Social Marketing as a Framework for Youth Physical Activity Initiatives: a 10-Year Retrospective on the Legacy of CDC's VERB Campaign.

PURPOSE OF REVIEW: In 2002, the U.S. Centers for Disease Control and Prevention (CDC) launched the VERB. It's what you do! campaign to increase physical activity among tweens and concomitantly respond to the rise in childhood obesity. This retrospective study summarizes the history of the VERB campaign's social marketing approach and its effectiveness in promoting behavior change in the targeted population. RECENT FINDINGS: The legacy of VERB, which ended in 2006, is discussed, with an emphasis on examining initiatives over the last decade and the degree to which they followed (or did not follow) the structural and thematic lead of the campaign. The article ends with suggestions for how VERB still has the potential to inform other social marketing campaigns going forward.

Community College Students' Health Insurance Enrollment, Maintenance, and Talking With Parents Intentions: An Application of the Reasoned Action Approach.

A primary objective of health care reform is to provide affordable and quality health insurance to individuals. Currently, promotional efforts have been moderately successful in registering older, more mature adults yet comparatively less successful in registering younger adults. With this challenge in mind, we conducted extensive formative research to better understand the attitudes, subjective norms, and perceived behavioral control of community college students. More specifically, we examined how each relates to their intentions to enroll in a health insurance plan, maintain their current health insurance plan, and talk with their parents about their parents having health insurance. In doing so, we relied on the revised reasoned action approach advanced by Fishbein and his associates (Fishbein & Ajzen, 2010; Yzer, 2012, 2013). Results showed that the constructs predicted intentions to enroll in health insurance for those with no insurance and for those with government-sponsored insurance and intentions to maintain insurance for those currently insured. Our study demonstrates the applicability of the revised reasoned action framework within this context and is discussed with an emphasis on the practical and theoretical contributions.

Promoting Physical Activity in Low-Active Adolescents via Facebook: A Pilot Randomized Controlled Trial to Test Feasibility.

BACKGROUND: The World Wide Web is an effective method for delivering health behavior programs, yet major limitations remain (eg, cost of development, time and resource requirements, limited interactivity). Social media, however, has the potential to deliver highly customizable and socially interactive behavioral interventions with fewer constraints. Thus, the evaluation of social media as a means to influence health behaviors is warranted. OBJECTIVE: The objective of this trial was to examine and demonstrate the feasibility of using an established social networking platform (ie, Facebook) to deliver an 8 week physical activity intervention to a sample of low-active adolescents (N=21; estimated marginal mean age 13.48 years). METHODS: Participants were randomized to either an experimental (ie, Behavioral) or attentional control (ie, Informational) condition. Both conditions received access to a restricted-access, study-specific Facebook group where the group's administrator made two daily wall posts containing youth-based physical activity information and resources. Primary outcomes included physical activity as assessed by accelerometry and self-report. Interactions and main effects were examined, as well as mean differences in effect sizes. RESULTS: Analyses revealed significant improvements over time on subjectively reported weekly leisure-time physical activity (F1,18=8.426, P=.009, η2 = .319). However, there was no interaction between time and condition (F1,18=0.002, P=.968, η2 = .000). There were no significant time or interaction effects among the objectively measured physical activity variables. Examination of effect sizes revealed moderate-to-large changes in physical activity outcomes. CONCLUSIONS: Results provide initial support for the feasibility of delivery of a physical activity intervention to low-active adolescents via social media. Whether by employing behavioral interventions via social media can result in statistically meaningful changes in health-related behaviors and outcomes remains to be determined. TRIAL REGISTRATION: ClinicalTrials.gov NCT01870323; http://clinicaltrials.gov/show/NCT01870323 (Archived by WebCite at http://www.webcitation.org/6SUTmSeZZ).

Visual and participatory research methods for the development of health messages for underserved populations.

