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.
Conclusion
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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Labels: Adolescent Health, Nutrition, Obesity, Pink
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