Sunday, December 16, 2012

Empowering Teens to Make Healthy Choices: Appealing to Core Values and Avoiding Shame and Stigma – Jennifer DeAngelis

Introduction: Adolescent Obesity and the Strong4Life Campaign
It is a problem that most Americans are well aware of. It has become almost impossible to turn on the news or look at the daily paper without seeing new research that paints a bleak picture of the future of America. Obesity rates are growing, and it is no longer an “adults-only” problem. Child and adolescent obesity rates are an all-time high, affecting 17% of all children and adolescents in the United States. When including overweight children, this number increases to more than one third of kids and teens in the US (1). From 1980 to 2008, the percentage of adolescents and children who are obese tripled (2). Research suggests that this may be the first generation of children that have a shorter life expectancy than their parents (3). Adolescent obesity has been shown to be associated with a risk severe obesity in adulthood, and 0bese children are more likely to become obese adults. Statistics show that children and adolescents who are obese have a 70% to 80% chance of becoming overweight or obese adults. (4,5). The U.S. Preventive Services Task Force found enough evidence to recommend both screening for obesity in children and adolescents and the referral overweight and obese children to behavioral interventions (6). The American Academy of Pediatrics and the Institute of Medicine have both developed national strategies to address the issue of child and adolescent obesity (7). To summarize, the importance and scale of child and adolescent obesity has been well-defined. As a nation, we are not lacking knowledge or understanding of the issue; we are failing in finding ways to solve the issue. The difficulty lies in translating what we know about issue into a successful public health campaign. The research is there, but the puzzle piece that health professionals are missing is how to implement that research into practice and reach out to the public directly.
One public health campaign that sought to address the issue directly is the Children's Healthcare of Atlanta's “Strong4Life” campaign. This video and print campaign attempted to bring attention to child and adolescent obesity through stark images of overweight and obese kids and teens with phrases designed as warning labels such as, “It’s hard to be a little girl if you’re not” and, “Big bones didn’t make me this way, big meals did” (8). Immediately after its release in May 2011, the campaign drew high levels attention and was drawn into a battle of controversy. By the time billboards were raised of images of overweight children with warning labels in January 2012, the issue became a national debate. Advocates touted the need to “wake up parents” and call attention to the issue of child and adolescent obesity. Critics questioned the in-your-face tactics of the campaign, and expressed concern over the message it was sending to children. By March of 2012, the billboards had been removed, and the Strong4Life website had been updated to include a more positive message (9, 10). The revised web messages, though, still dose out the harsh reality of the world of childhood obesity. The website does so by addressing parents with images of overweight children, along with the common “excuses” given by parents for why kids are overweight. The Strong4Life campaign has been successful in bringing attention to a public health issue that is in need of action that goes beyond the research level. The campaign, however, was unsuccessful in considering and integrating social science and marketing theories to address this public health problem and reach out to its audience. The following critique discusses the failings of the campaign, and offers suggestions of a revised approach. While the Strong4Life campaign is meant to address both children and adolescents, this critique focuses on adolescents, ages 12-19.

Critique 1: The campaign casts a wide net, and misses the core values of its audience.

            The Strong4Life campaign seeks to address the issue of obesity in children and adolescents with advertisements and print images of both young children and teens presented in a similar fashion. Young children and teens, though, are very different audiences that face different realities and have markedly different core values. The activities of young children are driven by that of their parents, which is why this campaign focuses on shocking parents into action. Teens are just reaching the point of their lives in which they can start making their own health decisions, and the campaign fails to recognize this when determining which core values to appeals to. The Strong4Life campaign relies on the core values of health and fear, which are weak core values regardless of audience. For teens, though, health is an extremely weak core value because research shows that teens are likely to be more motivated by immediate rewards, which are very rarely tied to health (11).
In addition to being weak core values, this campaign delivers these values through an authority figure. A main focus of the Strong4Life website is helping parents have “the Talk” about obesity with their child or teen. While this may be a technique that can work for younger children, this in direct conflict with the main core values of teens: independence, rebellion, and control. In the method utilized by Strong4Life, one authority figure, the campaign, is helping another authority figure, parents, dictate the choices of teens. The threat to freedom and control that teens are likely to experience as a result of the implementation of this campaign goes against the lessons learned by the theory of psychological reactance. The theory of psychological reactance states that individuals have an adverse reaction in response to regulations or impositions that threaten freedom and autonomy (12). When communicating a health message, it is important to be cautious not to evoke reactance or a likely result is an action that is opposite of the health behavior you are attempting to reinforce. There are ways to lower psychological reactance, including using interpersonal similarity when delivering a health message, but this campaign did not utilize these methods and instead chose to use the authority figure that teens resist the most, parents. As a result, the campaign is likely to result in high levels of psychological reactance in teens, lowering the likelihood that teens will be receptive to the message and have a desire to adopt the health behaviors that the campaign is advocating.
By not recognizing teens as an independent audience that differs from younger children, using core values that do not appeal to teens, and delivering those core values in a way that opposes strong teen core values, the Strong4Life campaign misjudges its audience and, as a result, is not able to appeal to that audience when delivering their health message.

