Pediatric Review

International Journal of Obesity (2011) 35, 472–479; doi:10.1038/ijo.2010.221; published online 26 October 2010

Contribution of social marketing strategies to community-based obesity prevention programmes in children

L Gracia-Marco1,2, G Vicente-Rodríguez1,3, J M Borys4, Y Le Bodo4, S Pettigrew5 and L A Moreno1,2

  1. 1GENUD ‘Growth, Exercise, Nutrition and Development’ Research Group, Universidad de Zaragoza, Zaragoza, Spain
  2. 2Department of Physiotherapy and Nursing, School of Health Science (EUCS), Universidad de Zaragoza, Zaragoza, Spain
  3. 3Faculty of Health and Sport Science (FCSD), Department of Physiotherapy and Nursing, Universidad de Zaragoza, Huesca, Spain
  4. 4EPODE European Network Coordinating Team, Proteines, Paris, France
  5. 5UWA Business School, University of Western Australia, Australia

Correspondence: L Gracia-Marco, Department of Physiotherapy and Nursing, GENUD: ‘Growth, Exercise, Nutrition and Development’ Research Group, School of Health Sciences, University of Zaragoza, Avd. Domingo Miral s/n. CP: 50009, Zaragoza, Spain. E-mail: lgracia@unizar.es

Received 14 June 2010; Revised 17 September 2010; Accepted 19 September 2010; Published online 26 October 2010.

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Abstract

Objectives:

 

To review child and adolescent obesity prevention programmes to determine whether they have included the Social Marketing Benchmark Criteria (BC). In addition, we analysed whether there was a relationship between the presence of the criteria and the effectiveness of the programme.

Methods:

 

Interventions had to be aimed at preventing obesity through behaviour changes relating to diet, physical activity, lifestyle and social support, separately or in combination. A total of 41 interventions were identified in PubMed and Embase that fulfilled the inclusion criteria.

Results:

 

The more recent the studies, the greater the number of the BC that seem to have been used. However, regarding behaviour changes, we found the most effective period to be 1997–2002, with 100% of the interventions resulting in behaviour changes (9/9). In addition, almost all interventions resulted in improvements in body composition variables: 5 of 6 for body mass index or overweight/obesity prevalence and 6 of 6 for skin-folds.

Conclusions:

 

The presence of a higher number of BC does not assure higher effectiveness. Further research is required in this field. At the moment, studies aimed at preventing obesity in children and adolescents have not included social marketing aspects in their interventions in a comprehensive manner.

Keywords:

prevention; social marketing; children

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Introduction

The prevalence of obesity and its comorbidities has dramatically increased in recent decades.1 As the long-term adverse consequences of childhood obesity are substantial and well documented, there is a need for prevention and early intervention to reduce the currently high incidence levels.2 However, few strategies have proved to be successful. Both nutrition and physical activity are important for the growth, development and emotional well-being of young children and for the establishment of healthy lifestyles that prevent childhood overweight and obesity. A recent US study3 showed that only 42% of children and 6–8% of adolescents reached the recommended physical activity levels established by the American College of Sports Medicine.

Obesity, once established, is difficult to treat. Thus, prevention of obesity is the main priority. Many community-based interventions have been developed to achieve this objective, but have produced inconclusive results.4, 5 This study examines these past interventions in the light of a social marketing framework that has been designed to increase intervention effectiveness. The aim is to add to the body of work available to social marketing campaign developers to enhance the effectiveness of their efforts.

Social marketing is an increasingly used approach to address social problems. Kotler and Zaltman6 defined social marketing as the ‘design, implementation, and control of programs calculated to influence the acceptability of social ideas, and involving considerations of product, planning, pricing, communication, distribution and marketing research’. The marketing literature has long referred to the 4 Ps of marketing: product, place, price and promotion. Social marketing is understood to encompass the additional P of ‘people’. In the case of social marketing focused on childhood obesity, this is reframed as the ‘partnership’ P in recognition of the need to coordinate efforts between various agencies and stakeholders.7 Most social marketing campaigns have focused on persuading the individual to adopt recommended behaviours (often referred to as the ‘downstream’ approach). However, it is being increasingly recognised that to maximise its effectiveness, social marketing needs to bring about a change in the social determinants of health and safety (referred to as the ‘upstream’ approach).8, 9, 10 Upstream approaches attempt to change the environment in such a manner as to influence individuals’ behaviour, often without their conscious cooperation.

