Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Body Moving: Social Theory, Physical Activity and the VERB Campaign - Kelley Bradshaw

It is 8pm on a Wednesday. Sally is sitting on the couch, watching the latest reality TV show. At the commercial break, an ad comes across the screen, encouraging people to get outdoors and to be active with their family everyday so that they all have long, healthy lives. Sally looks at the ad, contemplates getting up and going for a walk…and then changes the channel, looking for the next program. If you are like Sally, you are not alone. Most people are well aware of the health implications of not exercising or even the benefits of regular physical activity; yet a majority of people choose not to exercise. Only 32% of U.S. adults and 66% of children adolescents participate in regular leisure-time physical activity, which should amount to about 150 minutes per week according to Healthy People 2010 guidelines. For those who start an exercise regime, about 50% stop exercising after six months (Marcus, et. al, 2006). Many people site a barrage of excuses: no time, stress or anxiety, no money, too out of shape, lack of access, bad weather. While these reasons may have some legitimacy, essentially the problem lies in the fact that many people do not consider exercise a concern or a priority. They view it as time consuming, painful (both physically and emotionally), and want to see immediate benefits. People want exercise to fit into their life, not rearrange their life around it. In order for a physical activity intervention to be successful, it must get people to care. People need to be motivated. They need to feel that they have control over their lives, can create their own goals and have the ability to achieve these goals.
Most physical activity interventions fail because are built on individual health behavior theories, sell the idea of health rather than more appealing basic core values and remove autonomy by violating the illusion of control by pressuring individuals to subscribe to a predetermined attitude surrounding physical activity. In order to succeed, physical activity interventions need to account for external environment, focus on marketing core values rather than health, and to provide enough flexibility for individuals to feel that they are in charge of and responsible for their physical activity. We need to use new social behavior theories to help create effective physical activity interventions that not only remove these barriers, but that will give people the autonomy, motivation and self-efficacy to increase the physical activity in their lives. One physical activity intervention, the VERB campaign, has successfully incorporated such ideals into their intervention to get tweens (age 9-13) to increase their levels of physical activity. Its effective use of social science theory allowed it to succeed where other physical activity approaches have failed.
One major flaw of approaches towards increasing physical activity is that they tend to focus on the individual without addressing external social and environmental factors that can prevent an individual from engaging in physical activity. Physical activity interventions have continuously relied on individual, or interpersonal, social science theories to deliver their message of health. On the surface, it seems appropriate to focus on an individual’s thoughts that affect his or her actions, especially those actions that affect health status. We are the ones who choose whether or not we should exercise, often assessing the pros and cons of physical activity. But while we are the ones who make our decision, it is detrimental to ignore the context, or external environment, that affects our cognitive processes in relationship to increasing our physical activity.
Context is often dismissed or ignored in many individual theories, including the Health Belief Model (HBM) and the Transtheoretical Model (TTM), also known as the Stages of Change theory. The HBM focuses on an individual’s perceptions of why he or she should engage in a specific action (Edberg 2007). The HBM focuses on six constructs. Perceived susceptibility, which it the degree to which a person thinks they are at risk for a health problem that certain behavior may prevent. Perceived severity is the degree to which a person thinks the health problem is severe. Perceived benefits are the positive benefits of taking action or performing a behavior. Perceived barriers are the negative consequences of not performing a specific action. A cue to action is an external event that motivates someone to engage in a specific behavior. The last construct is self-efficacy, a person’s belief that he or she is capable of performing said behavior (Edberg 2007). In regards to physical activity interventions, approaches tend to focus on making people believe they are susceptible, or at risk, for a certain health problem if they are not physical active. However, individuals perceive risk differently. Some may believe they are not at risk; others may be belief they are at risk, yet still not care or engage in physical activity. We are usually shown that the severity of not being physically active is quite severe and that consequences include obesity and heart disease. In reality, these diseases (and others) are usually brought upon by a multitude of causes—genetic, socio-economic status, poor diet.
Physical activity interventions focus on the benefits of engaging in physical activity, but more often than not, these benefits are in relation to not getting certain diseases. While that is obviously a positive outcome of exercise, some diseases such as heart disease, may develop slowly overtime and do not show symptoms for years. Most people do not worry about preventing something that manifests so far into the future and would rather see the immediate benefits of physical activity, such as improved mood, better sleep and improved physical appearance. Yet physical activity campaigns rarely place these immediate benefits at the forefront of their campaign. Likewise, most physical activity approaches focus on informing the individual of the negative consequences of not being physical active. Again, an individual may not feel they are at risk for these consequences and such scare tactics rarely motivate most people to engage in a behavior. Lastly, most physical activity interventions tend to leave out or gloss over the self-efficacy piece. People are given all the knowledge and tools of how to be more physical active, yet are not empowered to feel that they are capable of achieving this goal. Sometimes, especially for individuals who have never been physical active or have gone for a long period of time without activity, starting a physical activity regimen can seem daunting and overwhelming. Most physical activity interventions do not give people the emotional prowess to apply physical activity to their life.
