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Executive Summary
This study examines fast-food marketing as an influence on the fast-food consumption of children served by community health centers in medically underserved areas. In particular, the authors explore the potential mediating role of parents' attitudes and normative beliefs on how often their child eats fast food. Understanding the mediating processes between marketing and fast-food consumption behavior is important for the design of public policies and related social marketing interventions. In addition, obesity rates vary significantly by ethnicity, with a higher prevalence among African Americans, Hispanics, American Indians, and Pacific Islanders than among non–Hispanic whites. However, relevant research with ethnically diverse populations is lacking. Therefore, the study also explores whether there is ethnic variation in perceptions of marketing exposure, attitudes, normative beliefs, and behavior.

The authors conducted a cross-sectional study at eight community health centers in medically underserved communities on the east coast of the United States and Puerto Rico. Such community health centers are funded by the Health Resources and Services Administration and serve more than 14 million predominately poor and minority clients with incomes significantly below the federal poverty level. The authors designed survey measures to capture parents' self-reports of fast-food access, exposure to fast-food promotion, fast-food attitudes, social norms about fast food, and their child's fast-food consumption. A questionnaire including these measures was administered on-site to parents of children ages 2 to 12, with the child present and in the parent's preferred language (English, Chinese, or Spanish). Height and weight of the child were measured using standardized research.

In the ethnically diverse sample of parents, reports of more exposure to fast-food promotion were associated with beliefs that eating fast food is normative to their friends, family, and people in their community, as well as with more frequent fast-food consumption among children. Furthermore, parents' perceptions of more favorable social norms toward fast food mediated the association of exposure to fast-food promotion with greater consumption of fast food by their children. That is, the degree to which parents perceived fast-food consumption as socially normative was associated with higher fast-food consumption by their children. The study results also identified ethnic group differences in parents' perceptions of fast-food marketing promotional exposure, access, attitudes, norms, and consumption. Specifically, Hispanics and African Americans reported being exposed to more fast-food promotions than whites and also reported fast-food restaurants being more conveniently located to them than whites. In addition, Hispanics reported significantly more favorable attitudes toward fast food than did whites, whereas Asians reported fast food as significantly less normative than all other groups.

The study suggests that fast-food marketing may affect consumption levels among children through parents' attitudes toward fast food and their beliefs about social norms surrounding fast-food consumption. Although these associations do not provide evidence for causal relationships, the results illuminate the pathways whereby marketing might adversely influence children's weight through effects on parents. For example, the apparent mediating role of social norms observed in this study suggests an approach to decrease fast-food consumption. Interventions that aim to correct misperceived social norms have increased in recent years and provide a potentially useful framework for the design of social marketing interventions. An important next step is to understand better the normative beliefs of specific intervention targets within the fast-food context and whether they are indeed misperceptions. Even if the beliefs are not misperceptions, they may still be positively influenced by social marketing.

Although the ethnic subgroup analysis was exploratory, the results suggest an important area for additional study. If fast-food marketing contributes to perceived social norms surrounding fast-food consumption within a community and if parents of different ethnic backgrounds have different reported exposure to fast-food marketing promotion, differences in the amount and content of targeted food marketing may create, shape, support, or maintain ethnic differences in the healthfulness of attitudes and norms toward fast food. The results imply that additional research on the potential contribution of parental-oriented target marketing to observed differences in child feeding behavior is needed. Research that examines the food-marketing environments of specific groups or compares the marketing environment of multiple groups might provide particular insight.

Overall, the results of this study indicate that fast food marketing may influence parents' child-feeding behavior. Thus, for a more comprehensive understanding of approaches to reduce childhood obesity and related cardiovascular risk factors, research that assesses the influence of marketing on children's eating behavior and policy debates about food marketing to children might also consider parents' marketing exposure. Additional insight into marketing as an influence on parental feeding behavior will assist researchers, policy makers, and marketers in developing interventions to ensure that food marketing plays a positive role in child health.