Mass communication health campaign messages play critical roles in public health, yet studies show mixed effectiveness in reaching and impacting underserved populations. The purpose of this study was to evaluate the benefits of using visual and participatory research techniques toward health message development targeting older Hispanic women. Demographic information and levels of physical activity were first obtained in a sample of older Mexican women (n = 23; ages 71.9 ± 7.6 years) living in the city of Chicago. Perceptions of physical activity were then assessed using a visual research method known as photo-elicitation. Health message concepts promoting physical activity were developed with a subsample of the target population using a participatory approach. Photo-elicitation helped develop a unique understanding into the many factors impacting physical activity among older Mexican women. Follow-up in-depth interviews provided detailed narratives that (a) built upon visual data and (b) identified characteristic differences between physically active and inactive women. Ultimately, these findings were beneficial in constructing new, culturally tailored message concepts. Findings suggest that this method may be a valuable tool in the development of mass communication health messages, extracting rich and meaningful data from target audiences while fostering a sense of partnership between researchers and community members. Tailoring and improving the message design process around the needs of underserved populations is essential in the effort to eliminate the burden of health disparities. This study uses innovative interdisciplinary research techniques to explore new approaches to public health communication in underserved populations.

Physical activity and screen time: trends in U.S. children aged 9-13 years, 2002-2006.

BACKGROUND: We examined trends of physical activity and screen time among nationally representative samples of children aged 9-13 years to explore whether children overall are becoming less physically active and less likely to be in compliance with screen time recommendations. METHODS: We analyzed Youth Media Campaign Longitudinal Survey data for trends and demographic patterns of free time and organized physical activity, and hours and minutes of watching television and playing video or computer games. Child-parent dyads for 2002 (N = 3114), 2004 (N = 5177), and 2006 (N = 1200) were analyzed. RESULTS: On the day before the interview, and for free time physical activity in the past week, children reported a significant increase in physical activity from 2002-2006. Screen time levels were stable overall; 76.4% of children met the recommendations of 2 hours or less of daily screen time. CONCLUSION: Levels of physical activity among U.S. children aged 9-13 years were stable, or levels slightly improved from 2002-2006. Except for some subgroup differences, trends for compliance with screen time recommendations were also stable from 2002-2006 for U.S. children aged 9-13 years.

Correlates of children and parents being physically active together.

BACKGROUND: Co-physical activity (between parents and children), as an outcome variable, and its correlates have not been examined previously. The purpose of this study was to investigate correlates of co-physical activity among a nationally representative sample of 9- to 13-year-old children and their parents. METHODS: Data were from the 2004 Youth Media Campaign Longitudinal Survey, a national survey of 5177 child-parent dyads. Parents of 9- to 13-year-old children were asked to report co-physical activity. Parents and children responded to a series of sociodemographic, behavioral, and psychosocial measures. Co-physical activity was treated as a dichotomous variable (ie, some or none). Logistic regression was used to assess associations of correlates directly and possible interactions between correlates. RESULTS: More than three-quarters of parents reported co-physical activity at least 1 day in the prior week. Age, race/ethnicity, sports team participation, eating meals together, parental confidence to influence the child's organized activity, and the child's perception of parental support were significantly associated with co-physical activity. CONCLUSION: The majority of respondents reported participating in co-physical activity, and multiple sociodemographic, behavioral, and psychosocial correlates were significantly associated with co-physical activity. This study provides insight for physical activity interventions that might involve parents.

Influence of limit-setting and participation in physical activity on youth screen time.

OBJECTIVES: To examine the associations of demographics, rules associated with television-viewing, and physical activity with daily screen time (including television, non-school-related computer use, and video games) in children and adolescents. METHODS: We analyzed data from a telephone survey of 7415 youth aged 9 to 15 years from the Youth Media Campaign Longitudinal Survey. We used logistic regression models to calculate odds of exceeding recommended screen-time limits (>120 minutes/day) according to demographics, rules, and physical activity. RESULTS: Odds that children would exceed recommended screen-time limits were positively associated with age and black race/ethnicity and negatively associated with income level. Children and adolescents who reported that they really agreed that their parents had rules about time spent watching television and playing video games were less likely to exceed recommended limits than those who strongly disagreed that their parents had rules. Similarly, when parents reported always or very often having limits on television watching (versus rarely or never) and when parents correctly identified the recommended limits, children were less likely to exceed recommended limits. Children whose parents reported consistent limits and who themselves reported consistent rules about time spent watching television had the lowest prevalence of exceeding recommended limits. Odds that children would exceed recommended limits decreased as physical activity in the previous week increased. CONCLUSIONS: Parental rules regarding screen time and participation in physical activity play a role in the amount of screen time among children and adolescents. Programs that encourage limit-setting by parents and promote physical activity may reduce screen time among youth.