Social marketing thinking and strategies are now located at the top of health improvement strategies in several countries.11 For example, in the United States, social marketing is increasingly being advocated as a core public health strategy for influencing voluntary lifestyle behaviours, such as smoking, drinking, drug use and diet.12 In the United Kingdom, the potential benefits of social marketing were recognised in the White Paper on Public Health, with specific reference made to ‘the power of social marketing’ and ‘marketing tools applied to social good’ being ‘used to build public awareness and change behaviour’.13 Apart from these strategies, several social marketing campaigns have been developed, such as the Change4Life campaign (UK)14 that it is aimed at preventing obesity through physical activity and nutrition.

The main focus of childhood obesity interventions has been to change parents’ and children's knowledge and behaviours. Social marketing represents an interesting option because its principles are not complex or expensive, and they can provide ‘intelligent solutions’10 to important social problems. To help strengthen the use of effective social marketing approaches, the Social Marketing National Benchmark Criteria (BC) were developed.15 The BC are those elements of an intervention that determine whether it is consistent with social marketing. The strength of social marketing is to apply these principles in a coordinated, sustained and innovative effort.

Increases in the prevalence of childhood obesity throughout Europe have focused attention on the need for large-scale community-based initiatives to tackle the problem. It is now accepted that effective action by individuals must be set within the framework of an environment that supports and facilitates change. The Ensemble Prevenons l’Obesite Des Enfants (EPODE) Program,16 implemented in France in 2004, was inspired by the outcomes of previous community- and school-based interventions.17 It constitutes an example of a large-scale initiative that focuses on creating supporting community environments that promote healthy eating and physical activity among children. The present research is carried out in the framework of the EPODE European Network project (see the ‘Acknowledgements’ section).

As social marketing has been integrated in several studies aiming to prevent overweight/obesity, it is important to assess which strategies and elements of social marketing have been used. This could help establish associations between the effectiveness of the programmes and the use of social marketing as it can be hypothesised that the higher the number of BC used, the higher the effectiveness of the programme. Therefore, our objective was to review child and adolescent obesity prevention programmes to determine whether they have included the BC. In addition, we analysed whether there was a relationship between the presence of the criteria and the effectiveness of the programme.

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Materials and methods

Selection of papers

Inclusion and exclusion criteria
 

Published English-language studies were located through the Medline and Embase computerised databases. The literature review was performed by searching for the following single terms or combinations thereof: ‘obesity’, ‘prevention’, ‘social marketing’, ‘childhood’ and ‘adolescence’. The selection process of the papers was conducted by two independent researchers (LG-M and GV-R), and differences between their assessments were resolved by discussion and, when necessary, in consultation with a third researcher (LAM).

Included studies were limited to those with participants younger than 19 years of age and to those published between 1990 and February 2009. The selection of 1990 as the commencement date was based on a review of the literature that yielded few published intervention studies targeting this group before this time. The intervention had to be aimed at preventing obesity through behaviour changes relating to diet, physical activity, lifestyle and social support, separately or in combination. Our search revealed 42 interventions that fulfilled the inclusion criteria. One was excluded because of a lack of access to the full text document, resulting in 41 studies being included in the review. Using only published data is acknowledged as a limitation of the review. We classified the studies into three categories according to publication year: 1990–1996, 1997–2002 and 2003–2009.

Social Marketing National BC
 

The BC were first described by Andreasen.18 We used the most recent adaptation, reported by French and Blair-Stevens.15 Each study was assessed according to the reported use of the BC and the effectiveness of the intervention introduced. None of the included studies made reference to factors relating to the benchmark criterion of ‘insight’; hence, this criterion was not included in the analysis. The papers were classified into tertiles according to the number of BC identified in the study: <2; 3–4 and greater than or equal to5.