Essentially, the HBM is flawed in that it assumes that everyone values health and thus, will be have accordingly to maximize his or her health status. In relation to physical activity, the HBM assumes that since everyone values their health, therefore, they will be physically active. In this regard, the HBM is assuming that humans are rational and thus will make objective, logical thought processes about physical activity. Yet, humans are anything but logical and rational, and if were, everyone would engage in at least a moderate amount of physical activity. Clearly, as the obesity epidemic shows, that is hardly the case.
Applying the Transtheoretical Model (TTM) to physical activity interventions is a common practice, but is hardly an improvement upon the HBM. The TTM is based on the idea that change takes place in stages over time. There several different stages that one goes through during a decision making process. Different thought processes and behaviors are going on in each stage (Prochaska 2002). A person can enter the TTM at any stage. The first stage is Precomtemplation, where a person is not intending to take action. Stage Two, Comtemplation, is where a person is thinking about making a change in the foreseeable future. Stage Three, Preparation, involves intention. The person is ready to act soon and has some plan for their behavior changes. In Stage Four, Action, a person has started to make adjustments in the behavior. They may also be making some changes that do not help reduce the risks of a health problem. Such changes do not count as action towards a health behavior modification. Stage Five is the Maintenance stage (Edberg 2007). A person has made significant changes in their behaviors to decrease his or her health risk. The focus is on maintaining these new healthy behaviors and not slipping back into old, unhealthy habits. The last stage, Termination, is when the individual has completed the process of behavior change and former unhealthy behavior is no longer a part of his or her life. This stage relies heavily on self-efficacy, a person’s confidence that they can change and maintain a behavior. Once a person has finalized the termination stage, they have developed self-efficacy. However, most people rarely get to this stage and hover somewhere in the maintenance phase. Within these stages, there are change processes that facilitate an individual to move to one stage to another.
The TTM has shown some success in studies, which is why it has been used in physical activity interventions. A recent study used the TTM to understand exercise behavior in a sample of older women (Findorff 2007). The results showed that a majority of the intervention group was in the action or maintenance stages, as compared to the control group, after a year of exercise. The study found that self-efficacy did predict long-term adherence to physical activity. However, this study focused on a specific age group (women, age 70 and above) who may not have some of the barriers that people in different life stages face, such as pressures of school, work or taking care of a family. Moreover, the subject enrollment in both the intervention and control groups was over 97% white. Most white women do not face the same barriers that ethnic minorities can face, such as racism, low socioeconomic status or poverty. Thus, the study cannot be generalized to a variety of populations. Likewise, a majority of the studies using TTM focused on the action stage, rather than all components of the TTM and the ones that did showed inconclusive results (Bock, et. al, 2001). As West points out, there is no concrete evidence that as an individual gets closer to action, a lasting behavioral change will occur (West 2005).
The TTM itself has several major flaws. First, it is a linear stage model. The TTM proposes that individuals move through the stages of change in order, from precomptemplation to termination, without deviating from this order (Edberg 2007). Likewise, it assumes that people are rational, will make plans and follow thru with them West 2005). Our intentions to change our behaviors are not as planned as we would like to believe. In reality, people often go back and forth between stages, often prior to completing a given stage. Our behavior is more circular and we are constantly reentering the process of change. Secondly, the TTM uses arbitrary constructs to define a change (West 2005). It is difficult to assess what stage a person is in, given that we are constantly cycling through the stages. The action stage is fairly recognizable, but is can be difficult to decide whether or not someone is in precomptemplation or are really in comtemplation (Edberg 2007). The TTM does not address the concepts of motivation, reward and punishment (West 2005). Lastly, the TTM is an individual social theory and does not account for the effects of social, external environments on behavior.
