Challenging Dogma - Spring 2008

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

Friday, April 18, 2008

The SmallStep Kids Campaign: How a Missed Target Prevents Success of an Innovative Public Health Promotion – Patricia Walsh

Childhood obesity is continuing to be a predominant issue within public health. The National Health and Nutrition Examination Survey (NHANES) estimated 17.1% of US children (aged 2-19 years) were overweight in 2003-2004 (1). The prevalence of pediatric obesity and overweight has been steadily and significantly increasing in recent time periods (2). In an effort to address this issue, public health campaigns which target the youth audience have emerged. One of the most recent and largest of these campaigns is SmallStep Kids.
The SmallStep Kids campaign is a sub-campaign of the HealthierUS initiative of the U.S. Department of Health and Human Services which was launched in April of 2007. It encourages children ages 6 to 11 to eat healthier, portraying food as fuel for play, and incorporates NFL players, other athletes, and cartoon characters to persuade children to get out and “play 60” or “be a player” everyday. This campaign integrates many traditional models of health behavior, and attempts to address some non-traditional models, such as framing and social marketing theories. However, the campaign does not address many issues which are crucial to understanding and mitigating the childhood obesity epidemic.
The SmallStep Kids campaign fails to address many factors in the lives of children who most need obesity intervention. Poorer, urban areas tend to have the highest concentration of obese children, and are also areas which lack access to affordable fresh fruits and vegetables and safe play spaces (3). It also misses in an attempt to establish social norms with the use of prominent athletic and entertainment figures as role models for healthy living. This campaign also makes the false assumption that children have a large degree of control over their meal choices and schedules, and will be able to integrate healthier choices into their lives.
Missing a Crucial Target
SmallStep Kids ignores the socioeconomic and racial/ethnic disparities within the obesity epidemic. While childhood obesity is a problem across all races in the United States, it is most prevalent among minority groups. According to NHANES data, 35.9% of non-Hispanic black children and 39.3% of Mexican-American children ages 6-11 are overweight or at risk, with a body mass index at the 85th percentile or higher. 19.5% of black children and 23.7% of Mexican-American children in this age group have BMIs in the 95th percentile or higher (1). Studies have linked deprived neighborhoods with increased prevalence of obesity, particularly in childhood and adolescence (4).
The SmallStep Kids campaign assumes that children at risk for obesity will have access to healthy foods, places to play, and technology such as television and the internet. The campaign reaches out through television commercials and an interactive website. It assumes, via the Health Belief model, that children can be influenced to make healthier food choices and engage in more physical activity as a means to avoid obesity (5). However, urban, impoverished areas tend to be those most hard hit by the childhood obesity epidemic; children in these areas are less likely to have access to the resources required for the SmallStep Kids campaign to work. Children in these areas are less likely to have consistent access to affordable fresh fruits and vegetables, due to a lack of nearby grocery stores, no means of reliable transportation, or economic issues (3). The potential threat of neighborhood violence limits time and space available for outdoor play, as does the lack of open areas in an urban neighborhood. Also, the extension of school days, particularly in urban areas, may make it nearly impossible for this demographic of children to “play 60” on a regular basis (6).
By not approaching the obesity epidemic from a standpoint which integrates more lifestyle factors, the Department of Health and Human Services is unable to reach the groups in most need of intervention. They ignore modern theoretical constructs such as Link and Phelan’s proximal and distal causes of disease, and instead approach this public health problem with traditional models of health behavior change, such as the health belief model (7). Within the health belief model, the primary motivation for a change in health behavior is a perceived threat of disease, while the primary resource for change is self-efficacy (5). The SmallStep Kids campaign works on this platform, encouraging children to make healthier choices as a means to avoid obesity. This requires children to both recognize their risk, and have the ability and means to make better food and activity choices.
Establishment of Shaky Social Norms
The SmallStep Kids campaign utilizes advertisements to establish a social norm of healthy diet and regular exercise, hoping that this will influence children to conform. It integrates athletes and entertainment figures into its television and internet advertisements, assuming that children will recognize and want to emulate them. The advertisements tend to show these figures playing outdoors with groups of children, while a catchy jingle plays. Advertisements advocating healthy eating have children eating fruit or sandwiches made with whole wheat bread, and a voiceover explains how the nutrients in these foods can fuel play.
