Overcoming Challenges to Build Strong Physical Activity Promotion Messages

Abstract

Physical inactivity is a serious public health issue. Physical activity promotion messages are part of a comprehensive approach to creating a society in which physical activity is the norm. Although public health messages can be influential, they face tough competition from other sources of physical activity information that offer conflicting advice about being active and thus may undermine public health efforts. It is therefore necessary to consider the multiple sources of messages (eg, commercial, public health) that can cause confusion for consumers. This article reviews research on sources of physical activity information, where such information is sought and by whom, and how messages are processed at both automatic (ie, with little thought) and reasoned (ie, deliberate) levels. Having outlined the challenges, suggestions are made regarding how public health messages can be heard in an environment dominated by commercial advertising. These suggestions include tailoring theory-based messages, ensuring the benefits of being active are highlighted, branding, and forging collaborative partnerships within the physical activity sector. By enacting these strategies, public health messages may be more effective at attracting attention and being subsequently read and recalled by consumers, and thus contribute to an active society.

‘Thus, due to repeated exposure to popular media, people may be more motivated to exercise for “6-pack abs” . . . than to enhance their health.’

Physical inactivity is a serious and complex public health problem. Solutions are needed at multiple levels, from changing individual cognitions (ie, thinking, learning, and memory) to environmental makeovers (eg, creating active schools, workplaces, or urban settings). One piece of the overall solution is messaging about the benefits of physical activity. Governmental and nongovernmental organizations around the world have created public health campaigns with the aim of increasing awareness about the importance of being active. ¹ However, public health campaigns must “compete” in a milieu in which conflicting, often confusing, messages abound.^2,3 Consider the myriad sources of physical activity messages from physicians and fitness professionals to commercial companies selling exercise products and programs, popular fitness magazines, and independent blogs written by people with strong opinions but little expertise. Although well-constructed public health campaigns can have a modest positive effect on population rates of physical activity, the many and often conflicting messages that exist in the wider media environment belie the call for “a single clear message for public education purposes, which can begin to change social norms to make physical activity a more usual part of daily life.”^1(p773)

Furthermore, as the Nobel Laureate Daniel Kahneman argues, humans are “inherently lazy thinkers.” ⁴ We often take mental short cuts and rely on automatic associations created through repeated exposure to an idea rather than take the time to think about a particular message and its implications. Thus, due to repeated exposure to popular media, people may be more motivated to exercise for “6-pack abs” (as promised by popular fitness magazines) than to enhance their health. It is imperative that the public health community considers the potential problems created by myriad and often conflicting physical activity and exercise messages and how these messages are processed may undermine public health efforts. This article gives an overview of research regarding various sources of physical activity messages, where information about physical activity and exercise is sought, how such messages are processed and understood, and recommendations regarding how to best create effective physical activity messages.

Sources of Messages

The scope of physical activity messages available and how the public interprets these messages (no matter what the source) is unknown. ⁵ On the one side are public health and not-for-profit campaigns designed to influence understanding and awareness of the benefits of being physically active. There is some evidence that such mass media campaigns can be effective, and several noteworthy campaigns have had population-level impacts. Two good examples are the Center for Disease Control’s VERB campaign targeted at American “tweens” (youth aged 9-13 years) and the campaigns launched by ParticipACTION, a Canadian non-for-profit organization with a mandate of promoting physical activity to all Canadians. ⁶ There is evidence to show both are good examples of campaigns that can effect change.^7,8 Despite these examples of success, authors of a systematic review concluded there is insufficient evidence to determine if stand-alone mass media campaigns (ie, without broader community supports) are worthwhile. ⁹ However, when mass media campaigns are part of coordinated community effort they can serve to change norms regarding physical activity. ¹ Thus, public health campaigns are a potentially influential tool but how they are positioned in the larger media environment remains unclear.