Critique 2: The campaign relies on shame, stigma, and isolation.
The criticism of Strong4Life that was used most often in the public resistance to the campaign was the potential for shame and stigma resulting from the methods implemented to get the message across. Shame and negative attitudes towards overweight and obese individuals is a major problem in the United States. Many studies have identified harmful stereotypes associated with overweight individuals including laziness, low will-power and a lack of self-discipline. It has been estimated that, over the past decade, weight discrimination in the United States has increased by 66% and is now comparable to prevalence rates of racial discrimination (13). Despite the knowledge in the public health field of the harm of stigma, and the movement to reduce the stigma against various diseases and population, little has been done in the public health field to address the issue of stigma and obesity. The Strong4Life campaign is an example of how some in the public health field are actually using shame and stigma as a tool to prevent obesity. Much like the research on stigma in other areas of health, research on obesity shows that using shame and stigma to encourage healthy behaviors is a potentially harmful method, particularly for children and adolescents (14). For kids and teens, stigma can be internalized and lead to low self-esteem and poor body image. Stigma about weight most frequently comes from peers, but can also come from parents, teachers, and other adult figures. Research has shown that weight-related teasing is associated with disordered eating behaviors that may increase the risk of weight gain in overweight youth (15). By using stigma as a tool, the Strong4Life campaign helps to foster the use of shame, blame, and teasing against overweight adolescents instead of finding ways to move past the stigma associated with being overweight.

Critique 3: The campaign unsuccessfully uses advertisements and does not speak to the aspirations of teens or effectively “sell” them on a movement.

            Even though the Strong4Life campaign uses advertisements, it does not effectively utilize advertising theory, which is a major flaw of the campaign. At the core of advertising is the promise of something; effective advertising identifies the target audience’s aspirations and promises that they can reach the aspiration through the product or activity that the advertisement is “selling.” Also central to advertising theory is the support for the promise. Without these two elements, even if advertisements are used, a campaign does not effectively use advertising theory to change behavior (16). The Strong4Life campaign promises health, and does so with the support of striking fear through using visuals of overweight teens. Neither this promise nor the support is effective in reaching teens. The promise of “health” is not something teens relate to, particularly since they are more likely to act when there is an immediate reward, rarely the case with health (11). The support of using fear and, “this could be you,” is also something that is not an effective tool while dealing with teens. As a group, teens are extremely susceptible to the phenomenon of optimistic bias. Optimistic bias is the feeling of “that won’t happen to me,” the misperception that an individual is less likely than others to experience negative consequences from health behaviors (17). Since the support of the Strong4Life advertisements is fear of future negative health outcomes, that support is likely to be discounted by teens through optimistic bias.
Another important component of advertising theory is imagery, which is part of the support of the promise. Part of this imagery is the messenger used to express the message.  An effective messenger should be engaging/likeable, credible and relevant to the audience by being similar or familiar (18). For the initial billboards of the Strong4Life campaign, Georgia children and teens were used as the messengers. While images of local teens should have led to a sense of familiarity for the teen audience, these billboards depicted black and white images of sad, overweight children of different ages and genders. A bleak, black and white image does not resonate with most teens, even if that image is of a teen. Even the revisions to the website, which now include more vibrant images, focus on conversations between parents and kids of varying ages. Again, this is not something that gives teens a sense of identity or belonging. The Strong4Life campaign does not depict images that teens relate to, or that they strive to be. As a result, the ads are not successful in motivating teens to act.
By missing the mark on identifying teens aspirations, offering an unappealing promise, providing ineffective support for that promise, and using messengers that teens do note relate to, the Strong4Life campaign is in direct opposition with advertising theory and the components of a successful advertisement.