The Social Marketing National BC are as follows:

  1. Customer orientation: Using data obtained from different sources to develop a better understanding of the target audience.
  2. Behaviour: Focusing on changing or reinforcing specific behaviours.
  3. Theory: Using a theoretical framework to develop the intervention.
  4. Insight: Focusing on consumer motivations.
  5. Exchange: Considering the costs and benefits incurred by the target group when changing their behaviour.
  6. Competition: Analysing the barriers that discourage the acquisition of the desired behaviours.
  7. Segmentation: Using a segmentation approach while avoiding stigmatisation.
  8. Methods mix: Using an appropriate mix of methods and avoiding a single method approach.

Intervention effectiveness
 

To analyse behaviour changes, we grouped the results as only one factor known as:

  • Healthy lifestyles: Those interventions that were aimed at improving PA levels, decreasing sedentarism and changing unhealthy dietary behaviours, such as sugar and fat consumption.

To analyse the final outcome of the interventions (body composition), we grouped the results into two categories:

  • Body mass index (BMI) or overweight/obesity prevalence: Improvement in at least one of these factors.
  • Skin-folds: Improvement in at least one skin-fold thickness was considered as an effective intervention.

Statistics

Non-parametric tests were performed to analyse the association between the number of BC used and the effect of the intervention in the selected studies.

SPSS version 14.0 for windows (SPSS Inc, Chicago, IL, USA) was used for the analysis.

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Results

Significant differences were not found in any of the analyses. The application of the BC in each of the 41 studies is shown in chronological order in Table 1. None of the examined interventions featured all the BC.


In the first period (1990–1996), 4 of 7 interventions showed less than or equal to2 BC and 3 of 7 showed 3–4 BC. In the second period (1997–2002), 5 of 13 interventions showed less than or equal to2 BC, and 8 of 13 showed 3–4 BC. In the most recent period (2003–2009), 5 of 21 interventions showed greater than or equal to2 BC, 7 of 21 showed 3–4 BC and 9 of 21 showed greater than or equal to5 BC. In the whole period, 14 of 41 interventions showed less than or equal to2 BC, 18 of 41 showed 3–4 BC and 9 of 41 showed greater than or equal to5 BC (see Figure 1).

Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Number of benchmark criteria. Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author, less than or equal to2; Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author, 3–4; Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author, greater than or equal to5.

Full figure and legend (36K)

In summary, the more recent the studies, the greater the number of the BC that seem to have been used. For example, from 1990 to 2002, none of the papers included greater than or equal to5 BC in their interventions. However, in the most recent period (2003–2009), 43% of interventions used greater than or equal to5 BC.

Table 2 provides a brief summary of the interventions and their effects. In the first period (1990–1996), 3 of 4 interventions targeting behaviour changes were effective. For body composition changes, 2 of 5 interventions targeting BMI or overweight/obesity prevalence were effective and 1 of 2 interventions targeting skin-folds were effective. In the second period (1997–2002), 9 of 9 interventions targeting behaviour changes were effective. For body composition changes, 5 of 6 interventions targeting BMI or overweight/obesity prevalence were effective and 6 of 6 interventions targeting skin-folds were effective. In the last period (2003–2009), 13 of 14 interventions targeting behaviour changes were effective. For body composition changes, 7 of 12 interventions targeting BMI or overweight/obesity prevalence were effective.


Over the whole period (1990–2009), 25 of 27 interventions targeting behaviour changes were effective. For body composition changes, 14 of 23 interventions targeting BMI or overweight/obesity prevalence were effective and 7 of 8 interventions targeting skin-folds were effective.

In summary, regarding behaviour changes, we found the most effective period to be 1997–2002, with 100% of the interventions resulting in behaviour changes (9/9). In addition, almost all interventions resulted in improvements in body composition variables: 5 of 6 for BMI or overweight/obesity prevalence and 6 of 6 for skin-folds.