Follow-up of an elementary school intervention for asthma management: do gains last into middle school?

OBJECTIVE: Albuquerque Public Schools (APS), in collaboration with the Centers for Disease Control and Prevention, conducted an evaluation to examine whether students who were exposed to the APS asthma program in elementary school retained benefits into middle school. METHODS: APS middle school students who participated in the APS asthma program in elementary school, including the Open Airways for Schools (OAS) education curriculum, responded to a follow-up questionnaire (N = 121) and participated in student focus groups (N = 40). Asthma management self-efficacy scores from the follow-up questionnaire were compared to scores obtained before and after the OAS education component. Additional items assessed students' asthma symptoms, management skills, avoidance of asthma triggers, and school impact. RESULTS: Although asthma management self-efficacy scores declined in middle school among students exposed to the asthma program in elementary school, they remained significantly higher than scores obtained during elementary school prior to the OAS intervention. CONCLUSION: The results indicate that although students benefited from the asthma program delivered in elementary school, they need booster sessions and continued school support in middle school.

The Influence of the VERB campaign on children's physical activity in 2002 to 2006.

OBJECTIVES: We evaluated physical activity outcomes for children exposed to VERB, a campaign to encourage physical activity in children, across campaign years 2002 to 2006. METHODS: We examined the associations between exposure to VERB and (1) physical activity sessions (free time and organized) and (2) psychosocial outcomes (outcome expectations, self-efficacy, and social influences) for 3 nationally representative cohorts of children. Outcomes among adolescents aged 13 to 17 years (cohort 1, baseline) and children aged 9 to 13 years from cohorts 2 and 3 were analyzed for dose-response effects. Propensity scoring was used to control for confounding influences. RESULTS: Awareness of VERB remained high across campaign years. In 2006, reports of children aged 10 to 13 years being active on the day before the survey increased significantly as exposure to the campaign increased. Psychosocial outcomes showed dose-response associations. Effects lessened as children aged out of the campaign target age range (cohort 1, baseline), but dose-response associations persisted in 2006 for outcome expectations and free-time physical activity. CONCLUSIONS: VERB positively influenced children's physical activity outcomes. Campaign effects persisted as children grew into their adolescent years.

The VERB campaign's strategy for reaching African-American, Hispanic, Asian, and American Indian children and parents.

The VERB campaign promoted physical activity to U.S. children aged 9-13 years (tweens) by surrounding them with appealing messages that were associated with the VERB brand and tag line It's what you do! To maximize the impact of the campaign, VERB had a two-level strategy for its marketing. One level was designed to reach a general audience of tweens (i.e., most tweens who use mainstream media). The second level was designed specifically to reach four racial or ethnic audiences: African Americans, Hispanics, Asian Americans, and American Indians as an augmentation to the first level. This article focuses on VERB's market segmentation strategy and reports how messages for the general audience were adapted to reach specific racial or ethnic segments of the U.S. population. Findings are reported from qualitative studies conducted with tweens and the parents of tweens from these ethnic groups, and the marketing strategies used to reach each ethnic group and the results of evaluations of those strategies are also described.

Overview of formative, process, and outcome evaluation methods used in the VERB campaign.

Evaluation was an integral part of the VERB campaign. This paper describes the array of evaluation methods used to support the development, implementation, and assessment of campaign activities. The evaluation of VERB consisted of formative, process, and outcome evaluations and involved both qualitative and quantitative methods. Formative evaluation allowed staff to test ideas for messages and to gauge their appropriateness for the intended audiences. Process evaluation allowed staff to test and monitor the fidelity of the campaign's implementation to objectives and to make changes while the campaign was under way. Outcome evaluation allowed staff to determine the campaign's effects on the target audience. Because a comprehensive approach was used, which included formative and process evaluation, the VERB team's ability to interpret the results of the outcome evaluation was enhanced.