In competition with public health messages are the large number of commercial advertisements and messages that use physical activity and exercise as a platform from which to sell products such as fitness apparel and magazines. ¹⁰ The majority of research investigating representations of exercise in the commercial media has examined the impact of appearance-related advertising on body image and related constructs. For example, exercise advertising featuring beautiful models elicited higher levels of body anxiety than advertisements that only included products. ¹¹ Others have shown that reading an article from a popular fitness magazine containing health-related exercise content resulted in increased ratings of health and appearance as reasons to exercise for university students. ¹² That both these reasons were cited may be because whereas health and appearance are each strongly associated with exercise, qualitative data showed that health, fitness, and appearance were overlapping ideas among active students. ¹³ Participants in that study commented on how the popular media relates health and fitness to appearance. Thus, disentangling the meaning, and subsequent interpretation, of health and appearance messages is challenging.

Exercise is also frequently represented on television. For example, reality television programming has been identified as a form of entertainment that may impart messages regarding health topics. ¹⁴ On the Biggest Loser reality program, individuals who are obese compete to lose weight through extreme diet and exercise, and it has been shown that viewing depictions of exercise on this program was negatively related to attitudes toward exercise. ¹⁵ Stories about physical activity in news media have also been explored. A discourse analysis of women’s exercise narratives in one American newspaper highlighted how exercise is constructed as a means to achieve the “ideal” female body (ie, slim and toned) or as a way to “control” one’s body. ¹⁶ Furthermore, three quarters of the analyzed articles emphasized consumerism through the purchase of fitness-related equipment or services. Other research showed a marked increase in reports about physical activity during televised news broadcasts from the 1970s to the 1990s. ¹⁷ The reports largely highlighted the health benefits of being active, and two thirds cited credible authorities such as professional organizations and scholarly journals. However, the credibility of such sources and what information they impart should be carefully considered as it has been shown that participants who attributed an appearance message to a nonprofit agency rated the message as more credible than participants who viewed the same appearance advertisement yet cited a commercial enterprise as the source. ¹⁸ Others have argued that the emphasis on health by many physical activity promoters may not necessarily be beneficial because whereas health and weight control are common exercise goals for women in midlife, they are less motivating than quality of life goals (which are less common than health goals).^5,19 The authors speculate this is because health and weight control are often and prominently associated with physical activity and exercise but quality of life is not. They argue that exercise has effectively been branded as a means for weight loss, disease prevention, and health benefits without necessarily influencing behavior. In summary, research shows that multiple sources are problematic and that messages that seem intuitively beneficial (ie, be active for health) may be confusing. Thus, physical activity promoters should carefully consider what message they want to impart and to ensure the source of the message is considered credible.

Physical Activity Information Seeking

Another issue to consider is how information about physical activity is sought. There are myriad sources of physical activity information and the information takes many forms, but how it is accessed, and by whom, is unknown. In general, research has shown that people with more education are more likely to search for information about physical activity. ⁵ Furthermore, adults with less education are more likely to name commercial sources (rather than public health sources) of physical activity information. These findings are consistent with the idea of the “knowledge gap,” which hypothesizes that people with higher socioeconomic status are better able to acquire information, and as new information is introduced into society, the gap widens. ²⁰ Knowledge gaps have been shown to exist between socioeconomic groups regarding many health promotion campaigns, ²¹ and a meta-analysis indicated that these knowledge gaps have not decreased over time. ²² Health knowledge gaps may account for the differences in prevention behaviors found between different socioeconomic groups. However, there is very little research examining the knowledge gap with respect to physical activity information seeking.

There is some evidence that one of the most popular places to look for physical activity or exercise information is the Internet, but there is little understanding of what this means in practical terms. ⁵ Some researchers have focused on very specific sites or online communities, for example, a qualitative study of an online body building discussion forum highlighted the extreme exercise-related beliefs of some members of the bodybuilding community. ²³ Others have shown that visitors to a public health Web site promoting walking that was featured on cereal boxes containing pedometers as prizes (a very good example of a public–private partnership) were for the most part, middle-aged women. ²⁴ However, the face of physical activity information on the Internet is unexplored and is likely to remain so because the Internet is a medium defined by constant change. Whether representations of physical activity across various Internet sites influence public thinking about physical activity and exercise behavior is unknown and very challenging to investigate.

