risk or not.” (15) This is an important part of his story because most likely, this kind of thought goes through the mind of a player and it’s important that a coach keep that in mind. It may just be easier for a coach to step in and tell the athlete they are not allowed to return to play until cleared by a health professional.

Specific to children and teens, said Lisa Unsworth, the executive vice president of the Boston-based ad agency who is responsible for a separate state government sponsored anti-drug ad campaign, “Kids think they will live forever. Talking about a disease you may get when you’re 50 or 60 isn’t a compelling motivator.” (18) So, if this is true, then the evidence needs to be seen in a young athlete, someone like John Doe, whose name his parents asked to remain anonymous, was a multi-sport athlete, who suffered from multiple concussions and died at the age of 18. His brain was donated to the Center for the Study of Traumatic Encephalopathy (CSTE) at Boston University, who collects and studies the brain and spinal cord tissue of deceased athletes to gather more information and evidence on the effects of trauma to the human nervous system. John Doe, the youngest brain at the CSTE Brain Bank, was already showing signs of CTE, which was defined earlier. (19) This may motivate children and teens to re-think they’re attitude that they are invisible to this type of hazard.

3. In order to encourage athletes to report symptoms, the culture needs to change

This is where the NFL can set the bar and make the most impact. They can serve as the role model for not just college, high school, and Pop Warner football, but all of sports to achieve a trickling down effect. Fortunately, they are now really taking the issue seriously. In December, Roger Gooddell sent a memo to all NFL teams informing them of a new concussion policy where, if a player has symptoms of amnesia, poor balance and an abnormal neurological examination; they are required to be removed from a game. A player can return to the field with symptoms of dizziness and headache, but only if they are not “persistent”. Formerly, players could return to a game or practice once their symptoms subsided, assuming they actually reported it. (20) Most recently, the NFL formed a new “mild traumatic brain injury” committee and Roger Goodell hired two new chairman for this panel, Dr. H. Hunt Batjer, the chairman of neurological surgery at Northwestern Memorial Hospital in Evanston, Ill., and Dr. Richard G. Ellenbogen, the chief of neurological surgery at Harborview Medical Center in Seattle. Unlike the previous chairmen, who were paid by the NFL, which consequently, was considered a conflict of interest, the NFL, except for costs associated, will not pay these two doctors. (4) Other changes that are being looked at for future policies are banning helmet-to-helmet hits on ball carriers, roster exemptions for a player suffering from a concussion, stricter guidelines for practice that would limit the amount of hits, new helmet design, and a possible removal of the three point stance in the line of scrimmage. (20,21)

Instilling change is not easy and takes time. Being persistent and planning for a long time frame is necessary. If you consider the lessons learned from some of the cardiovascular risk reduction programs, it may take up to ten years for an effective distribution of new policies and ideas to produce social change that is measurable. (11)

Conclusion

While the NFL is taking other measures to make the game of football safer and implementing new policies for when a player is injured, they have a crucial opportunity to be the leader and send a clear and successful message to those athletes in any sport. They seem to be taking a positive step in the right direction and acting as the future role model to combat the traumatic brain injury problem. They just need to do a better job of delivering that message to instill change across the sports world.

References

1. “Traumatic Brain Injury” Centers for Disease Control and Prevention accessed from http://www.cdc.gov/TraumaticBrainInjury/index.html
2. “Conveyers Plans Hearings on NFL Player Injuries” US House of Representatives Committee on the Judiciary (2009) Accessed from http://judiciary.house.gov/news/040908.html
3. Daneil Kain “NFL’s Work on Concussions Far From Over” National Football Post, (1/4/2010) Accessed from http://www.nationalfootballpost.com/print.html&post=NFLs-work-on-concussions-far-from-over
4. Alan Schwarz “N.F.L. Picks New Chairmen for Panel on Concussions” New York Times, (3/17/2010) Accessed from www.nytimes.com/2010/03/17/sports/17concussions.html
5. National Football League and Centers for Disease Control and Prevention Head Injuries PSA You Tube Accessed from http://www.youtube.com/watch?v=NhgIfWl40m4
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