Alternate Intervention: Empowering Teens and the Prove them Wrong Campaign   

            The Strong4Life campaign had the right idea in getting the message of adolescent obesity into the public agenda. It fell short, though, in properly using social science theory to reach one of its target audiences, teens. A successful campaign that got the issue out to the public but was also successful in reaching teens directly is the Truth campaign. The success of the Truth campaign stems from accurately identifying the core values of teens, using advertising theory to appeal to those values, and proving a sense of belonging and the creation of a movement (19). In keeping with the lessons learned from the Truth campaign, the proposed Prove Them Wrong campaign would appeal directly to teens as the target audience, using social science theory to avoid the pitfalls that other public health campaigns have faced. The Prove them Wrong campaign puts teens in charge and appeals to their core values of independence, rebellion, and control. The campaign centers around its titular slogan, “Prove them Wrong.”  Teens are called to action to gather as a generation and prove that the researchers, marketers, parents, teachers, and other figures of authority that label them as lazy, unmotivated, and unhealthy are wrong. To get its message out to the public, Prove them Wrong commercials would contrast black and white images of authority figures stating what they think of teens and health behaviors with vibrant images of teens being active and using positive health behaviors. The focus, though, is on proving whatever the authority figure states as wrong, instead of telling the teen that the alternative behavior is the “right” thing to do. An example commercial would run as follows:
Prove them Wrong- TV Spot 1
Black and white footage of older, stodgy looking researchers poring over papers full of figures and numbers.
-(teen voiceover) “Researchers say that our generation will be the first to not live as long as our parents”
Shift to a group of kids playing a pick-up game of basketball at a local court.
-(one teen looks directly at the camera) “Prove them wrong.”
Black and white footage of a marketer giving a presentation, the PowerPoint notes that teens are an easily influenced group and notes to “use peer pressure!”
-(teen voiceover) “Marketers and fast food companies think that they can control what we eat just by showing commercials with ‘teens like us’ doing what they want us to do.”
Shift to a group of kids hanging out around a table outside of school, eating a variety of different healthier foods.
-(one teen looks at camera and shrugs) Prove ‘em wrong.
Black and white footage of a parent or grandparent figures shaking a finger at a teen.
-(teen voiceover) “Our parents and grandparents say that our generation has it easy, and that they used to be more active and walk miles to and from school every day.”
Shift to a group of teens walking to school, some on skateboards, while others bike by.
-(teen with a skateboard stops and look at the camera). “Just prove them wrong.”
Black and white footage of a classroom where a teacher is lecturing.
-(teen voiceover) “Our teachers tell us that we spend the entire day sitting in front of a screen and that we are wasting our time being lazy.”
Shift to a group of teens playing a dance video game and challenging one another to a dance off
-(while dancing, a teen turns to the camera) “Prove them wrong!”
Shift to alternating images of teens for each sentence.
“Our future is in our hands. We have the power to change an entire generation, our generation. Become a part of the movement…let’s prove them wrong!” (pan out on a large group of teens, all shouting together, holding three large signs “Prove” “Them” “Wrong”).
This commercial, and the slogan, appeals not only to teens need to have freedom and control, but also to the desire to be part of a group. This commercial, and others like it, would be used to draw attention to the movement and direct teens to the core of the campaign, which would be its website and social media pages. The website would house different areas that are integral to the campaign and focus on eating well and physical activity, as described below.
A recipe section entitled “Teach Your Parents a Thing or Two” acknowledges, in an indirect way, that many negative eating habits start at home and empowers teens to change that by providing easy to make, healthy recipes. One barrier that many overweight teens will face in the area of eating well is access to healthy foods. Obesity rates are higher in low-income areas, and many of these areas also have fewer options of ways to get healthy food (20). While this campaign is not focused on increasing availability of healthy food, the website would have a “Where to Shop” section that would allow teens to search by zip code to find supermarkets and farmers’ markets in their area, as well as how to get there. In addition, there would be a “Money Matters” section that offers budgeting tools as well as links to coupons. As the campaign develops, partnerships with grocery stores and health food companies could lead to an increase in the availability of coupons. These sections of the site are provided to help teens feel a sense of ownership and control over their eating habits.
Similar sections would be created for physical activity. There would be lists of free activity ideas (“Get out and Move, Without Spending a Dime”), a gym/fitness/community center search by zip code (“Where to Break a Sweat”), and other tools for teens to incorporate more physical activity into their day to day life. The key to this section is to appeal to different types of teens. This is not a “jocks only” section of the site. There will also be ideas for skateboarders, gamers, dancers, and those with two left feet. The activities will not be labeled in a specific way, but each activity will link to others that offer suggestions based on that activity. This way, if a teen finds one that fits their lifestyle, they will be able to link to others that might as well.
To reinforce the slogan, the final components of the website are all interactive ways for teens to get involved. This will include a “Go Ahead, Show Off” section that houses annual contests of schools, teams, clubs, and other groups to show how they are proving the assumptions about their generation wrong. Also, there will be a moderated “Rant and Rave” page that allows teens to express barriers they face, stereotypes they have encountered, and other issues that are bothering them, as well as to share success stories. This would not be a discussion board, but instead a snapshot of issues that teens face when trying to be healthy and examples of how to overcome. This page will serve as a symbol of teens coming together as one generation with common experiences. Lastly, there will be a “Make a Difference” section that provides teens with resources to help them fight for bringing PE back to schools, healthier lunches, better access to healthy foods, and other policy areas that teens can start to get involved in.
The goal of the campaign is to provide teens a sense of belonging and give them the tools they need to fight against the perceptions that individuals of authority have placed on them when it comes to eating right and being active.

