Interventions that address child overweight and obesity remain an important, international public health priority (1). Early childhood, ages 2 – 5 years, has been identified as a critical time to impact lifelong weight-related behaviors (2, 3), but to date, public health efforts have made little progress to reduce overweight and obesity in young children (4, 5). Since approximately one-third of children under the age of six in the United States spend an average of 25 – 30 hours per week in center-based early care and education (6), this is an opportune setting for interventions to influence obesogenic behaviors (7-10). Many early care and education-based interventions have been developed to address dietary and physical activity behaviors, but the results have been inconclusive regarding what works (11, 12). Based on the number of children who are at risk for overweight and obesity, and the lack of evidence for effective obesity prevention strategies, it is essential to identify how to develop more useful approaches for interventions in early care and education settings (13).

Social marketing is one possible approach for enhancing early care and education-based interventions. Social marketing emerged as a discipline in 1971 as a way to address social problems including health and the environment (14). In 1994, Andreasen defined social marketing as “the application of commercial marketing technologies to the analysis, planning, execution and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of their society”(15). Core concepts of social marketing have been applied to design interventions that successfully influenced voluntary lifestyle behaviors, such as reducing tobacco use, increasing immunizations, and increasing fruit and vegetable consumption (16). Specifically, the social marketing approach: 1) emphasizes understanding the perspectives of the full range of target audiences necessary to bring about change (e.g., children and midstream audiences such as child care providers, center directors, or parents), 2) underscores the importance of developing a research-based program, relying on formative research to develop and test concepts with members of the target audience(s), and 3) recognizes the need to include all elements of the methods mix (i.e., product, price, place, promotion) to bring about behavior change (16). In addition, social marketing acknowledges that there are multiple levels of influence on individuals' health behaviors – downstream (i.e., intrapersonal level), midstream (i.e., interpersonal), and upstream (i.e., organizational or public policy level). Accordingly, social marketing can be applied to change voluntary behaviors of upstream targets (e.g., policy makers), midstream targets (e.g., children's caregivers), and/or downstream targets (e.g., children).

The National Social Marketing Centre has developed a set of eight social marketing benchmark criteria to promote the understanding and use of core social marketing concepts (17, 18). The Centre's benchmark criteria are a set of integrated concepts, or domains, and include: behavior, customer orientation, theory, insight, exchange, competition, segmentation and methods mix (Table 1). The benchmark criteria provide a useful framework for assessing the extent to which an intervention is consistent with the social marketing approach and for identifying opportunities to potentially increase the impact of an intervention (17). Although many interventions may not consciously apply the benchmark criteria, some or all of the underlying concepts of the criteria are often present in intervention design. Gracia-Marco et al. (19) and Aceves-Martins et al. (20) reviewed the use of benchmark criteria in childhood obesity prevention programs. More specifically, Gracia-Marco et al. reviewed community-based interventions targeting participants 18 years and younger from 1990 to 2009 and found increasing use and reporting of social marketing benchmark criteria. Aceves-Martins et al. reviewed school-based interventions for participants aged 5 to 17 years from 1990 to 2014 and found that the inclusion of at least five benchmark criteria in the development of school-based interventions could benefit efforts to prevent obesity in young people.

Although there is evidence that interventions utilizing a social marketing approach can improve dietary and physical activity behaviors (15, 16, 21, 22) and effectively support behavior change among children aged 5 to 18 years (23-27), explicit application of the social marketing approach to design interventions for young children within the early care and education setting has been rare. However, as previous reviews have shown, social marketing still provides a useful lens through which to describe the development, refinement, and evaluation of interventions. The social marketing approach and its benchmark criteria describe a rigorous planning process, similar in some ways to intervention mapping (28). In fact, social marketing and intervention mapping include many similar elements such as clarifying specific goals and behavioral targets, integrating theory, and incorporating formative work and pilot testing. Hence, the social marketing approach and its benchmark criteria can still provide an informative method for describing the thoroughness of the intervention design process even when applied to interventions that are not explicitly described as social marketing.

Therefore, the primary aim of this study is to assess the use of social marketing benchmark criteria to develop and implement diet and physical activity interventions in early care and education centers and to identify opportunities to apply benchmark criteria to the development and implementation of such interventions in the future. A second, exploratory aim is to determine whether there is a relationship between the application of the benchmark criteria and the effectiveness of interventions in the early care and education setting. A novel, interdisciplinary approach that combined the systematic review method typical of health behavior intervention assessment with the content analytic methods commonly used in the field of mass communication was employed to achieve the aims of this study. Interdisciplinary work, including the integration of techniques and tools from different disciplines, is increasingly recognized as important for confronting and addressing complex issues, such as obesity prevention (29).

This review aimed to describe the use of social marketing benchmark criteria in early care and education center-based nutrition and physical activity interventions and explore relationships between the application of the benchmark criteria and the effectiveness of these interventions. By virtue of inclusion criteria, all interventions in this sample included at least two benchmark criteria, behavior and methods mix, yet fewer than half of the interventions incorporated four or more benchmark criteria.

