Challenging Dogma

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

Saturday, April 21, 2007

Why Even Well-Designed Health Campaigns Fail: The National Bone Health Campaign-Christine Odell

Osteoporosis is a common disease of increased skeletal fragility accompanied by low bone mineral density (1). It affects more than 25 million people in the United States, resulting in 1.5 million fractures annually with an annual direct cost to the health care system of $18 billion due to disability, decreased quality of life, and premature death (1,2). Peak bone mass is one of the major risk factors for fractures in both childhood and in osteoporosis. Because about 40% of the skeletal bone mass is built and enlarged during late childhood and early adolescence (2), interventions aimed at promoting bone mass development in late childhood and early adolescence may delay the development of osteoporosis in later life. Women are particularly at risk for osteoporosis because they do not engage in behaviors that promote the development of bone mass. According to the Centers for Disease Control and Prevention (4), preadolescent and adolescent females participate in physical activity less than males the same age, and as many as 85% of adolescent females consume less than the recommended daily allowance of calcium (2). By increasing calcium intake and weight-bearing physical activity, children and adolescents have successfully increased their bone mass (3).

The National Bone Health Campaign entitled “Powerful Bones. Powerful Girls.” was developed to promote optimal bone health among girls 9-12 years of age to reduce their risk of osteoporosis later in life. Its goal is “to encourage girls to establish lifelong healthy habits, focusing on increased calcium consumption and weight-bearing physical activity to build and maintain strong bones.” (5) It claims to use a social marketing approach “to reach girls where they live and play” including a web site for girls and their parents and print materials, and radio and print advertisements (5). This paper will assess the “Powerful Bones. Powerful Girls.” health campaign from the social marketing perspective to demonstrate why it is failing.
Social marketing is a model for promoting voluntary behavior change in a group of individuals, referred to as the target audience, to improve their wellbeing and that of society (6,7). It is based on commercial marketing concepts and techniques such as exchange theory and the 4 “P’s” (product, price, place, and promotion), a consumer orientation, segmentation of populations and careful selection of target audiences, formative research to understand consumer’s desires and needs, competition, and continuous monitoring and revision of program tactics (6,7).

In the social marketing model, the consumers are at the center of an exchange process in which they attempt to maximize their abilities to satisfy wants or needs and minimize the sacrifice involved to obtain them (7). The exchange process involves five key concepts: the product (the health behavior being promoted) versus its competition (the behavior currently practiced); the price (social, emotional and monetary costs that are exchanged for the product’s benefits); place (where the exchange takes place and/or where the target behavior is practiced); and promotion (activities used to facilitate the exchange) (7). Research is critical to identifying the aspirations, values, beliefs, attitudes, and behavioral patterns of the target audience and the interplay of social and cultural factors that affect whether or not the target audience adopts the desired behavior. A promotional strategy is developed using this information to create a marketing plan that will appeal to the target audience. Feedback is critical to this process to assess the visibility, message recognition, and effectiveness of the health campaign and to revise aspects of the campaign that may not be working for the target audience.

Target Audience’s Values

The National Bone Health Campaign, “Powerful Bones. Powerful Girls.” was the product of a partnership between two agencies of the U.S. Department of Health and Human Services (the Centers for Disease Control and Prevention and the Office on Woman’s Health) and the National Osteoporosis Foundation in collaboration with state health departments, the Girl Scouts of the USA, and Girls Inc (5). The National Bone Health Campaign relies on educational programs to reach its target audience (8,9). The state and local bone health campaigns are primarily community-based and occur in coordination with health fairs, Girl Scouts, school curricula, and school sports (8). All of the materials focus on health education and appear to be based on the health belief model, not the social marketing model. Their concept is that if the public understands the causes and effects of osteoporosis and its risk factors then they will want to engage in activities designed to prevent osteoporosis in middle age. The assumption is that the intention will result in the desired behavior. This is NOT a message that will appeal to 9-12 year old girls. Girls at this age are not planning for middle age. Marketing research has shown that girls 8-12 years of age are developing a sense of identity and are anxious to cultivate a sophisticated self-image; they want to be “cool” (10). Corporations have capitalized on the insecurities of pre-teens and teens by making them believe that their product will make them really “cool” (10). Marketers have found that what is considered “cool” is constantly changing, so that ongoing research is necessary to identify and package the latest trend (10).