The BC ‘Behaviour’ was the only one that was applied in all the studies. Other commonly used BC were ‘Exchange’, ‘Customer Orientation’ and ‘Segmentation’.

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Discussion

The main conclusions of our study are that: (1) the BC have not been consistently used and reported in interventions aimed at preventing obesity in children and adolescents, although there is a higher prevalence in more recent years and (2) there does not seem to be a direct relationship between the effect of the interventions and the number of BC used and reported.

The BC ‘Behaviour’ was the only one that was applied in all the studies examined. Other commonly used BC were ‘Exchange’, ‘Customer Orientation’ and ‘Segmentation’. However, it seems that an important factor ‘Competition’, which takes into account the barriers that impede the acquisition of healthy behaviours and lifestyles, has not featured in most studies.

As social marketing was initially conceptualised in 1971, its principles and characteristics have been used mainly by health agencies and government departments. The BC allow an assessment of whether community-based interventions are consistent with social marketing. To our knowledge, our study is the first to evaluate the reported presence or absence of these criteria in interventions aiming to prevent obesity in children and adolescents. Most of the interventions focused on changing specific behaviours relating to PA and nutrition and developed their interventions according to the results of previous experiences, studies or reviews. To understand better the underlying mechanisms leading to intervention effectiveness, more studies are required.

The presence of the BC in the intervention programmes has increased since 1990. It is interesting to note that although the interventions have not used the BC consistently, their presence is higher in more recent years. This might be explained by the fact that more and more new strategies and factors are applied in interventions, and many of them reflect the BC used in social marketing. We found the most effective period to be 1997–2002, with 9 of 9 of interventions aimed at behaviour change being effective. For body composition variables, 5 of 6 and 6 of 6 of interventions were effective for BMI or overweight/obesity prevalence and skin-folds, respectively. The presence of a higher number of BC does not assure higher effectiveness, which may be because most of the studies did not use and report the BC in a comprehensive and conscious manner.

For the whole period, 25 of 27 of interventions were reported to be effective in achieving behaviour changes and 21 of 31 interventions were effective for at least one of the two body composition variables analysed. This suggests that the analysed interventions aimed at preventing obesity through changes in diet, physical activity, lifestyle and social support have been based on sound principles. However, there is the potential to improve these outcomes, and social marketing in the form of the BC may have an important role in achieving this. Identifying those BC with greater influence on body composition could be of interest for those specific interventions. Further social marketing studies are required to detect the most important BC when developing overweight/obesity interventions and the best way to fulfil these criteria.

The strength of social marketing is to apply its principles and strategies in a coordinated, sustained and innovative effort. This was the case in the previously mentioned EPODE intervention that was based on the Fleurbaix and Laventie intervention.17 In brief, EPODE is an initiative that now extends to 226 French towns, and similar initiatives are being developed in 38 Spanish towns, 15 Belgium towns and 5 Greek towns. In general, the model consists of the strategic set-up and coordination at a national and local level of concrete initiatives fostering pleasant and balanced eating habits and greater physical activity in everyday life. The methodology enables creation of new educational schemes and mobilisation of local stakeholders, thus empowering families and individuals in a sustainable manner. These actions are coordinated by a local project manager, nominated by the mayor (or by another local leader) and delivered under the guidance of a social marketing team and the expertise of an independent scientific committee. The EPODE social marketing implementation has been based on the traditional model of 4 Ps of marketing, along with the new ‘P’ of partnership, for preventing obesity.7

Further research is required in this field. At the moment, studies aimed at preventing obesity in children and adolescents have not included social marketing aspects in their interventions in a comprehensive manner.

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Conflict of interest

The authors declare no conflict of interest.

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Acknowledgements

EPODE European Network Study Group: Zaragoza University (Spain), Proteines (France), Free University of Amsterdam (The Netherlands), Gent University (Belgium), Lille 2 University (France) and Fleurbaix Laventie Ville Santé NGO (France). Grants: Directorate General for Health and Consumers (European Commission, Agreement 2007 327). EEN Private Partners: Ferrero International, Mars, Nestlé S.A, Orangina-Schweppes Group.

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