Challenging Dogma

...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

Fundamentals the VERB™ Campaign Should Not Have Missed: Key Factors in Promoting Physical Activity in America’s Youth – Christopher Lourenço

There is growing concern over the effects of sedentary lifestyles on the health of young people. Recently, there has been much scientific and media attention given to the escalating rate of juvenile obesity. Researchers have attributed this phenomenon partly to an increase in television viewing, computer gaming, and other sedentary behaviors common among adolescents (1). These kinds of behaviors are thought to impede physical activity. During the past 20 years, the percentage of overweight children and adolescents has doubled(2). Recent reports indicate that five of every eight children aged nine to 13 do not participate in any organized physical activity during their non-school hours, and almost one fourth do not engage in any free-time physical activity (3). There is a moral panic concerning the “couch kids” culture in modern western society.

In response to the increased concern about the health of our nation’s youth, Congress appropriated $125 million in 2001 to the Centers for Disease Control and Prevention (CDC) to develop a campaign to change children’s health behaviors (4). The CDC’s response to this broad mandate was to focus on the sedentary lifestyle of young adolescents and to develop VERB™, a national media campaign launched in June 2002 to increase and maintain physical activity among “tweens”, or children aged 9 to 13 years (4). Its purpose was to reframe beliefs and norms about being physically active daily by playing, having fun, and trying new “VERBs”, or new ways to be physically active (4). The campaign combined paid advertising, marketing strategies, and partnership efforts to reach the distinct audiences of tweens (5). VERB’s primary vehicle for reaching into the home were commercials that aired on age-appropriate television and radio channels such as Cartoon Network, Nickelodeon, The WB, ABC Saturday Morning Disney (4).

Although the campaign brought together a diverse array of public health, marketing, and community experts, VERB used public health models that focused on individualized approaches to behavioral change (6). Current researchers have found that children’s health depends a lot on their economic, social and physical milieu (7). For the VERB campaign to be more successful, it should look at the level of physical activity of children within the context of their "ecosystems" - family, community, culture and physical environment. These elements all provide the economic, physical and social conditions compatible with health and a healthy lifestyle involving physical activity.

“Physical” Environment
One major factor that the VERB campaign developers could have focused more on was the environment. Environments have large implications on the amount, kind, and level of physical activity a child has (8). The first environmental concern is the child’s physical surroundings. Issues like whether the teens live in urban or suburban settings and whether they have access to sport/recreation facilities affect their physical behavior (6,8). Children can have environments, including neighborhoods and households, that do not encourage physical activity. Ultimately these environmental factors create a fundamental difference in physical activity levels and motivation levels (8). The CDC conducted various studies during the life of the VERB campaign to examine it’s effectiveness (9-12). In one focus group that was part of these studies, children pointed out when parks or playgrounds in ads did not look typical of those in their neighborhoods, it lowered their motivation to participate in those types of activities (10).

Another concern was population density. Some VERB commercials did show some simple neighborhood games that could appeal to all youth, but not all children live in areas where there are many other peers around. The CDC studies stated that having others around in the same age seemed to be important for providing spontaneous play (8). A child with no one his or her age living in the neighborhood does not have the kids close by the play with. Consequently, they tended to spend more time alone, watching television, talking with friends on the phone and playing on the computer (8).

VERB also failed to address the availability of resources to tweens in relation to their environments. Children could feel drawn to a certain activity, but might live in an area where that activity might not be conducive. Take swimming for example, a child could be excited to try swimming but if he or she does not live near a body of water, or has no access to any public pools, they might not have the chance to engage in that activity that excited them and feel more discouraged (10). These differences will also depend on the geographical differences of where tweens live. For instance, physical activity options may vary from a Mediterranean zone like Southern California where seasons stay reasonably warm and constant, to the North of the country where they will experience harsh winter months. Water sports could be available in some zones, where mountain sports could be useful in others.

