Counter-Marketing Sugary Drinks with Indigenous Culture

Aggressive commercial marketing toward children and especially in communities of color contribute to health disparities. There is ample data that the beverage industry has specifically targeted young people in communities of color to increase sales of their products, and contributes to diet-related disparities observed in these groups. This private-sector influence on health disparities is sometimes referred to as commercial determinants of health (CDOHs).  The World Health Organization has described the impact of CDOHs on health outcomes ranging from smoking, alcohol use, obesity, and mental health, and has highlighted the disproportionate impact of aggressive marketing of unhealthy commodities on young people and communities already experiencing economic and racial inequalities. In 2021, the Rudd Center for Food Policy and Obesity at University of Connecticut reported that beverage companies are spending billions on fast foods and sugary drinks specifically targeting children and teens. 

The strategies of targeted marketing are also important to note. The marketing environment includes four factors: products, promotion (i.e. advertising and messaging), place (regional distribution of the product and placement of products within a retail space) and price. In retailer spaces, placement of items at the check-out or at the height of a child’s line of vision and packaging with popular cartoon characters are common strategies used to target children. Increasingly promotion has shifted from television and retailer spaces to digital platforms, such as children’s gaming sites (“advergaming”) and social media apps (influencers), opening opportunities for interactive and tailored marketing to children. In a study conducted in the UK, 72% of children were exposed to food and beverage marketing, and a recent content analysis of 24 websites found that the majority of ads targeted children below age 12. Several recent systematic reviews have shown that digital marketing is associated with preferences for unhealthier foods and increased pester behavior. 

Given targeted marketing of high-calorie foods and beverages to minority populations and in particular youth, public health interventions confront challenges when attempting to coax individuals toward healthier behaviors. Counter-marketing is a public health strategy which calls out intentional false messaging and highlights the negative health effects of popular brands. Counter-marketing campaigns often mimic advertisement styles and have been shown to reduce consumption of unhealthier foods.

Indigenous communities can use their traditional teachings, values, stories, art, and culture to provide a counter-narrative to commercial marketing. Using a community-based participatory model, we will develop a culturally-based campaign to promote water consumption among children and young people in Navajo Nation. 

When discussing the pervasive influence of marketing toward children, we received feedback from our Community Advisory Group (CAG) to consider counter-marketing strategies that focus on local heroes and celebrate the importance of water in Diné culture and teachings. This type of counter-marketing campaign would be novel because typically counter-marketing uses negative messaging to call out industry. In contrast, the feedback that we heard from the CAG would be focused on promoting healthier choices (water) and using the positive influence of Diné culture and role models, rather than a negative tone.  

We will work with youth and artists to develop a story and social media materials with three main messages: a) Water is K’é: water is a living spiritual presence that is part of our clans, our places, and our health; b) all children are heroes: using technology, all Navajo children will have an interactive opportunity to participate as local heroes; c) counter-marketing strategies: through store promotion and digital technology and social media to reach young people, we will combat commercial marketing to promote connectedness and a sense of empowerment, and motivate healthy behaviors (healthier beverages, adequate hydration). 

While we have experience with developing store promotional materials, our team would like to build additional skills and knowledge by learning from technology and advertising experts to apply evidence-based commercial marketing strategies to our own campaign and effectively reach the younger Navajo generation including children and young adults.

This solution serves Navajo families, children, caregivers, elders, even teachers and healthcare providers who are the front-line voices to promote healthy lifestyles. The solution will primarily serve those who live on or around the Navajo reservation. The community can be considered underserved in the sense of vast distances and access to healthcare services and healthy foods, and data showing disproportionately high rates of diet-related health conditions.  One the other hand, the community has unique strengths and assets, which is an important reason why we think this solution will work: their strong cultural and community ties.