Alternate Intervention Response to Critique 1: Appealing to teens through the core values of independence, rebellion, and control.
At the center of the Prove them Wrong campaign is the recognition of the core values of its audience, independence, rebellion, and control. The campaign does not attempt to cast a wide net that includes both children and teens, instead it focuses completely on teens. Using lessons learned from the Truth campaign, the Prove them Wrong campaign asks teens to take control of their life, and fight against the preconceptions that adults have about their generation. With the Truth campaign, there was a clear “enemy” to rebel against, tobacco companies. An “enemy” in the fight against obesity and sedentary lifestyle is harder to identify. The utility of the enemy, though, is simply to ban teens together. So, the Prove them Wrong campaign uses different figures of authority telling teens how they see the future of the teen’s generation, which is a direct violation of a teen’s sense of control and autonomy. Marketers that believe they can manipulate what teens eat through peer pressure and commercials, parents that label their generation as lazy, researchers that are convinced that this generation will be the first to have a shorter life expectancy than their parents; all of these authority figures serve as the faces of control over the choices teens make. This campaign gives teens the tools and resources to fight for their core values of independence, rebellion, and control.
            By appealing to teens’ core values and avoiding limiting their sense of control, this campaign also attempts to lower psychological reactance against health behaviors. Psychological reactance against positive behaviors stems from the belief that an authority is trying to limit ones control or force a specific behavior on individuals (12). Since the health message needs to be delivered in some way, though, the campaign employs proven methods of reducing psychological reactance. Specifically, since all messages in the commercials, advertisements, and website are delivered to teens by teens, the method of using similarity to reduce reactance is employed. Research shows that messages delivered by individuals that the audience can relate to and are similar to are better received, seem less threatening, and are most likely to be acted on (21). The Prove them Wrong campaign recognizes the utility of this aspect of social behavior, and uses it to help build a successful campaign.