There is no evidence that the creators of the National Bone Health Campaign tested their educational materials on girls 9-12 years of age and their parents, particularly among different socioeconomic and cultural groups. The main character on the “Powerful Bones. Powerful Girls.” website is a Caucasian girl with red hair named Carla. She has friends: a Caucasian boy, African-American girl, and a girl with dark hair who may be Asian. It is unlikely that all girls who are 9-12 years of age will identify with Carla and her friends, particularly if they do not read and understand English. There are crude animations, usually of Carla playing a sport with a statement written in English underneath saying that a sport such as hiking “is a good weight-bearing activity that helps build powerful bones.” Why would a girl 9-12 years of age want to participate in a sport just because a they are told that it is good for them? There is a section in the “Powerful Bones. Powerful Girls.” website entitled “Powerful Girls Like Me” which describes the eating habits and physical activities of four girls, three of whom are Caucasian and one of whom is African-American. Unfortunately, there are many girls in the United States who are NOT like the four girls featured on the website for this health campaign who will NOT identify with these purported role models.

The games on the “Powerful Bones. Powerful Girls.” website cannot compare with the video games played by most girls 9-12 years of age on their portable game systems. A health campaign does not have to use commercial quality games to convey its message, but if games are going to be used, they should reflect the target audiences’ values and be “cool”.

Although the “Powerful Bones. Powerful Girls.” campaign also seeks to influence prepubescent girls’ behavior by empowering parents and adult role models to encourage girls to take action, none of the aspects of the campaign directed at parents does this effectively. Convincing parents that a diet high in calcium and weight-bearing exercise are important for young girls in order to prevent osteoporosis does not help the parents to motivate their children to go out and play after school instead of watching television, particularly if the child is home alone.

In a one-year study of a program similar to the “Healthy Bones. Healthy Girls.” campaign among Girl Scouts, the girls in the intervention group did not increase the amount of weekly weight-bearing physical activity compared with the control group (2). In the past, schools in the United States provided some opportunities to exercise during physical education classes, but nationwide in 2005, only 54.2% of students attended physical education classes on one or more days in an average week when they were in school (11). This leaves the time when school is not in session for physical activity. However, adequate play areas may not exist or may be unsafe in some neighborhoods so that even if a group of girls 9-12 years of age wanted to play basketball or baseball together they may not be able to find a place to do so. Extracurricular sports for girls have been limited to school sports teams, and thus are limited to those girls with the talent and interest to play competitive sports. Girls who might be interested in playing sports at school, but who do not make the team or who do not want to endure the pressure of playing on a competitive team are excluded. According to the social marketing theory, the place where the desired health activity occurs is an important part of the campaign. In the case of The National Bone Health Campaign, this is an aspect of the campaign that appears to have been neglected.

Competing Messages

The “product” that the National Bone Health Campaign, “Powerful Bones. Powerful Girls.” campaign is promoting is increased consumption of calcium-rich foods and weight-bearing exercise among girls 9-12 years of age. A similar campaign among Girl Scouts was ineffective in increasing the calcium consumption of girls 9-12 years of age who consumed less than the recommended daily allowance of calcium (2). The National Bone Health Campaign does not address its cost in terms of the actual cost of fruits and vegetables for families who may be on a fixed income. The program does not offer vouchers for fruits and vegetables or additional food stamps specifically designated for calcium-rich foods. The campaign also does not consider whether or not fresh fruits and vegetables are easily accessible in all neighborhoods.

However, fast food restaurants can be found in every neighborhood in urban areas and in many small towns. Currently, McDonald’s is offering two bacon, egg, and cheese biscuits for only $3, each of which contain 440 calories, 5 grams a piece of trans fat, 1340 mg sodium, 245 mg cholesterol but 15% of the RDA of calcium and iron in each one (12). For a family with little money, time, and transportation for comparison shopping, one bacon, egg, and cheese biscuit and milk may provide “the complete breakfast” at low cost. From the perspective of a girl 9-12 years of age, McDonald’s may be a “cool” place to “hang out” with friends. The meals marketed toward children, the Happy Meal or the Mighty Kids Meal, contain toys in addition to a heavy load of calories, cholesterol, trans fats, and maybe 22% of the RDA of calcium. In many young girls’ eyes, the Happy Meal beats broccoli every time. What “cool” toys come with a serving of broccoli, and is broccoli served in a place where you can “hang out” with friends like the food courts in the malls?