This solution will benefit the Navajo Nation, but could be applicable to other indigenous communities through sharing of ideas and platforms. For instance, we have been part of learning collaboratives hosted by Notah Begay 3 Foundation and have been able to exchange ideas with other groups working in Navajo Nation and elsewhere. We would envision that, if effective, we could share our experience and approach with interested indigenous partners through the NB3 network and other networks even through the SOLVE fellowship.

In terms of the target population, we would specifically hope to benefit children and teens, as well as their caregivers (parents, grandparents) by empowering them to make healthy choices. We believe that children are capable of being informed consumers and making good choices, but these are skills that we need to teach early and would last a lifetime. 

All of our approaches start with listening to the community, through community needs assessments, listening tours, surveys, interviews, “rez cafes” with school children, and through repeated meetings with our CAG. In fact, this entire proposal is based on suggestions by our community advisors who voiced the desire for Diné marketing materials as a public campaign. If this project moves forward, we would continue to work with children, teens and young adults to develop materials and messages that are meaningful to this audience.

Our team has been working with a local, established Water is K’e Community Advisory Group (CAG).  Our CAG is composed of teachers, traditional knowledge holders, health care providers and local leaders.  The CAG meets regularly with a shared goal of seeing a healthier future for children.  With the CAG’s guidance and direction, our team is well-positioned to deliver our solution.

The Team Lead is a member of the Navajo Nation tribe with close ties to the communities we serve.  The Team Lead has been working on the Navajo Nation for the past 18 years.

As the Team Lead and CAG work together, the community remains engaged and involved in the solution.  The idea for this project came from a CAG gathering and we will continue to work together to combat sugary drinks and promote healthier drinks on Navajo Nation.

We are excited to partner with Solve and learn from technology experts while bringing our own community voice, wisdom and creativity to the table. We believe this opportunity is particularly exciting because of Solve’s “outside-the-box approach” and the opportunity to learn from experts. Perhaps even more importantly, we would have the opportunity to join the network of Indigenous Communities Fellowship. 

We know that CDOHs are increasingly online and exposing targeted populations to commercial marketing right under our noses. We would like to build greater savvy to understand the extent to which marketing of unhealthy foods and beverages is happening online and most importantly to counter these aggressive marketing strategies with our own stories and communications using the same technology platforms, especially in a way that is engaging to youth and young people. 

We would also like to learn more about different social entrepreneurship models that are successful with indigenous fellowship peers. 

Team lead resides in Navajo Nation and has been working on the Navajo Nation for the past 18 years.  Team lead is a member of the Navajo Nation as well.

There are a number of examples of counter-marketing strategies that have been led by youth in communities of color. For instance, The Bigger Picture is a spoken-word movement led by youth artists that call out CDOH and use their own art, voice and culture to raise awareness of how CDOHs are adversely affecting the health and wellness of their own communities. But to date, we are not aware of any counter-marketing strategies led by indigenous community organizations, particularly focusing on positive messaging. Rather than only focusing on the negative forces of CDOH, we have heard from our CAG that building positive cultural motivations to opt for healthier options would be very powerful and well-received. We would like to have a two-pronged approach, disseminating in retailer spaces while also reaching youth through social media. By using digital technology and social media, we believe that this campaign will be much more effective than traditional public health approaches, directly counteracting online CDOHs and with greater potential for scale.

In the next year, our impact goal is to have a counter-marketing campaign that promotes healthy beverages among youth that has been developed by and for the Navajo community.

In the next five years, we would like to achieve the following goals:

• Increase awareness of how water relates to Diné traditions among Navajo community members

• Increase positive attitudes toward drinking water

• Empower local youth to engage in social media in a healthy way (promoting positive messaging about themselves as local heroes and/or about drinking water)

• Increase water consumption and promote adequate hydration among children (we know that drinking water instead of SSBs and ensuring adequate water intake to avoid inadequate hydration are directly linked to health benefits)   

In our work to date, we have been working on promoting healthy beverages among children and their families. Indicators that we have already been using include: survey questions regarding knowledge about traditional teachings related to water; validated questionnaires to quantify beverage consumption among children and adults to determine if individuals are meeting consensus recommendations for healthy beverage patterns and adequate hydration. If there is community interest and support for additional indicators, we would also add questions about empowerment and self-efficacy among local communities heroes, community awareness of the campaign and local heroes. 