Other sources of physical activity information include magazines, television, and personal contacts. It has been found that friends are the most cited source of physical activity information among undergraduate students. ²⁵ This, of course, is recursive and thus unhelpful because the question then arises of where the friends get their information. Fitness magazines are also a popular source of information, but as already highlighted, the images of “ideal” bodies in sports and fitness magazines may contribute to body image issues.^11,26 A content analysis of physical activity–related advertising in popular (not necessarily fitness) magazines revealed the dominance of commercial advertisements, which were better designed to attract attention than the few public health advertisements.^5,10 However, it has also been shown that exercise-related articles in 4 magazines popular with young women (ie, Shape, Cosmopolitan, Glamour, Vogue) were largely consistent with American Heart Association guidelines, with 66.2% of the articles reporting accurate information. ²⁷ Although these few studies exist, there is a paucity of evidence regarding sources of physical activity information, either where information is sought or how different sources influences consumers. Although much more work is needed, it is advocated that those who wish to encourage others to be active should try to understand what sources of information their clients access and how the messages contained therein are understood. This effort is particularly important for more marginalized societal groups who are less likely to be reached by public health campaigns.^20,21

Message Processing

How consumers process (ie, think about) messages is an important consideration. The emphasis on appearance in many messages or the intertwining of health and appearance by consumers, confounded by the dominance of commercial media, ¹⁰ may influence the automatic associations people have for physical activity and exercise. Automatic associations are fast and require little effort, in contrast to deliberative processing, which requires conscious engagement to process a message. In his popular book, Thinking Fast and Slow, Daniel Kahneman describes how cognitive processes can be conscious and deliberative (ie, reflective or explicit) or fast and automatic (ie, implicit) and how these so-called dual-processes influence behavior. ⁴ The elaboration likelihood model is a dual-processing model ²⁸ that has been used to examine the effects of exercise-related information on changes in attitudes.^18,29,30 According to this model, a persuasion variable (such as reading exercise-related information or watching depictions of exercise on television) can influence attitudes in a number of ways including affecting how much the information presented is processed. Information that is thought about more (ie, is centrally and more explicitly processed) may result in stronger attitudes than information that is elaborated about less (ie, is peripherally and more automatically processed). However, the amount of elaboration depends on factors such as personal relevance, message comprehensibility, or source of the message. Furthermore, persuasion can occur through emotion or reason. Accordingly, exercise-related attitudes have been conceptualized as affective (eg, fun) or instrumental (eg, healthy) with affective attitudes shown to be more predictive of behavior than instrumental attitudes. ³¹ A person may have been persuaded regarding the health benefits of exercise (an instrumental attitude) but nonetheless find exercise unpleasant (an affective attitude) and therefore choose not to participate. It is also conceivable that one may have an automatic negative association with exercise, but on reflection of the benefits of exercise indicate a positive attitude.

Decisions regarding health behaviors can be made using both explicit and implicit cognitive processes, yet most research examining physical activity messages has focused on explicit processing (eg, through the use of questionnaires). But it is important to consider that commercial marketers do not rely on rational processing of advertisements, and consumer psychologists use measures that capture automatic processes to better understand how to sell products. When individuals are not actively engaged in message processing (eg, glancing at advertisements while flipping through a magazine), they may be persuaded simply by the number of arguments presented. This approach provides an advantage for commercial promoters who dominate the advertising landscape. ¹⁰ Researchers have shown a positive relationship between the implicit and explicit believability of physical activity for health messages but no relationship between implicit and explicit believability of physical activity for appearance messages. ³² In other words, participants may not have explicitly indicated belief that by being active they would quickly become slim and beautiful but at the same time showed automatic belief of the message. Those with greater automatic agreement of the appearance message had lower intentions to be active. This limited evidence highlights that public health promoters should look to consumer psychology practices when creating advertising campaigns in the same way as commercial marketers. It is likely that consumers spend very little time processing health messages, and how this affects the success of health promotion efforts is unknown. It is possible that someone will profess disbelief that the appearance ideals promoted through images in fitness magazines can be achieved, yet automatically associate such images with exercise, and it is the automatic associations, created through media exposure, that drives behavior. However, it should be cautioned that there is very little research examining these ideas. Based on the small amount of research conducted thus far, it is not possible to make recommendations related to automatic processing, but it is fair to raise a skeptical eyebrow if someone argues about the motivating effects of appearance-based exercise messages.