Neighborhood safety is another factor. Perhaps the VERB campaign could have worked better back in a decade when children were told to ‘go out and play’, but some parents today might not feel comfortable with their children out by themselves in certain neighborhoods. In the VERB focal groups, safety was a major concern for all mothers, which affected how much and what types of activities their children could participate in (9). Most found it a challenge just letting their children play freely in the neighborhood, as they feared kidnapping (9). Others felt that their neighborhoods had a lot of traffic and potentially bad influences making it unsafe to be outside (9). Some children might have the luxury of having parents around to accompany them, for example bringing them to parks or public sports facilities, while other children might have parents that have long work schedules or low incomes, and do not have the recourses necessary to promote safe physical activity.

VERB, since it was a national campaign, maybe could have been more ubiquitous in its effects if these environment issues were addressed. Perhaps it could have had separate marketing for urban youth and suburban youth, focusing in activities that would be feasible in each environment. Results from one of the CDC studies show that developers should focus more on ads that depict simple activities that have year-round and universal appeal (10).

The Balance of Culture and Gender
Cultural perceptions of physical activities need to be considered in physical activity campaigns. Two of the CDC studies examining VERB looked at Hispanic/Latino and Asian family responses to the campaign. Differences could be seen in the way each family perceived the same advertisement (11,12). Hispanic/Latino mothers responded favorably to ads that they felt generated the excitement of being active (12). These same ads elicited negative responses by the Asian American parents. The commercials showed children talking out of turn, especially interrupting adults; being noisy; and running indoors. These were interpreted as rude behaviors and distracted parents from grasping the intended message (11). Verb physical activity messages should align with traditional Asian values that promote respect for ones’ elders, family togetherness, parental involvement, and parental responsibility for their children’s development.

Gender issues also arise in cultural responses to VERB. In the studies done by CDC, Asian American mothers were touched by the image of a father running after his children in a park. Some mothers (Chinese and Filipino), however, pointed out that the ads tended to be male-centered (11). In their perception, the ads exaggerated the level of involvement of fathers in their children’s lives, making the role of mothers seem less significant. They believed that mothers have the strongest influence on their children’s lives, but that it is most important for concepts to promote equity when depicting parent’s involvement in their children’s activities (11). These responses were more pronounced among the Chinese and Filipino single mothers and were less acute among Korean fathers and Vietnamese mothers, who overall regarded the father as the central figure of the family. Similar parental reactions occurred when ads focused on male, but not female, tweens (13). Verb ads have to avoid depicting physical activities generally associated with boys by using only male actors in the ads; similarly, avoid depicting physical activities typically associated with girls using only female actors. Ads that show both boys and girls actively playing together are more likely to appeal to both genders. A perception of gender bias may distract the audience from the intended message (13).

To reach both boys and girls, campaign developers have to be aware that differences do exist between tween girls and boys. These differences are even reflected in the preferences for words, images, and activities (13). For example, one CDC study on VERB’s efficacy indicated that tween boys liked ads, Web sites, and videos that are edgy. Girls, however, responded negatively to the same ads (5). Tween boys especially responded best to things that they think would be considered edgy among children 2–3 years older than themselves, where as this made no difference to the girls (5). For a campaign like VERB to be effective in reaching all youths, it must understand these differences and should try to seek a middle ground whenever possible.

Parents Matter
Even if VERB successfully incorporated the elements mentioned above, all would be to no avail without parent involvement. It is a reality that children alone cannot be solely responsible for their levels of physical activity. Studies done at the Vanier Institute of the Family demonstrated that parents and adults play an integral role in the health of their children (7). According to Professor Louise Potvin of the Department of Social and Preventative Medicine at the University of Montreal, young children develop most of their strategies for interacting with their environment from their parents (7). She also states that it is also within the family that most adults make important decisions regarding health-related behaviors such as dietary habits, or taking time for physical exercise (7).

Even if the children responded well to the VERB campaign, the program does not last without adult involvement. The CDC focal groups examining the VERB campaign showed that in general, the parents of low activity children were not thinking of activity for their children (9). The majority of the parents felt activity was a good thing, it was just was not viewed as a priority and they seemed to be most focused on the present, getting through each day. Many of these mothers felt torn and guilty. They knew they should get their children more active, but were extremely busy and many found it exhausting and difficult to stay on top of all of the demands and schedules of their family (9). Other parents just simply held physical activity at a lower priority level. Most pushed their children to do homework and do well in school. They felt that education was the primary road to success. Exercise and activity were secondary to schoolwork (9).

