Challenging Dogma

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

Thursday, April 19, 2007

“Powerful Bones. Powerful Girls” Goes Unheard-Applying Agenda Setting Theory for a Stronger Message. – Rita Gillam

Affecting over 44 million Americans, most of who are over the age of 50, osteoporosis is a major health threat for the aging population of the United States. Women are at particular risk, comprising four-fifths of the population currently suffering from osteoporosis. Unfortunately, the onset of osteoporosis in late adulthood is prevented by health behaviors acquired and practiced before the age of 30 (1). It is for these reasons that the US Department of Health and Human Services, which includes the Centers for Disease Control and Prevention and the Office on Women’s Health, and the National Osteoporosis Foundation joined forces to create the National Bone Health Campaign, part of which consists of “Powerful Bones. Powerful Girls.”

“Powerful Bones. Powerful Girls.” is a federally funded educational, web-based campaign designed to give girls between the ages of 9 and 12 and their parents the motivation and tools to embrace the bone-friendly behaviors which may thwart the onset of osteoporosis in later adulthood. In addition to a website, linked from the CDC’s site, for girls and a separate site for their parents, “Powerful Bones. Powerful Girls.” includes print materials, radio advertisements, and printed materials for both the girls and their parents (2). The goal of this campaign is two-fold: to persuade girls in the target age group to consume more calcium, and to encourage weight bearing exercise, which has been shown to contribute to increased bone density in the hopes that the participating girls will form the life-long habits which prevent osteoporosis (1, 2). At the present time, this campaign has been integrated into some state programs such as school curricula and health fairs; however, it is by no means ubiquitous. Therefore, while “Powerful Bones. Powerful Girls.” utilizes several key features of social learning theory, which might allow it to become an effective public health intervention, it exists mainly isolated from the real world. The application of several additional social science theories, including agenda setting theory, to this campaign would greatly enhance its effectiveness.

Media Presence
Although the “Powerful Bones. Powerful Girls.” website for girls retools osteoporosis as a problem to be prevented in the present, rather than worried about in the future, this message is not pervasive in the media. The campaign does use both radio and print advertisements aimed at the girls themselves and their parents (2). However, one might ask oneself the following: when was the last time you witnessed a 9-12 year old girl listening to a public health announcement on the radio? Therefore, in order for “Powerful Bones. Powerful Girls.” to effectively reach its target audience and become an important topic on the public health agenda, the National Bone Campaign needs to penetrate the two media outlets most utilized by young girls: the internet and television.

Ironically, although “Powerful Bones. Powerful Girls.” is a web-based outreach, evidence of it is difficult, if not impossible, to find away from the CDC website. For example, the CDC site references a partnership with Girl Scouts of America, however, a visit to the Girl Scouts website reveals two things: first, it contains a section geared specifically toward the demographic targeted by “Powerful Bones. Powerful Girls,” and second, there is no mention of the campaign (3). Furthermore, a search for the phrase, “Powerful Bones. Powerful Girls” with any of the widely used internet search engines mainly produces links to the CDC, National Osteoporosis Foundation, and sites for education professionals; sites that young girls are unlikely to visit (4, 5). It should be noted that a Google search does pull up a link to Yahoo! Kids on the fourth page of results; however, it is impossible to navigate to the link through the Yahoo! Kids site (4, 6). “Powerful Bones. Powerful Girls.” will only effectively deliver its message to young girls if they are aware of its existence. As a web-based campaign, it seems logical to maximize its presence in the portions of the internet that young girls are likely to peruse.

In addition to the dearth of material on the internet directing young girls towards “Powerful Bones. Powerful Girls,” there is also a lack of televised media coverage regarding the campaign. Arguably, television plays an important role in the after-school life of many of America’s young girls; therefore, advertisements directing girls toward the website may reach more girls per dollar than cheaper methods, including radio airtime. However, “Powerful Bones. Powerful Girls.” doesn’t have airtime on, or mention on the websites of, Cartoon Network, Nickelodeon, or ABC (7-9). Without proper media coverage, particularly via the two outlets most frequented by young girls, the framing of the “Powerful Bones. Powerful Girls.” website for girls does not matter; it will go unseen by its target audience

Framing and Agenda Setting for an Effective Message
Unfortunately for the National Bone Health Campaign, much of the mass media focus regarding female physical health is centered on weight, namely the attainment of a certain degree of thinness, rather than a healthy lifestyle, that includes proper nutrition and exercise. However, if the public health community utilizes social behavior models, such as the Framing and Agenda Setting Theories within the mass media, it may be able to facilitate the realization of “Powerful Bones. Powerful Girls.” full potential.

Framing theory may aid in the effort to counteract the current focus on weight, rather than health. A social science theory, framing theory dictates that the rhetoric used to describe and structure an issue influences individual perception of the issue. So much so, in certain cases the framing may weigh more heavily than the actual content of the message (10). In order for “Powerful Bones. Powerful Girls.” to be truly effective, the issue of weight vs. overall health in the media should be retooled to focus more heavily on healthy behaviors that including the diet and exercise requirements necessary for young girls to build strong bones for their future. A satellite campaign utilizing Framing Theory may increase he effectiveness of the “Powerful Bones. Powerful Girls.” campaign. Such a campaign might include the placement of print messages regarding the importance of health, rather than thinness, in women’s magazines that focus on fashion, or regularly run articles about weight loss. Without these additional messages, it may not matter if pre-adolescent girls are directed towards the “Powerful Bones. Powerful Girls.” website, since they will be less concerned about the healthy habits that promote skeletal health, and more concerned about whether what they see in the mirror conforms with societal standards.