How to Create Effective Messages That May Compete

Public health promoters are challenged to create messages that have impact amid the many other promoters of physical activity, all clamoring for attention. The resources (financial, expertise) available to support the development and dissemination of public health physical activity promotion messages is only a fraction of what is available to commercial marketers. ³ Thus, the challenge becomes creating optimally effective messages with the available resources. Using evidence to inform message development and delivery is critical to direct attention to strategies that hold the greatest promise. Thus, although public health promoters are unlikely to dominate the messaging landscape in terms of volume, evidence-based practical recommendations for optimizing message impact can be made. The recommendations provided next are a reflection of prominent themes within the current published literature on social marketing^2,33 and physical activity promotion. ³⁴

Create Messages That Grab Attention

Several models from communications and marketing studies (eg, hierarchy of effects model ³⁵ and the communication behavior change model ³⁶ ) position attention as a critical first step in the process of using a message to change people’s thoughts and behavior. Accordingly, for messages to have impact, they must grab people’s attention (usually at an automatic level). Message tailoring and message framing are 2 approaches to constructing physical activity messages that enhance attention to messages.

Message tailoring involves providing messages that are suited to the message recipient. Messages can be tailored in a number of ways. ³⁷ At the most cursory level, they may be tailored to demographic characteristics (eg, physical activity messages tailored to moms). Other strategies involve tailoring to individual’s motivation to become active (eg, stage of change ³⁸ ) or to stable dispositional characteristics (eg, consideration of future consequences, ³⁹ regulatory focus ⁴⁰ ). The principles underlying the concept of message tailoring relate to the elaboration likelihood model. Tailoring a message increases its relevance. When individuals determine that a message is relevant, they are more likely to engage in central route processing—thoroughly considering the message content. Information that is thoroughly processed is more likely to change thoughts and behaviors. Moreover, changes are more likely to endure. ⁴¹ Controlled interventions studies demonstrate the benefits of messages tailoring. Two meta-analyses compared tailored health behavior change messaging interventions to nontailored or control interventions.^42,43 One meta-analysis examined tailored print messages and the other examined Web-based strategies. Although these reviews include studies covering a range of health behaviors, physical activity was the most frequently targeted behavior among the studies reviewed. Both meta-analyses demonstrated a small-sized effect favoring tailored messages and physical activity specifically.

When tested in the context of a population-level mass media campaign where messages are competing amidst other physical activity messages, message tailoring demonstrates promise. In 2007, ParticipACTION launched a mass media campaign tailored to parents. The campaign aimed to raise parents’ awareness of childhood physical inactivity. Evaluation of the campaign revealed a trend in which parents had higher unprompted recall of television advertisements compared to nonparents. ⁸ Accordingly, it seems that tailored messages have potential to draw attention and thus should be considered as a strategy for constructing impactful messages.