Another flaw in most physical activity interventions is that a majority of approaches tend to violate reactance theory, thus diminishing an individual’s perception of control and placing it in the hands of an authority figure. Reactance occurs when an individual perceives that their freedoms are being threatened or taken away (Brehm 1981). Individuals believe they encompass “free behaviors”, which are behaviors that one can choose to act upon whenever one feels like it. If an individual feels that these free choices are being taken from them, then the individual actions are a negative, aversive response (Baumeister 2002). The individual tends to do exactly the opposite of what is desired of them, which is connected to the concept of reverse psychology, where telling an individual not to do a certain behavior actually makes it more enticing (Baumeister 2002). The amount of one’s reactance is directly correlated to the amount of threat they feel regarding the removal of a certain freedom. The greater the amount of the individual’s perceived loss of freedom, the greater the magnitude of his or her reactance will be. Physical activity approaches tend to violate reactance theory and result in reverse psychology behaviors. An individual may feel bombarded with messages that urge him or her to increase the level of physical activity. The problem is exacerbated as physical activity interventions tend to show the negative consequences of not being physically active, such as heart disease or being overweight (Marcus, et. al 2006) rather than positive benefits of exercise, such as better moods, autonomy or spending more time with friends or family. As a result, an individual’s “illusion of control” is often violated. This theory involves an individual’s perceived level of control over a certain situation or behavior. Whether or not control is actually lost is not as important as if a person feels that their control has been taken from them. If an individual feels as if he or she has lost control, it will result in decreased confidence and self-efficacy. Individuals often feel motivated to control their environment (Langer 1975), but typical approaches to increasing physical activity often diminish one’s illusion of control.
In addition to violating an individual’s illusion of control” and thus increasing reactance, another overarching theme seen in many physical activity interventions is that they tend to sell the health benefits of being physically active. In theory, this premise makes seems logical and plausible. If a physical activity intervention shows (through education, data and statistics) how being active can improve one’s health status and prevent health problems in the future, then it will be successful in getting people to increase their activity. However, this paradigm and how physical activity is marketed is flawed and violates the basic premises of Marketing and Advertising Theories.
Marketing Theory (and its subset, Advertising Theory) deliver a “promise”, which is “supported” with pertinent examples, suggesting that this promise fulfills a “core value”, which reflects that which is truly important to us (Spiegel 2007, 2009). The message of a “promise” that a product can fulfill is being sold. This promise offers benefits to the consumer, sometimes while barely mentioning the product. The larger the promise the ad is delivering, the more effective the ad will be in enticing consumers to purchase the product. The consumer sees the benefits of the product will enable it to fulfill the promise. The “promise” is fulfilled by support, typically in the form of images, symbols and metaphors. Stories are told, music is played and we are enticed by the visuals that convey the “promise.” Taglines and slogans are commonly used to brand products Marketing Theory focuses on selling mostly intangible “core values” that are desired by many individuals (Spiegel 2007, 2009). Freedom, autonomy, acceptance, love, and opportunity are just some of many values that are subconsciously being sold by advertisers. Advertisements are designed to appeal to these core values, in hopes that we will link a desired core value with the product. In contrast, physical activity interventions have failed to correctly use Marketing Theory to deliver their message. They are promising health, with statistical data showing what health benefits physical activity has, while promising the core value of better health, if the individual engages in physical activity (the product).
The inherent flaw in such delivery is that physical activity interventions convey the message that if you do not exercise, you will not be healthy and your quality of life will suffer. They are under the pretense that health is a core value for all and that this value is of the same degree. In reality, this is not the case. Different people place varying degrees of value on physical activity—some view it as a high priority that takes precedence in their lives, some barely give it a second thought, and others fall within these two extremes. Thus, the “promise” of health as a result of physical activity does not resonate with the audience the way one would assume. Many campaigns tend to have a negative focus, where statistics usually tell how detrimental not exercising is, citing health problems that may arise as a result. Such negative supports do not entice people to be more active, especially if better health is not of value to them. Yet marketing campaigns for increasing physical activity continue to market improved health as a core value, rather than focusing on acceptance, happiness, attractiveness, accomplishment, or other values that may trigger a desire to increase one’s physical activity. In order to be successful, physical activity interventions need to restructure their message by tailoring it towards people want, showing how physical activity can fulfill these wants and needs and by appealing to such aforementioned core values.
Despite previous unsuccessful attempts, there is hope for physical activity interventions, if the approach is redesigned. The VERB campaign is one of few physical activity interventions that have reframed the behavior and proven successful. Started in 2002 by the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention (CDC), VERB was a national, multicultural, social marketing campaign aimed to increase physical activity among the youth in America (US DHSS, 2008). With a vision for all youth to lead healthy lives and a mission to increase and maintain physical activity in “tweens” (age 9-13), VERB was an innovative marketing campaign. It combined paid advertising, marketing strategies and partnerships to reach specific audiences of tweens. This age group was targeted because the CDC felt that at this age, children are becoming more independent from their parents (in regards to decision making) yet are still influenced by adults. VERB also addressed parents, adults, youth leaders, health professionals, coaches and any other adults who were influencers of youth health behaviors (US DHSS, 2008). The campaign encouraged tweens to “find their VERB”, any action that fit their personality, such as sing, run, or bounce. The VERB campaign owes its success to its focus on the tweens’ social, external environments; the campaign’s ability to give tweens power and autonomy; and by selling intangibles that tweens desire (such as freedom, happiness, control) rather than selling ‘health’.