Another problem with VERB was that many adults were just simply unaware of it. The campaign specifically focused on the tweens, and ads aired around shows that most adults did not follow. In one of CDC’s VERB follow up studies, most parents who were interviewed stated that they rarely watched these channels with their children and were unaware of the ads (14). "There is not a tremendous amount of adult awareness of Verb, but we haven't targeted them," says Stella Kusner, account director on the Verb campaign for Frankel, a Chicago marketing agency (4). “Any youth program (promoting physical activity) would fail if it does not consider the parental impact” (4). Adults are the ones that would speak up to congress to advocate for the VERB campaign, and who are the ones primarily paying for it (10). In fact, in 2006, the VERB campaign was denied funding and came to an end. Studies on VERB’s effectiveness showed that the lack of integration on the part of parents and policy makers into the program is the reason it was shut down (10). The VERB campaign forgot that families have everything to do with health.

The Future of Physical Activity Campaigns
The VERB media campaign was a strong tool and showed much promise, but it didn’t have nearly the amount of money and support invested in it. Any amount invested in physical activity promotion, however, remains miniscule compared to the health and social costs of inactivity and obesity, or indeed to the amount spent on commercial marketing to tweens. Thus, campaigns like VERB represent a strong commitment to improving youth health because it requires a large investment in paid media (5). A child’s lifestyle or behavior change like increasing physical activity is difficult to achieve and even more difficult to sustain, especially at the national level, given the ingrained societal acceptability of sedentary behaviors (5).

The public health challenge is to penetrate the commercial-marketing media morass with well-designed messages that reach their target population of children and parents. Inducing change in beliefs and norms is only the first step, however. Subsequent challenges are to create physical environments and spaces for tweens to move, play, and be active. The challenge involves advocacy, support, and policy change at the local and state levels to provide resources to construct or redevelop activity-friendly environments, such as schools, parks, trails, and neighborhoods. Physical activity promotion has to extend beyond a media campaign like VERB and must emphasize the need to form community partnerships to reinforce the media component and initiate community events (1). It will be quite difficult to combat the sedentary influences of the technology age and pop culture institutions, but if a future VERB campaign could have anything close to the media tools that these companies have, we could see a chance to influence physical activity in the youth of America.

1. Biddle, et al. Physical activity and sedentary behaviors in youth: issues and controversies. The Journal of the Royal Society for the Promotion of Health 2004; 124: 29-33
2. Ogden CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002; 288:1728-32.
3. National Health and Nutrition Examination Survey; NHES 11/111 (1963-70) NHANES I (1971-74), NHANES II (1976-80), NHANES III (1988-94). Hyattsville (MD): National Center for Health Statistics; 2003. NHANES Databriefs.htm.
4. Bauman A. Commentary on the VERB™ campaign — perspectives on social marketing to encourage physical activity among youth. Prev Chronic Dis 2004; July
5. Wong F, et al. VERB™ — a social marketing campaign to increase physical activity among youth. Prev Chronic Dis 2004 Jul
6. Kahn et al., The effectiveness of interventions to increase physical activity. A systematic review. American Journal of Preventive Medicine 2002; Vol 22, Issue 4:73-107
7. Potvin, L. Health promotion -- a family affair. Transitions. Vanier Institute of the Family 1995; June.
8. Hill JO, et al. Obesity and the environment: where do we go from here? Science 2003; 299:853--5.
9. Spencer Hall. Inspiring Children’s Physical Activity: Exploratory Research with Parents. CDC 2003.
10. Huhman, M. Effects of a mass media campaign to increase physical activity among children: 1-year results of the VERB campaign. Pediatrics 2005; 116:277-284.
11. Synthesis of Learning across 3 Years of Concept and Message Testing among Asian American Tweens and Parents. CDC 2003.
12. Synthesis of Learning across 3 Years of Concept and Message Testing among Hispanic/Latino Tweens and Parents. CDC 2003.
13. Strauss RS, et al. Psychosocial correlates of physical activity in healthy children. Arch Pediatr Adolesc Med 2001; 155:897-902.
14. Shwartz, Nacy. CDC's Verb Campaign to Get Kids Active Drops the Ball on Engaging Teachers and Parents. Getting Attention 2006.

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