Alternate Intervention Response to Critique 2: Leaving shame and stigma aside and giving teens a sense of belonging and a way to become part of a movement.
Unlike the Strong4Life campaign, there is no room in the Prove them Wrong campaign for shame or blame. The campaign does not use stigma as a way to call attention to the issue of teen obesity and unhealthy eating habits. In this campaign, teens are all in it together; the campaign creates the movement of a generation. Attention is brought to the issue through a call to action for all teens to change the way others view them and to change the future of not only their generation, but generations after them. Instead of using stereotypes as a component of the campaign, the Prove them Wrong campaign sets out to banish stereotypes and create a sense of belonging. By giving teens a common goal, there is no need to use stigma to relay a message. Giving teens a group identity is more effective than trying to isolate out those with “weight problems”. Research has shown that a successful way to deal with the growing issue of obesity is by reducing the stigma related to obesity. This use of stigma is prevalent in individual-focused interventions geared only towards those that are overweight or obese. This campaign uses a method of reducing that stigma by choosing to focus on implementing healthy behaviors in all individuals, regardless of size (13).
By going beyond those that have already been labeled obese or overweight, and not focusing on labels at all, the campaign is also able to reach a wider group of teens. Since the campaign focuses on the identity of an entire generation, it reaches the full cohort, even though some may not be considered overweight or obese. This technique benefits both those who are overweight/obese (by reducing stigma) and those who are not be reinforcing positive health behaviors. Empowering all teens to be healthy, instead of isolating a group of teens to work to improve their health, bonds the group together and allows them all to work towards a common goal instead of following a set of pre-determined rules.

Alternate Intervention Response to Critique 3: Effectively using advertising theory by appealing to teen’s aspirations and depicting relatable images.
The Prove them Wrong campaign seeks to effectively use the core components of advertising, the promise and the support of that promise (16). Moving away from the promise of health and future health outcomes, this campaign instead focuses on the promise of control over one’s behavior.  It empowers teens to want to take control over their own life instead of relying on a desire to be healthy. There are immediate, tangible outcomes of making a difference instead of focusing on down the road negative health outcomes that may or may not happen. The promise is one that speaks to teens; that empowers them to make healthier choices instead of giving them a list of dos and don’ts. Unlike the Strong4Life campaign, this promise is not fulfilled through listening to authority and doing the “right” thing for your health, as determined by others. It is the promise from one teen to another, multiplied across the entire group, that if they work together, they can make a difference in the way the world looks at them. It is a lofty promise, but lofty promises are at the core of effective advertising. It hits teens emotionally and in the heart, instead of appealing to rationality and the brain.
The Prove them Wrong campaign utilizes a wide range of support for this promise: images of relatable teens that are showing healthy behaviors in day to day life, putting a face to the “enemy” of the fight against teen obesity, sharing struggles and success stories over the web, and showing real ways that teens can get involved and make a difference. This support works to appeal to the core values of teenagers and recognizes what they aspire to. Unlike the Strong4Life campaign that uses fear of future negative health outcomes as support for its promise of health, this campaign recognizes that there are values more important than health, and vehicles far superior than fear in delivering those values.
The promise and support of the Prove them Wrong campaign work together to create a brand for the campaign, an identity that is projected to teens and to those that question teens. Prove them Wrong includes the necessary elements of a brand, imagery (of both the teens and “enemy), a slogan, and a group identity that allows them to compete with the branding of unhealthy messages (22). By creating a brand, Prove them Wrong goes beyond a simple public health campaign and becomes a movement.

            The Strong4Life campaign, as with so many other public health campaigns, has an important goal but a flawed approach. The weakness of the campaign stems from one basic misstep, not fully understanding their audience, particularly the teen portion of their audience. The Strong4Life campaign misses the mark on identifying the core values, aspirations, and struggles of teens. For an age group that is constantly dealing with feeling misunderstood, this campaign plays right into the teen hand of the, “they don’t get me” mentality. The Prove them Wrong campaign takes a different approach. It is built specifically for teens. It appeals to the core values of control, rebellion, and independence. It recognizes the importance of delivering messages to teens, by teens. It offers them ideas, tips, and tools that can help them take control, be independent, and make a difference for their generation. It is not simply a list of what they should do or how they should change their behavior; it is a brand, a movement, an identity, and a way of life that teens can join and be a part of. It allows teens to take control, and prove everyone that underestimates them wrong.
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