Behavioral interventions based on the theory of social norms focus on peer influences, which are held to have a greater impact on individual behavior than biological, personality, familial, religious, cultural and other influences (8). Extensive research has documented the importance of peer influences and normative beliefs on health behaviors of youth (9). SmallStep Kids attempts to influence children via social norms theory by portraying healthy activities being enjoyed by children with each other, as well as with some familiar and famous faces.
The major figures of the campaign are NFL players, LPGA golfers, and characters from DreamWorks Shrek movies. The choice of these figures as role models or peers is troublesome in that they may not actually be the best influence on children. While many NFL players are exemplary athletes and citizens, recent news stories have covered the crimes and debauchery committed by high profile players. Shrek is an accessible figure for many children, but not necessarily the best picture of good health or hygiene. It is also questionable if the LPGA is popular with a large cohort of children ages 6 to 11 at all, and if any will recognize the women in the commercials.
According to DeFleur and Ball-Rokeach, the mass media establishes impressions upon its audiences that common cultural norms concerning emphasized topics are structured in a specific way (8). This is the basis of social norms theory, which is followed by the Department of Health and Human Services in this campaign. They utilize mass media to create an idea that children are supposed to go outside and play (with interaction by adults) and should happily eat fruits, vegetables, and whole grains. However, this social norm may backfire, as all children may not have access to these foods, outdoor play space, or adults who are willing to play with them. While the advertisements produced by SmallStep Kids have a positive message, they highlight a fatal flaw of this campaign—it does not reach out to underprivileged children who are most at risk for obesity.
This campaign also ignores the theory that children and adolescents are often inclined to “rebel” or deviate from social norms established by adults and other authority figures (9, 10, 11). The use of adults such as athletes to establish the idea of healthy behaviors may backfire, as children may associate these adults with those who exercise control over their daily lives.
Control Issues
A major failing of this campaign is that it assumes children are able to exercise enough control over their schedules and food choices to change them. Children in the target age group of 6 to 11 do not control their school schedule, means of transportation, or what food is readily available to them. This control is in the hands of parents or guardians, school districts, and local government. By assuming that children in the target age group will be able to make the choice to change health behaviors, the campaign sets itself up for failure.
In its adherence to the health belief model, this campaign ignores that social networks exist around these children and that problem could be better addressed by targeting the entire family, neighborhood, or school system. Social networks provide long term influence over health behaviors, unlike the short-lived influence which may be created by this campaign. Recent research from the Harvard School of Public Health has stated, “Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions” (12).
Rather than addressing the issue of childhood obesity and overweight by influencing children through a commercial campaign, the Department of Health and Human Services may have been able to be more effective by reaching out to the social and ethnic communities who are suffering the most from this epidemic. Encouraging access to healthy foods and outdoor space through programs and subsidies, as well as though community health education, could provide a lasting benefit for those at highest risk. The organization of healthy activities for children by community members can also lead to decreased obesity, as was shown by Weintraub, et al. in their randomized study of overweight and obese children in a low-income community (13). Studies have also found that prolonged parental and familial involvement in juvenile weight-loss programs is necessary for continued success (14).
The SmallStep Kids campaign is not all bad. Its utilization of both television and the internet in a way that is friendly to children is commendable, at is its use of time limits on internet games. The portrayal of healthy foods as fuel for play may be a message which is attainable for many children who do have access to these foods and the time and space to play, but have chosen not to. However, it has missed a few major aspects of the nature of childhood in the United States which may prevent its positive messages turning into changes in behavior. This campaign does not approach the childhood obesity epidemic from a social science or social epidemiology standpoint, but instead follows more traditional models of health behavior. This leads it to miss many important aspects of this epidemic, particularly how socioeconomic status plays into the development of obesity. By ignoring modern theories such as the proximal and distal causes of disease, the SmallStep Kids campaign does not address a child’s social situation and how this may impact their availability of healthy food and their ability to go outside to play.