Biography
Sonya A. Grier is an Associate Professor of Marketing at the Kogod School of Business at American University. She joined American University from the University of Pennsylvania, where she was a member of the first cohort of the Robert Wood Johnson Foundation Health & Society Scholar Program. Before joining the program, Dr. Grier was an assistant professor at the Stanford University Graduate School of Business. Professor Grier's research converges on topics related to the influence of social context on consumers, the social impact of marketing efforts, and social marketing. Her current research investigates the relationship between marketing efforts, both corporate and social, and consumer health-related attitudes and behaviors. Dr. Grier also has practical industry experience, having worked in market research at Kraft, in brand management at General Foods, and as an independent marketing consultant. She received her PhD in Marketing, with a minor in Social Psychology, from Northwestern University in 1996. Dr. Grier also has an MBA from the J.L. Kellogg Graduate School of Management, Northwestern University, with an emphasis on Marketing, Nonprofit Management, and International Business.

Janell Mensinger is Director of the Clinical Research Unit in the Department of Medicine at the Reading Hospital and Medical Center. She teaches the Public Health of Nutrition, Weight, and Eating Behaviors and Principals of Biostatistics in the Masters of Public Health Program at Downstate. She is trained as a health psychologist and received her PhD from the Graduate Center of the City University of New York. She received postdoctoral training at Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine in biostatistics and behavioral health research. She is the recipient of an National Institutes Mental Health National Research Service Award and an National Institutes of Health Loan Repayment Award. Her recent publications have appeared in American Journal of Addictions, Professional Psychology: Research and Practice, Journal of Ambulatory Care Management.

SHIRLEY H. HUANG, MD, is an attending physician for the Healthy Weight Program and the Division of Gastroenterology, Hepatology, and Nutrition at The Children's Hospital of Philadelphia. She received her BS in Nutritional Sciences at Cornell University and her MD from the State University of New York at Buffalo. She completed her general pediatrics residency at the University of North Carolina at Chapel Hill and her nutrition fellowship at the Children's Hospital of Philadelphia. Dr. Huang's background and interests include clinical nutrition (obesity prevention and management, dyslipidemia, and nutrition support), nutrition program development, community nutrition, nutrition education, and international nutrition. Her clinical research has included vitamin E and cystic fibrosis, environmental risk factors of childhood obesity in medically underserved areas, and obesity prevention counseling by primary care providers. Another recent publication has appeared in Journal of Pediatrics.

Shiriki K. Kumanyika, PhD, MPH, is Professor of Epidemiology in the Departments of Biostatistics and Epidemiology and Pediatrics and is Associate Dean for Health Promotion and Disease Prevention at the University of Pennsylvania School of Medicine. She holds a BA degree in Psychology from Syracuse University, an MS in Social Work from Columbia University, a PhD in Human Nutrition from Cornell University, and a Master of Public Health from the Johns Hopkins University. Dr. Kumanyika's research focuses on diet and chronic diseases, particularly obesity prevention and weight management to improve the health of African American and, more recently, Latino adults and children. Relevant to obesity, Dr. Kumanyika is interested in clarifying the role of food marketing as a potential contributor to excess caloric intake and the obesity epidemic. Dr. Kumanyika is the founder of the African American Collaborative Obesity Research Network (AACORN), which seeks to improve the quality, quantity, and translation of research on weight issues in African American communities and to increase the number and visibility of African American scholars involved in obesity-related research fields (www.aacorn.org). She has published more than 200 scientific articles and monographs; has lectured widely on nutrition and public health topics, both in the United States and abroad; and has been an advisor to numerous national and international organizations, including the National Institutes of Health and the World Health Organization. She is an elected member of the Institute of Medicine of the National Academies.

Nicolas Stettler is a pediatrician trained in nutrition, tropical medicine, and epidemiology and Assistant Professor of Pediatrics and Epidemiology at the Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine. His research centers on the epidemiology of obesity and related cardiovascular risk factors, with particular emphasis on the causes and consequences of obesity over the life course. To perform this research, he mainly uses the tools provided by epidemiology, such as longitudinal cohort studies of children. He also uses the tools necessary to determine the nutritional status and body composition of children, such as anthropometry; DXA; selected blood tests; and the measurement of energy balance performed by indirect calorimetry, doubly labeled water, and dietary intake assessment. 

Journal of Public Policy & Marketing, Vol. 26, No. 2, Fall 2007
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