Part of the success of the VERB campaign is due to its use of group-level, interpersonal social science theories. VERB used Social Cognitive Theory (SCT) to understand how an individual’s environment affects their behavior in regard to physical activity. For tweens, environment includes their social environment (teachers, peers, parents), as well as their physical environment (backyard, park or neighborhood (Huhman 2004). The theory itself describes the ongoing process in which personal factors, environmental factors and human behavior influence each other. The theory postulates that three factors will affect the possibility that someone will make a behavioral health change: self-efficacy, goals and outcome expectancies (Bandera 1988).
The SCT developed from the Social Learning Theory (SLT), as well as cognitive, behaviorist and emotional models involving behavior change. As a result, it involves several constructs. Reciprocal determinism is the interaction between the person, a behavior and the environment. Behavioral capability is the knowledge and skills an individual has to make accomplish a behavior. Expectations are the anticipated outcomes of performing that behavior. Self-efficacy is the person’s confidence in their ability to do the behavior and to overcome obstacles. Observational learning, or modeling, is examining the behavior of others and looking at the resulting actions and consequences. Lastly, reinforcements are responses to a person’s behavior that can increase or decrease the probability of that behavior being performed again.
In relation to the VERB campaign, it used extensive research to understand the reciprocal determinism of tweens and their environment. VERB conducted telephone surveys, known as the Youth Media Campaign Longitudinal Study (YMCLS) with tweens and their parents prior to the start of the study (US DHSS 2008). At baseline, he surveys measured the physical-activity related beliefs, attitudes and behaviors of tween and their parents. Through its interactive website,, the campaign supplied tweens with knowledge and ways they could increase their physical activity, but in a positive way that encouraged tweens to interact with their peers and created autonomy (Bauman 2004), thus enhancing tweens behavioral capabilities. also contained toolkits for parents and educators. Expectations focused on having fun, creating friendship, learning new things and autonomy, rather than better health, which is something that many tweens often do not think about. The campaign incorporated modeling by having other tweens or famous celebrities in brochures and advertisements. The idea was to inform tweens that their peers and people they looked up to were physically active. Lastly, VERB focused on the positive reinforcements of activity, such as building friendships, being outdoors, having control over the activities a tween does and having fun (Huhman 2004).
Like the SCT, the Theory of Physical Activity Maintenance (PAM) is another group level theory whose concepts are evident in the VERB campaign. Although VERB did not directly use this theory, as it did with SCT, components of the PAM are easily applicable to VERB and nicely manifest the reasons for its success. While other theories, such as the TTM and the Theory of Planned Behavior (TPB) focus on determinants of health behavior adoption, they have yet to provide evidence that their concepts can help increase physical activity (Nigg et. al 2008). The PAM differs from other theories commonly used in physical activity interventions in that it focuses on maintenance, includes triggers that typically cause an individual’s relapse of physical activity and includes individual and external environment concepts that are critical for physical activity maintenance (Nigg et. al 2008). The theory draws from the SCT, goal setting theory and the theory of self-efficacy. Self-efficacy, goal setting and motivation are the core components of PAM. Self-efficacy can greatly affect an individual’s goals and motivation. Barriers or relapses that interfere or decrease one’s self-efficacy can also affect physical activity maintenance. Goal setting is task oriented and often involves satisfaction, attainment and commitment (Nigge et. al 2008). Motivation can help an individual adhere to his or her behavior change to increase physical activity. The physical environment of activity, including access to facilities, quality of aesthetics and social support from family, friends and peers, can affect an individual’s physical activity. Life stress, such as being unemployed, financial troubles, safety and family problems can impair physical activity (Nigg et. al 2008). Ultimately, life stress can diminish and derail one’s ability to achieve their long-term physical activity goals.
Components of the PAM are evident in the VERB campaign, primarily in the stages of study design. By using the YMCLS prior to implementation, VERB examined self-efficacy and social influences among a sample of tweens (Huhman, et. al 2007). To maintain interest and motivation, the VERB campaign asked tweens to develop new ways that they could be physically active. VERB Make It Up and VERB Crossover were designed to have tweens combine various types of physical activity and mental games (US DHSS 2007). To assist with goal-setting components, VERB’s long-term outcomes focused on increasing tweens activity from minimum to moderate and trying out new activities (Huhman 2004). Social ecological theories, like PAM, were critical to the success of VERB.