Appropriately framing a message is another evidence-based strategy that can be used to draw attention to a message. Messages can be framed to emphasize the benefits of being active (gain-framed) or the consequences of inactivity (loss-framed). According to message framing theory, ⁴⁴ gain-framed messages are most persuasive for behaviors that are risk averse and have certain outcomes. Loss-framed messages are most persuasive for behaviors where the behavioral outcome is risky or uncertain. Because, for the majority of the population, the outcomes of physical activity are certain and risk averse, it follows that gain-framed messages should be the most persuasive. Indeed, evidence from Gallagher and Updegraff’s ⁴⁵ meta-analysis of 6 physical activity and message framing studies support this premise. Increased attention to the message has been proposed as a potential mechanism for this observed gain-framed advantage. ⁴⁶

To date, this mechanism has only been tested in experimental lab-based research. In one experiment, 77 inactive college students were primed with information regarding acute and chronic health conditions. ⁴⁷ Next participants read a framed message describing the role of physical activity in addressing these health conditions. The gain-framed message positioned physical activity as a means of preventing the health conditions; the loss-framed message emphasized that being inactive results in failure to prevent the health condition. Attention to the messages was evaluated objectively using an eye tracking system that monitored how long participants looked at the messages they read, and the results revealed a gain-framed advantage. ⁴⁸ Participants in the gain-framed condition attended to the physical activity messages longer than participants in the loss-framed condition. Building on this initial work, Berenbaum and Latimer-Cheung (unpublished data) examined whether increased attention to gain-framed physical activity messages translated into increased physical activity behavior. In this study, 60 moderately active, female, college students viewed 20 gain- or loss-framed ads while their eye movements were recorded via eye tracking. Immediately following the ad-viewing session, the women engaged in a 20-minute exercise session. Compared to the loss-framed messages, the gain-framed ads attracted greater attention, elicited greater effort during the exercise bout, and resulted in greater behavior change 1 week later. While additional research is needed determine the generalizability of the findings from these 2 studies to other populations and within the wider media context, this work nonetheless provides preliminary evidence that gain-framed messages should be considered as a strategy for drawing attention to physical activity messages.

Build a Brand

In his book, Social Marketing: Why Should the Devil Have All the Best Tunes? Gerard Hastings ⁴⁹ challenges practitioners to consider the application of commercial marketing practices to social issues including areas of public health promotion. Building a brand is one commercial marketing technique that increases potential for public health promotion effort to compete. A brand can be conceptualized as a distinctive label, sign, or symbol that distinguishes the products and services of one organization or company from another. ⁵⁰ The symbol aims to convey the value of the brand and in turn entice the consumer to engage with the brand (eg, have feelings about the brand, relate with the image of the brand) and the branded product. In the case of public health, the behavior itself is the branded product. ⁵¹

The strategic use of a brand within public health and physical activity specifically is a relatively new approach. ⁵² However, the few examples of brand use within the physical activity domain provide clear indication of the power of branding. In 2002, the Centers for Disease Control launched the VERB campaign. The VERB brand was carefully crafted by a team of commercial marketers, researchers, and public health practitioners to convey inclusiveness, playfulness, having fun being active with friends, and accessibility to all children. ⁵³ These brand attributes were reflected in all the messages and activities associated with the campaign. Evaluation of the campaign indicated that the brand was successful; tweens who recognized the brand and understood the messages engaged in more physical activity than tweens with lower brand awareness. ⁷

Over its more than 40-year history, the Canadian nongovernmental organization ParticipACTION has built a strong brand by combining the words “participate” and “action.” In this way they created a word new to both French and English (the official languages of Canada), which is meant to inspire every Canadian to action. ⁵⁴ Population surveys indicate high brand recall. With reinforcement from campaign activities, the brand has helped shape norms regarding activity in Canada. ⁵⁵ Even after a 7-year hiatus (the program was suspended in 2001 due to a lack of funding and relaunched in 2007), brand recall was high, albeit more so in active people with more income and education. ⁵⁶ Both ParticipACTION ⁵⁷ and VERB ⁷ used effective branding, which while expensive, was demonstrably effective in increasing awareness of campaign messages through repeated pairings of key messages with the brand.