Methodology of the outcome evaluation of the VERB campaign.

This article summarizes the methods used in the outcome evaluation of the VERB campaign. The outcome evaluation was designed to measure the awareness and understanding of VERB among the target audience of children aged 9-13 years (tweens) and to determine the effect of VERB awareness on psychosocial and behavioral outcomes. Cohorts of tweens and parents were interviewed annually via a telephone survey (Youth Media Campaign Longitudinal Survey). The first cohort (baseline) was surveyed in 2002 prior to VERB advertising and was repeated annually through 2006. A second cohort was surveyed in 2004-2006. A third, cross-sectional sample was surveyed in 2006. Each cohort consisted of a nationally representative sample of tweens to enable generalizability to the nation as a whole. Propensity scoring was used to control for confounding influences. The outcomes were analyzed for dose-response effects (i.e., whether higher levels of awareness led to stronger effects) and overall awareness effects (i.e., the difference between tweens unaware of VERB and all tweens in the U.S.). Secular trends in tweens' physical activity during the life of the campaign were also examined. This article also discusses weighting and imputation, alternative analyses used to assess the adequacy of the propensity methods, and the challenges involved in media campaign evaluations.

Initial outcomes of the VERB campaign: tweens' awareness and understanding of campaign messages.

BACKGROUND: Assessing the immediate effects of mass-media campaigns provides early evidence of campaign reach into the defined target populations. Assessing these effects early in a multi-year campaign allows for better message targeting in subsequent years. DESIGN: Cross-sectional analysis of a population cohort. Data were collected annually; this paper reports on 1-year outcome data following a mass-media-led intervention to increase physical activity among children aged 9-13 years. The groups initially reached by the campaign and those that understood the campaign messages were identified. Analysis was carried out using logistic regression. PARTICIPANTS: Nationally representative cohort of 2729 children aged 9-13 years (tweens). INTERVENTION: National mass-communications campaign (VERB) from June 2002 to June 2003, using television, print, and radio as the primary communication channels. In addition, there were promotions in communities, in schools, and on the Internet. MAIN OUTCOME MEASURES: Prompted and unprompted awareness of the VERB campaign and understanding of the key campaign message. RESULTS: After 1 year, tweens' unprompted awareness of VERB was 17.3%; prompted awareness was 57%; 25.6% had no awareness of VERB. Prompted awareness did not differ by child's age, gender, or ethnicity but was associated with being from a middle- or high-income household, having a parent who was a college graduate, and being active on 7 or more days the previous week. Unprompted awareness was significantly associated with being a girl, being aged 12-14 years, being white, being from a moderate- or high-income household, having a parent with a college degree, and doing 7 or more sessions of physical activity during the week before the survey. The variables associated with high levels of understanding of the campaign message were similar to those for campaign awareness, except there were no differences in campaign understanding by age, and a significant association was found between campaign understanding and parental approval of physical activity. CONCLUSIONS: Measuring initial campaign impact identified the magnitude of immediate effects on population target groups achieved through a mass-media campaign. Campaign planners used the information to develop new messages and adjust media purchases in subsequent years of the VERB campaign.

Testing a hierarchy-of-effects model: pathways from awareness to outcomes in the VERB campaign 2002-2003.