The National Bone Health Campaign “Powerful Bones. Powerful Girls.” also does not deal with the effect of television commercials, approximately 56% of which are for food (13), on the target audience. The amount and type of advertising aimed at children via media channels has increased markedly over the last few years (14). As the number of cable television channels and direct satellite broadcasts proliferated, there was a growth of programs that targeted narrow segments of the public, such as those devoted exclusively to children such as Nicklelodeon, ABC Family, Disney Channel, Cartoon Network, and Noggin (14). These channels provided a venue for marketing aimed specifically at children including not only traditional commercials but also product sponsorships linked to programs and program characters such as licensing agreements with food companies, toy companies, fast food restaurants (14). For example, Kraft Macaroni and Cheese products have used characters from popular children’s shows such as “Rugrats, “Pokemon,” “Blue’s Clue’s,” and “SpongeBob SquarePants” to market their products to children (14). Food manufacturers have been very successful in using marketing techniques to influence nutritional beliefs, attitudes and food consumption patterns of children (13,14). Unfortunately, 44% of the foods advertised were in the fats, oils, and sweet food groups (15). Fruits and vegetables are rarely advertised on television (13). The end result is that the more television a child watches, the less fruits and vegetables he or she consumes (13). Unlike social marketing campaigns, marketing campaigns do not have an ethical obligation to be truthful as exemplified by tobacco advertisements (6). In 49% of food advertisements on children’s television programming, foods were portrayed as healthy or nutritious when in fact they were not (14). Children aged 10-13 (within the target audience for the “Powerful Bones. Powerful Girls.” campaign) accept the majority of television advertisements as true (14). Obviously this presents a problem for health campaigns such as “Powerful Bones. Powerful Girls.” in counteracting the messages portrayed in the food commercials. The most common strategy used in advertising to children is to associate the product with fun and happiness, such as images of Ronald McDonald dancing, singing and smiling without mentioning any particular food products in advertisements for McDonald’s restaurants (11). Cereal advertisements frequently use characters such as Tony the Tiger or Cap’n Crunch to increase children’s awareness of the brand, so that a child will ask the parent to purchase the cereal when they see the character on the box in the supermarket (14,15).

Unfortunately, The National Bone Health Campaign does not educate adolescents about advertising manipulations and focuses its message on educating girls 8-12 years old and their parents on establishing healthy habits, focusing on increased calcium consumption and weight-bearing physical activity (5). As a result, its campaign is very unlikely to be able to compete with the television advertisements produced by fast food restaurants and food manufacturers.

Campaign Visibility

The National Bone Health Campaign does not have an easily identified character to promote its campaign or an easily identifiable brand. It relies on educational programs to reach its target audience (5,8,9). Has anyone outside of with state and local health departments, the Girl Scouts of the USA, and Girls Inc heard about the National Bone Health Campaign “Powerful Bones. Powerful Girls”? Most of the publicity in the news media for the National Bone Health Campaign comes from press releases (9), which will not reach the target audience of girls 9-12 years of age, and probably will not reach many of their parents. Bone health information and materials were distributed to state and local health departments for use at health fairs, Girl Scouts, school curricula, and school sports. These materials are educational, but they are boring and clinical and unlikely to be read in their entirety by girls 8-12 years of age or their parents. It is unlikely that even the people who are interested in healthy behaviors who attend these activities are going to retain the messages of the National Bone Health Campaign.

The National Bone Health Campaign “Healthy Bones. Healthy Girls.” is ineffective because it failed to employ the basic principles of social marketing. It did not address the values of its target audience and thus cannot compete with more colorful, fun, and engaging advertising campaigns that promote unhealthy messages. Even if the National Bone Health Campaign had more effective messages, it is unlikely that it would change the behaviors of its target audience because the campaign is not visible to most girls 8-12 years of age.


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4) Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-United States. Atlanta, GA: Centers for Disease Control, 1998.
5) Centers for Disease Control and Prevention. Bone Health: About the Campaign. Atlanta, GA; Centers for Disease Control and Prevention.
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8) Centers for Disease Control and Prevention. What Are the States Doing? Atlanta, GA; Centers for Disease Control and Prevention.
9) Centers for Disease Control and Prevention. News and Press Releases. Atlanta, GA; Centers for Disease Control and Prevention.
10) Media Awareness Network. Special Issues for Tweens and Teens.
11) Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-United States, 2005. Morbidity and Mortality Weekly Reports 2006; 55 (No.SS-5).
12) McDonald’s USA. McDonald’s USA Nutrition Facts for Popular Menu Items.
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14) Kunkel D, Wilcox BL, Cantor J, et al. Report of the APA Task Force on Advertising and Children. Washington, D.C.: American Psychological Association, February 20, 2004.
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16) Lewis CE, Lewis MA. The Impact of Television Commercials on Health-Related Beliefs and Behaviors of Children. Pediatrics 1974; 53:431-35.

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