Construct Messages Founded in Theory

Behavior change theories such as the theory of planned behavior and social cognitive theory provide a foundation for developing message content. Using a theory to construct messages helps guide practitioners in identifying important behavioral determinants and accompanying strategies for changing these determinants. ⁵⁸ Evidence from meta-analyses,^59,60 systematic reviews, and comprehensive intervention evaluations^61,62 suggests that messages targeting theoretical constructs such as affective attitudes, self-efficacy (confidence to be active), and self-regulation (self-monitoring and related skills necessary to be active) hold promise as effective message content. Indeed, Michie and colleagues’ review of physical activity interventions, including messaging-based strategies, revealed that interventions incorporating theory are more likely to elicit behavior change relative to interventions without a guiding theoretical framework. ⁶³

Unfortunately, practitioners do not always use theory to inform the content of their messages. A review of existing physical activity brochures, such as those commonly displayed in physician clinics or pharmacies in North America, showed little use of such proven behavior change techniques. ⁶⁴ Among the brochures that did include some theory-based content, few targeted self-regulation and affective attitudes. Practitioners should consider targeting these constructs not only to enhance the theoretical content of their messages but also to enhance the novelty of their messages. For example, messages that do include theoretical content often focus on instrumental attitudes and highlight the physical and health benefits of an active lifestyle. The constant emphasis on the same outcomes can lead to audience fatigue and disregard for the message. As one qualitative study showed, health promotion messages may not be attended to because it has been heard repeatedly. ⁶⁵ Emphasizing fun, enjoyment, and stress relief (the affective benefits of physical activity that are rarely conveyed) has potential to bring new information to message recipients and result in more engaging messages.

Work Together to Develop Comprehensive Campaigns

Physical activity promotion falls within the mandate of all levels of government (eg, US Department of Health and municipal public health units) and is an area of priority for many nongovernmental organizations ranging from not-for-profit organization such as ParticipACTION to private corporations such as the National Football League. Aligning the objectives of the organizations contributing to the physical activity sector is only logical. Such alignment ensures that public health promotion physical activity messages are not contributing to the cluttered media landscape by delivering a unified message that is consistent, coherent, and strong. This approach removes duplication of efforts and allows for efficient use of resources. For example, rather than multiple organizations producing costly advertisements and promotional materials, organizations could pool resources to produce messaging materials (eg, advertisement, posters) that have repeated exposure and to implement activities to support these activities.

In the existing siloed approach where organizations work independent of each other, physical activity messages are often delivered in the absence of supporting interventions. ⁵⁸ Success comes from comprehensive interventions with multiple opportunities to be exposed to, and to act on, messages. Again, the impact of the VERB campaign reinforces the need for a partnered, multifaceted approach. In this campaign, messages promoting physical activity disseminated through mass media and school and community promotions were supported by campaign partners who created opportunities for youth to be active (eg, making activity spaces more accessible). ⁶⁶ This partnered approach increased opportunity for message exposure and resulted in supplementary interventions that allowed tweens to act on the messages. Unfortunately, uptake of such coordinated approaches has been slow. For example, in Canada, ParticipACTION has offered cobranding opportunities on their professionally produced advertising materials. Only 3 of 10 provinces have taken advantage of this opportunity. ⁶

Conclusions

Although there is a dearth of evidence examining physical activity messaging, this article serves to highlight important issues for consideration, not only by researchers but also by those working to effect physical activity behavior change. First, those who promote physical activity for health should consider the implications of competing messages in the media. Conflicting messages from different sources may be confusing. Health promoters should have realistic expectations regarding the impact of their campaigns with the larger media environment. The goal is not necessarily to change behavior but rather to initiate change in how people think about physical activity and to communicate that active living is the norm. Second, it is important to think about messaging in the same way commercial marketers do. It should be assumed that reactions to advertisements are fast; often little attention is paid to the message so attention needs to be captured quickly. The target audience should not be relied on to take the time to rationally process (ie, sit down and read) a promotional message. Third, it is imperative to look to the work of behavioral scientists, consumer psychologists, and commercial marketers to inform the content and delivery of messages. Research and practice from these domains provide direction for constructing messages with optimal impact. In conclusion, physical activity messaging can aid in making physical activity a societal norm, but thought needs to go into the creation of the messages and their place in the larger media environment. The impact of messages that promote physical activity for reasons other than health needs investigation.