 We believe that the solution to addressing health disparities affecting indigenous communities lies within the communities themselves. By listening to and learning from community members across all generations (children, young people, adult caregivers, and elders) we can create strength-based approaches that draw from traditional teachings related to healthy living and water. We also believe that local heroes exist in every community. By sharing cultural knowledge and celebrating local heroes, and using technology (e.g. social media) to widely reach community members, we believe that lasting changes in healthy habits and the way we raise our children can counter-act commercial marketing and lead to healthier long-term lives.

Our approach is grounded in both Western technology and traditional Dine knowledge systems. From a Western approach, we will use digital technology to create a real-time system where community members (children, parents, youth) can become local water heroes, and counter-marketing strategies can rapidly diffuse attitudes and knowledge using social media and digital platforms. At the same time, we are grounded in traditional knowledge systems that center around the core value of respecting water as a spiritual living entity, so as we work towards a solution, we will make sure to keep this teaching at the forefront.  Our CAG will also guide our work and we will look to them to review our ideas and help provide input on what makes sense to the Navajo communities in a respectful way.

Navajo CPHE is a community coalition that is embedded within a larger network of communities across the United States that have shared experiences to travel to Cuba and bring transformative ideas back to our respective communities, sponsored by MEDICC. In addition, the core team that coordinates Navajo CPHE are staff at Brigham and Women’s Hospital’s Division of Global Health Equity and operates in close partnership with the local non-profit COPE Program. 

We work to prioritize diversity, equity, and inclusivity by making sure that we have leadership that is open and accessible to all. We have open lines of communication across the board and are consistent with making sure that all those involved with the organization are informed about the organization's activities. This can be demonstrated through the CAG that we regularly meet with. The CAG is composed of professionals from various areas of expertise including public health, education, and community representatives. Additionally many CAG representatives come from different parts of the Navajo Nation and are able to discuss issues that affect their communities.

Our business model has been primarily based on the non-profit model, where we have obtained funding from foundations, research grants and donations to develop and innovate based on CAG guidance. We have developed materials with sustainability in mind: considering data, deliverables and products belong to the Navajo Nation, we have worked in partnership with teachers, healthcare providers, families and partners and handed over products and deliverables to these partners once they have been shown to be effective. We have not charged community partners for services, but rather believe that community partners should be compensated for their time and wisdom. Instead, external funding has been brought in as a way of building capacity and co-creation.

Our financial plan has historically been to pursue social enterprise external to the services that we offer to the community. Because research and program partnerships have a precedence of extractive relationships with indigenous communities, we believe there is a responsibility to secure and bring in resources to catalyze innovative programs that are driven by community partners themselves. Once we have secured seed or pilot funding, we are careful to develop and evaluate our collaborative programs using systematic and rigorous approaches in order to build a knowledge base related to the program model and its impact. Once this knowledge base is established, we have been successful transitioning scaled programs to public sector partners for sustainability.  

One example of successful sustainability is a past project of implementing a produce prescription program. From 2012 - 2014, thanks to the Rx Foundation and NB3 Foundation, our team obtained seed funding to do a community needs assessment, connect to and receive technical assistance from national experts in Produce Prescription Programs, and fund a pilot program with several Navajo clinics. We were able to demonstrate that the program was successful in terms of retention, healthier diets, and reduced health disparities. We also developed operating and training procedures so that we could recruit and onboard additional sites. Based on these successes, we were able to scale the program throughout Navajo Nation and obtain sustainable public sector funding (e.g. USDA, state programs) the program continues to operate to date.