1. Department of Health and Human Services: Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention.
2. Ogden CL, Flegal KM Carroll MD, Johnson CL. Prevalence and trends of overweight among US children and adolescents, 1999-2000. JAMA 2002; 288:1728-32.
3. Perez-Lizaur et al. Environmental and personal correlates of fruit and vegetable consumption in low income, urban Mexican children. Journal of Human Nutrition and Diet 2007; 21: 63-71.
4. Dragano N et al. Neighbourhood socioeconomic status and cadiovascular risk factors: a multilevel analysis of nine cities in the Czech Republic and Germany. BMC Public Health 2007; 7: 255.
5. Baranowski, et al. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research, Vol. 11 Supplement. October 2003.
6. Massachusetts 2020. Expanded Learning Time (ELT) Schools. Boston, MA:
7. Link BG, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995; Extra Issue: 80-94.
8. DeFleur M, Ball-Rokeach S. Socialization and theories of indirect influence (pp. 203-227). In: Theories of Mass Communication, 5th Edition. White Plains, NY: Longman, Inc., 1989.
9. Berkowitz, AD. Responding to the Critics: Answers to Common Questions and Concerns About the Social Norms Approach. The Report on Social Norms: Working Paper #7. 2002. Little Falls, NJ: PaperClip Communications.
10. Allen JP, Porter MR, McFarland FC, Marsh P, McElhaney KB. The Two Faces of Adolescents’ Success With Peers: Adolescent Popularity, Social Adaptation, and Deviant Behavior. Child Development. 2005; 76:747-60.
11. Martin CA, Kelly TH, Rayens MK, Brogli BR, Brenzel A, Smith WJ, Omar HA. Sensation seeking, puberty and nicotine, alcohol and marijuana use in adolescence. Journal of the American Academy of Child Adolescent Psychiatry. 2002; 41:1495-502
12. Moffitt T. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review. 1993; 100:674-701.
13. Christakis NA and Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 2007; 357(4):404-407.
14. Weintraub D et al. Team sports for overweight children: the Stanford sports to prevent obesity randomized trial (SPORT). Archives of Pediatrics & Adolescent Medicine 2008; 162(3): 232-237.
15. Stewart L et al. Parents’ journey through treatment for their child’s obesity: a qualitative study. Archives of Disease in Childhood 2008; 93(1): 35-39.
16. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295:1549-1555.
17. McCombs M, Shaw DL. The agenda-setting function of the mass media. Public Opinion Quarterly 1972;36:176-185.
18. Salazar MK. Comparison of four behavioral models. AAOHN 1991;39:128-135.
19. Stubbs CO, Lee AJ. The obesity epidemic: both energy intake and physical activity contribute. Med J Aust2004;181:498-91.
20. Krieger N. Theories for social epidemiology in the 21st century: and ecological perspective. International Journal of Epidemiology 2001; 30:668-677.
21. McLeroy K et al. An Ecological Perspective on Health Promotion Programs. Health Education and Behavior 1988; 15: 351-377.
22. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11:246-252.
23. Shishebor M et al. Association of neighborhood socioeconomic status with physical fitness in healthy young adults: the CARDIA study. American Heart Journal 2007; 155: 699-705
24. Goodman E et al. The public health impact of socioeconomic status on adolescent depression and obesity. Adolescent Health 2003; 93: 1844-1850.
25. Wang Y et al. Obesity and related risk factors among low socio-economic status minority students in Chicago. Public Health Nutrition 2007; 9: 927-938.
26. Wang Y, Zhang Q. Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the association between overweight and family income between 1971 and 2002. American Journal of Clinical Nutrition 2006; 4: 707-716.
27. Wang Y. Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. International Journal of Epidemiology 2001; 30: 1129-1136.
28. Wills W et al. The influence of the secondary school setting on the food practices of young teenagers from disadvantaged backgrounds in Scotland. Health Education Research 2004;20(4):458-465.
29. Lewis E. Children’s views on non-broadcast food and drink advertising, Report for the Office of the Children’s Commissioner. UK National Children’s Bureau, Office of the Children’s Commissioner. September 2006;1-20.
30. Freedman D et al. Racial and ethnic differences in secular trends for childhood BMI, weight, and height. Obesity 2006; 14: 301-308.
31. U.S. Department of Health and Human Services. SmallStep Kids. Washington, D.C.:

Labels: , , , ,


  • At April 23, 2008 at 9:45 PM , Blogger Matthew said...

    Access to fresh fruits and vegetables in these communities of lower socioeconomic status seems to be a key problem. How do you attract a company such as whole foods - which has a wide variety of attractive looking healthy food choices - to build a store location in an area of lower socioeconomic status, when it would likely be more dangerous and subject to higher theft, etc? Personally, this fundamental hurdle is a crucial first step in curbing childhood obesity, but a very challenging one ,at that.

  • At April 24, 2008 at 8:50 AM , Anonymous Kerin said...

    I fully agree that this campaign misses the boat in regards to low income urban kids. However, regarding the use of adult athletes, I think that was a great move. The campaign is targeted at younger kids, not teens who tend to rebel against authority. By encouraging the young kids to strive to be like their heroes seems to me like a good move.


Post a Comment

Subscribe to Post Comments [Atom]

<< Home