An additional tool available to public health policy makers that may augment the potential effects of the “Powerful Girls. Powerful Bones.” campaign is Agenda Setting Theory. Another social science theory, Agenda Setting Theory states that the media sets the table for what the public, and occasionally policy makers, think about (11). It therefore follows that in order for osteoporosis and the “Powerful Bones. Powerful Girls.” campaign to be an important order of business in the public mind, it has to be placed before the public eye by the media. As previously mentioned, the media coverage of the “Powerful Bones. Powerful Girls.” campaign is paltry at best (3-9). Additionally, osteoporosis itself is not currently a highly debated topic, with the exception of Merck’s newest pharmaceutical designed to prevent and treat the disease (12-14).

Those individuals in the public health forum charged with public relations and the implementation of media campaigns would be wise to put the tenets of Agenda Setting Theory to use; rather than allowing the media to simply be either a force that detracts from the goals of the National Bone Health Campaign with its messages of thinness at all costs, or merely an instrument to spread the word about the “Powerful Bones. Powerful Girls.” website for girls, public health officials should utilize the media to its fullest potential. In short, they should use the media to not only set the tone regarding the discussion concerning the health of pre-adolescent girls, but the media should also be used to bring osteoporosis, and in turn, “Powerful Bones. Powerful Girls.” to the forefront of the public agenda. After all, it is unlikely that parents, teachers, or policy makers will push girls to utilize the valuable resource of “Powerful Bones. Powerful Girls.” that’s available to them, if these adults are not urged by the media to consider the threat of osteoporosis.

Two is Better than One
Unfortunately, the current emphasis of weight rather than health in the media is likely to play into the insecurities and self-esteem issues that are ubiquitous in pre-adolescence. In this inhospitable landscape, the success of “Powerful Bones. Powerful Girls.” would undoubtedly be facilitated by a sister campaign addressing young girls’ perception of their peers in relation to their own behavior regarding such issues as weight vs. health and self-esteem. The social science model of Social Norms Theory could be used to create an effective campaign which orients girls toward the “Powerful Bones. Powerful Girls.” website while confronting these issues.

Social Norms Theory states that an individuals’ behavior is guided more by the perceived behavior of one’s peers than actual peer behavior (15). Therefore, an intervention utilizing Social Norms Theory must change perceptions rather than actual behaviors, in an attempt to ultimately allow the individual to change their choices and behaviors. Previously implemented successful campaigns targeting youths utilized course curricula, print media including posters in places frequented by the target audience, and interactive websites (15). Subsequently, it seems reasonable for this suggested sister intervention to serve its dual purpose with little difficulty. While attempting to change perceptions, this campaign could also orient girls via its media campaigns and course curricula to the interactive “Powerful Bones. Powerful Girls.” website.

Additionally, this suggested campaign would be most successful if implemented at the state or local level, thus ensuring that the messages about perceived social norms be tailored to the community in which the message will be disseminated. While the perceived social norms facing pre-adolescent girls are likely to be basically the same across the board, the details are likely to be dissimilar for those in a rural community in Oregon compared to girls in Dorchester, MA. Additionally, implementing the campaign at a state or local level may facilitate its integration into school curricula. As demonstrated with federal level interventions such as “Powerful Bones. Powerful Girls.”, it up to a communities’ discretion whether to incorporate a program into course work (2).

In conclusion, one cannot fault the messages put forth by the Centers for Disease Control and Prevention and the National Osteoporosis Foundation via the “Powerful Bones. Powerful Girls.” website for pre-adolescent girls. However, under the current circumstances, this public health intervention is destined for failure; it exists largely separated from the real world and the areas of cyber-space frequented by its target audience (3-9). Public health policy makers must take further action to ensure that this campaign does not go unheard. Such steps include synergistically utilizing such social science theories as Framing, Agenda Setting, and Social Norms to promote “Powerful Bones. Powerful Girls.” in the media, to create a receptive mindset within the community of pre-adolescent girls, and to also bring this campaign, and osteoporosis, to the public eye. Without such steps, “Powerful Bones. Powerful Girls.” will fall by the wayside, and osteoporosis will plague another generation of American women.

1. National Osteoporosis Foundation. Fast Facts. Washington, DC:
National Osteoporosis Foundation.
2. Centers for Disease Control and Prevention. Bone Health Campaign. Atlanta, GA: Centers for Disease Control and Prevention.
3.Girl Scouts of America. search for “Powerful Bones. Powerful Girls.”
powerful+girls.&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en- US:official&client=firefox-a.
5. search for “Powerful Bones. Powerful Girls.” ttp://
6. Yahoo! Kids.
7. Cartoon Network. Search for “Powerful Bones. Powerful Girls.” on
8. Nickelodeon. Search for “Powerful Bones. Powerful Girls.” on ttp://
9. ABC. Search for “Powerful Bones. Powerful Girls.” on
10. Framing (communication theory).
11. Agenda-setting theory.
12. Boston Globe. Search results for “Osteoporosis” on
13. Washington Post. Search results for “Osteoporosis” on
14. The New York Times. Search results for “Osteoporosis” on
15. Berkowitz A. The Social Norms approach: theory, research, and annotated bibliography. Higher Education Center.

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