BACKGROUND: The McGuire hierarchy-of-effects (HOE) model, used extensively in mass-media interventions to describe the mechanisms for understanding effects, has not been tested in physical activity campaigns. DESIGN: Data collected at baseline (2002) and follow-up (2003) surveys in the VERB evaluation were used in structural equation modeling to test pathways and hierarchies of campaign effects. SETTING/PARTICIPANTS: Population-based cohort of youth aged 9-13 years (N=2364) for whom complete baseline and follow-up data were available. MAIN OUTCOME MEASURES: Awareness of the VERB campaign, understanding of the VERB message, attitude toward being active, outcome expectations, and physical activity participation. RESULTS: Among youth aged 9-13 years (tweens) in the study cohort, significant paths were identified between awareness and understanding (0.72, p<0.001) and between understanding and being physically active (0.11, p<0.05). At baseline there was a high prevalence of positive attitudes and outcome expectations, and these were not influenced by change in understanding or awareness. Among inactive tweens only, the same paths were identified except that, in this subgroup, attitude was related to physical activity (0.13, p<0.05), and awareness was more strongly related to physical activity than it was for the whole sample (0.14, p<0.01). CONCLUSIONS: These findings provided limited support for the HOE model and suggest that increased awareness and understanding were the key proximal effects that led to behavior change. A distinct sequence of effects, which bypassed attitudes and outcome expectations, was found for these U.S. young people. The findings could inform the design of future campaigns to address youth physical activity.

Did augmenting the VERB campaign advertising in select communities have an effect on awareness, attitudes, and physical activity?

BACKGROUND: Although VERB was designed as a national media campaign, funding and donated media time enabled more-intensive advertising and marketing in certain communities. To investigate the effect of increased advertising on physical activity outcomes, six "high-dose" communities were selected to receive more hours of advertising and additional promotional activities. DESIGN: Longitudinal quasi-experimental design comparing outcomes in six communities that received additional VERB marketing activities with outcomes in a comparison group that received only the national dose of advertising. SETTING/PARTICIPANTS: Two cohorts of dyads of youth aged 9-13 years (tweens) and one parent at baseline (2002), followed for 2 years. INTERVENTION: During the first year of the VERB campaign, each of the six high-dose communities received 50% more advertising and conducted special campaign activities. During the second year, only four of the six communities received the larger dose of advertising and additional promotional activities because of reduced funding. MAIN OUTCOME MEASURES: Awareness and understanding of VERB messages; attitudes about physical activity (self-efficacy, social influences, and outcome expectations); and physical activity behaviors. RESULTS: After 1 year, tweens in the high-dose communities reported higher levels of awareness and understanding of VERB and scored higher on the social influences scale than did tweens in a comparison group in areas that received only the national dose of advertising. After 2 years, tweens in the high-dose communities reported higher awareness and understanding of VERB, greater self-efficacy, more sessions of free-time physical activity per week, and were more active on the day before being surveyed than tweens in the comparison group who received the average national dose. CONCLUSIONS: Providing communities with a higher dose of marketing activities and sustaining those activities over time yields more positive outcomes.

Influencing the parents of children aged 9-13 years: findings from the VERB campaign.

BACKGROUND: The CDC's VERB campaign was designed to increase physical activity among children aged 9-13 years (tweens). As part of the strategy to surround tweens with support to be physically active, VERB developed messages for parents, the secondary target audience, to encourage them to support their tween's physical activity. DESIGN: Multiple regression analyses were conducted to determine whether parent awareness of VERB was a significant predictor of seven factors that related to parental attitudes, beliefs, and supportive behaviors for tweens' physical activity using the Youth Media Campaign Longitudinal Survey (YMCLS). SETTING/PARTICIPANTS: Parents (N=1946) of U.S. children aged 9-13 years. INTERVENTION: Advertising directed at tweens through paid television, radio, print, Internet, and schools was the primary VERB intervention; tween advertising could have been also seen by parents. Messages directed at parents encouraging their support of tweens' physical activity were delivered in English through mainly print and radio. In-language messages for Latino and Asian audiences were delivered through print, radio, television, and at events. MAIN OUTCOME MEASURES: Parents' awareness of VERB; parents' attitudes, beliefs, and support for their tweens' physical activities. RESULTS: Awareness increased each year of the campaign; more than 50% of parents were aware of VERB by the third year of the campaign. Parents reported that their main source of awareness was television, the main channel used to reach tweens. Awareness of VERB was predictive of positive attitudes about physical activity for all children, belief in the importance of physical activity for their own child, and the number of days parents were physically active with their child. CONCLUSIONS: Parents' awareness of VERB was associated with positive attitudes, beliefs, and behavior. Parents' awareness probably resulted from a combination of messages directed to parents and tweens. To maximize audience reach, social marketers who are developing health messages should consider the potential value of parents and their children seeing or hearing the same messages, separately or together.