VERB was able to succeed because it gave tweens autonomy and power and focused on using peers to deliver its message. The Illusion of Control theory is one theory that involved power and autonomy. It is tendency for individuals to believe they have control over a particular situation, when in reality, that is often not the case. Introducing a skill into a certain setting or population can give the audience the illusion that they can control the situation (Langer 1975). By encouraging tweens to pick their “verb” and become more physically active, tweens feel as if they have more control over their lives, specifically their choices regarding activity and health. The VERB Yellowball promotion involved thousands of yellow balls being delivered to schools, recreational centers, malls, concerts and sporting events—places that tweens typically go. Each ball had instructions and a unique code. Tweens were instructed to play with the ball, visit to register their activity on the blog and then pass the ball on to a friend (Huhman 2008). By giving tweens control, VERB theorized that they would increase their physical activity levels. An evaluation of VERB from 2002-2004 proved this to be true. The study observed a statistically significant dose-response effect of exposure to VERB and physical activity (Huhman, et. al 2007). Awareness of VERB was also measured. Tweens who reported being aware of VERB participated in 3.9 weekly sessions of “free-time activity”, where as tweens who were unaware of VERB participated in 3.0 weekly sessions. Tweens who were aware of VERB had a higher score of outcome expectations, beliefs that participating in physical activity would have benefit. Awareness of, and thus exposure to, VERB gave tweens the autonomy and control to make physical activity changes.
Lastly, the VERB campaign effectively used Marketing and Advertising theories to create a brand around the health behavior of physical activity. Where as most physical activity interventions (and public health interventions in general) are selling the idea of health, VERB used various forms of mass media, tailored to a very technology-savvy youth, to sell core values of freedom, acceptance happiness and control that can be obtained from physical activity. VERB was turned into a product and a brand to achieve these core values. An integrated marketing approached that combined communications, public relations and direct marketing was used to create a unified message that physical activity is fun and cool and can be a social activity, rather than an unpleasant, forced experience (Huhman 2008). A VERB logo and slogan (“It’s what you do.”) plastered the website, blogs, commercials, and print media. The website was updated with new material on a monthly basis and periodically updated with new marketing activities. The site was initially very text-heavy and lacked simple applications, so the website was updated. Later versions included MyVERB Recorder, which tweens could use to log their physical activity (Huhman 2008). The website had tutorials from professional athletes who demonstrated how to do certain skills, such as throwing a football, serving a tennis ball and performing soccer tricks. The 8372 (or “VERB”) text message campaign sent cell phone text messages to tweens. 8372’s goal was to create a more personalized relationship between the tween and VERB. 8372 sent the tween information about regional VERB events, trivia games, quizzes and celebrity webcasts, as well as messages that encouraged physical activity (Huhman 2008). Corporate partnerships, contests and sweepstakes were incorporated into the VERB campaign to draw in tweens and establish credibility with brands that tweens already supported, such as Nickelodeon and Cartoon Network.
Ultimately, the advertising of VERB offered new promises that are not commonly seen in public health campaigns. While VERB’s true product is health and physical activity, the campaign did not market it in that light. The “promise” that VERB offered was that a tween would be cool, popular and part of a mass movement, providing that tweens engaged in physical activity. VERB focused on making physical activity cool, fun and socially acceptable (Krisberg 2005). VERB supported its promise with images of tweens having while being active, using VERB as a metaphor for being active, creating catchy slogans, using trendy technology that captures tweens interest and using peers or roles models in its campaign. Lastly, VERB’s advertising approach focused on core values of one of freedom, independence, control, happiness, and acceptance.
Sadly, the VERB campaign came to an end in 2006, as a result of federal budget cuts. An expensive campaign that totaled approximately $350 million in a five-year period, the federal government did not want to continue to spend money on a campaign that didn’t produce the immediate, short-term benefit that the government was seeking. But its success was undeniable. VERB targeted over 21 million tweens. In its first year, 90% of tweens who were aware of VERB also understood its messages (Krisberg 2005). Moreover, VERB actually worked to get tweens moving. Perhaps if VERB was still around, its message may have continued to impact tweens and eventually spread to other age groups. Alas, we are an impatient society. We want to see the immediate benefit now, not several years or even decades down the road. As Faye Wong, MPH and director of the Youth Media Campaign at CDC stated, “When people look at a single campaign with a larger price tag, it may be difficult to understand. Prevention takes more time, but it doesn’t mean there’s no pay-off” (Krisberg 2005).


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