Parental influences on youth television viewing.

OBJECTIVE: To assess associations among youth television (TV) viewing and parental TV viewing, parental knowledge of the American Academy of Pediatrics (AAP) recommendations to limit children's TV viewing time to < or = 2 hours per day (knowledge), and parental limits on the frequency of children's TV viewing (rules). STUDY DESIGN: Adult participants in the 2002 Styles surveys answered questions about their weekly TV viewing, knowledge, and rules. TV viewing time of children of the adult participants (520 boys and 525 girls) age 10 to 18 years was also collected. Associations between hours of child TV viewing and parental TV viewing, parental knowledge, and parental rules were quantified using linear regression techniques. RESULTS: Variables included in multivariate regression models accounted for 8% to 18% of the variance in TV viewing among boys and girls. Parent TV viewing was significantly associated with TV viewing in 10- to 12-year-old and 16- to 18-year-old boys and girls. Knowledge was not associated with TV viewing in boys and girls in this sample. Rules were associated with TV viewing in boys and girls of all ages. CONCLUSIONS: Our findings suggest that parental TV viewing and rules limiting their child's TV time may play an important role in children's weekly TV viewing time.

Evaluation of a national physical activity intervention for children: VERB campaign, 2002-2004.

BACKGROUND: Amid concern for the consequences of physical inactivity among children, the Centers for Disease Control and Prevention started a campaign using commercial marketing methods to promote physical activity to children. DESIGN: Longitudinal study using a telephone survey to assess physical activity behaviors and attitudes at baseline and for 2 years of follow-up. Relationships of campaign awareness to behavioral and psychosocial effects were analyzed with use of propensity scoring. PARTICIPANTS: Nationally representative cohort of 2257 parent-child dyads. INTERVENTION: Marketing campaign (VERB) directed to all U.S. children aged 9 to 13 years. Components included general market and ethnic-specific advertisements on television and radio, in print, and through promotions in communities, schools, and on the Internet. Advertising ran nationally at consistent levels from June 2002 through June 2004. MAIN OUTCOME MEASURES: Psychosocial measures and self-reports of free-time and organized physical activity during nonschool hours in the week before the interview and on the day before the interview. RESULTS: After 2 years, a dose-response effect was detected in the study population. The more children who reported seeing VERB messages, the more physical activity they reported and the more positive their attitudes were about the benefits of being physically active. Children aware of VERB reported engaging in significantly more physical activity than children unaware of VERB. These results were considerably stronger than the effects after Year 1, which were only for physical activity among subpopulations. CONCLUSIONS: The VERB campaign continued to positively influence children's attitudes about physical activity and their physical activity behaviors and expanded the effects to more children. With adequate and sustained investment, health marketing shows promise to affect the attitudes and behavior of children.

Correlates of physical activity in a national sample of children aged 9-13 years.

BACKGROUND: Physical activity (PA) is critical for children's normal growth and development. The purpose of this study was to assess potential correlates of physical activity in a US national sample of youth aged 9-13 years. METHODS: A nationally representative telephone survey of parent-child pairs was conducted from April through June 2002. The questions assessed organized and free-time physical activity behavior and psychosocial and environmental variables that are potentially related to youth physical activity. RESULTS: Children's positive outcome expectations or beliefs about the benefits of participating in physical activity and parent's beliefs that participating in physical activity is important were related to participation in both organized and free-time physical activity. Children's perception of parental support and parent's reports of direct support were strongly related to organized physical activity. Feeling safe, having lots of places to be active, and parental participation with their child were strongly related to free-time physical activity. CONCLUSIONS: Messages and interventions aiming to increase children and adolescent's participation in organized and free-time physical activity should continue to focus on promoting the benefits that are associated with being active, the importance of parental support, and the provision of safe and enjoyable opportunities to be active.