We did not find statistical significance for effectiveness of interventions on child-level diet, physical activity, or anthropometric outcomes based on the number of benchmark criteria used. This is in contrast to the findings from Alceves and colleagues who suggest there may be a tipping point. They found that inclusion of five or more benchmark criteria was associated with better outcomes. While we did observe similar trends around physical activity and diet outcomes, unlike Alceves, we did not find this to hold true for anthropometric outcomes. Some of the inconsistencies in our findings across outcomes may have been the result of an uneven distribution of interventions across categories of low, medium, and high inclusion of benchmark criteria. Hence, caution is warranted in attempting to draw conclusions regarding the effectiveness of benchmark criteria to institute change in children's behaviors, because 1) only a small number of interventions (three) explicitly referenced a ‘social marketing’ approach; 2) interventions were judged on the presence or absence of criteria, not the quality of how criteria were applied; 3) interventions utilized different measures over differing periods of time; and 4) the quality of study design or potential for bias was not taken in to account when evaluating effectiveness of an intervention, and without rigorous evaluation, an intervention may be more likely to exhibit positive outcomes. We also refrain from offering specific recommendations about which criteria are “most effective” because the value of the social marketing approach stems from these criteria building off of each other to inform intervention development. As a result, these criteria cannot be considered mutually exclusive, which makes it impossible to disentangle the effects of one criterion over the other.

This review of interventions in early care and education centers identified several gaps in applying a comprehensive planning and evaluation approach, such as social marketing, for designing interventions to influence children's dietary and physical activity behaviors. Through the lens of social marketing, all interventions addressed the benchmark criteria of behavior and methods mix, and more than half of the interventions identified audience segments (segmentation). However, the other benchmark criteria (customer orientation, theory, insight, exchange, and competition) were present in less than one-third of the interventions. Although we applied the social marketing framework to interventions that did not identify as social marketing, we were careful to look for presence of the underlying concepts rather than the particular terminology used in the manuscripts. These concepts often align with other recommended approaches for planning, executing, and analyzing outcomes of behavioral interventions, including use of formative research, theoretically guided behavior change approaches, and pretesting materials (28, 38). Despite our broad interpretation, the interventions in this sample had an overall low application of these benchmark criteria. Hence, this review helps to identify several missed opportunities whereby future researchers might apply a more comprehensive approach to the design, implementation, and evaluation of these types of interventions in early care and education centers. Adhering to, and reporting on, systematic planning approaches like social marketing will help improve the transparency of intervention development and facilitate synthesis of findings to generate evidence-based recommendations (39, 40).

One opportunity for future research in the early care and education setting is for more comprehensive use of behavior change theories. It is generally accepted that interventions with an explicit theoretical basis are more effective than those without (41). For the purposes of this review, interventions received credit for theory if they articulated using a behavior theory, but we were unable to evaluate the quality of how theoretical constructs were operationalized. Even with liberal criteria for crediting interventions for use of behavior change theory, only a small proportion of interventions incorporated theory. This highlights an opportunity, and need, to systematically use theory to both understand the target audience behavior(s) and inform intervention development and evaluation. It is suggested that targeting multiple levels of influence is better for long term change. This is important context for this review, because children (downstream) are dependent on the behaviors of their caregivers, parents and/or teachers (midstream), and the environment that is created within early care and education centers (upstream). Many interventions targeted multiple levels; however, a missing attribute could be engaging in customer orientation to better understand each target market and existing relationships.

Another opportunity to strengthen future research is to incorporate customer orientation and insights (e.g., formative work and pilot testing) into studies. Addressing these criteria allow for researchers to incorporate perspectives and get early buy-in from target audiences, which should improve intervention compatibility and fidelity (33). For interventions, such as the ones reviewed in this study where children were the primary downstream target audience for behavior change, it may not be realistic or feasible to conduct formative research. In these instances, midstream audiences, such as parents and caregivers, become increasingly important. In addition to serving as representatives for children, the midstream audiences serve as gatekeepers and stakeholders whose own changes in behavior will be required for prompting and supporting change in children's behaviors. Furthermore, while not a focus of this review, upstream audiences, including community agency or health service leaders and policy makers, are another important target for supporting change in children's and caregiver's behaviors. Accordingly formative research with these upstream target audiences should also be considered for the development of community-based (e.g., Romp and Chomp) and state or federal policy interventions (e.g., child care licensing, Child and Adult Care Food Program). Although time and funding resources may be limited, it is likely a worthwhile investment to engage all appropriate downstream, midstream, and upstream audiences early in the intervention development and testing process so that the resulting program is practical and addresses the needs of all the audiences who are necessary to initiate change within the centers.

While all interventions employed some parts of the methods mix, there is still an opportunity for future research to incorporate all elements of the methods mix more comprehensively. Interventions in this setting frequently incorporated the place (e.g., the child care center) and product (e.g., curriculum) components of the methods mix, but price and promotion were largely unaddressed. Effectiveness of the social marketing approach is ideally maximized when all four elements of the methods mix are included (16). Price is particularly important to address when targeting children in early care centers because centers are highly regulated and have increasing demands for staff, yet the organizations are often under-resourced (42). The competing behaviors and costs to change practices or policies for both the midstream audiences and the organizational setting could deter the desired behavior changes for children. It is necessary to acknowledge what needs to be given up (e.g., time, money) in order to achieve the new, target behavior(s) and design programs that highlight the perceived benefits and minimize barriers.

Lastly, evaluation is a critical component for any intervention. While many of the manuscripts analyzed for this review identified parents and other caregivers act as a conduit for behavior change for children and designed intervention components for these midstream audiences, very few assessed the behaviors of those audiences. This is a missed opportunity to not only fully understand the effect of the intervention at all levels, but also to explain the observed results. Furthermore, only half of the interventions mentioned process evaluation in their papers. This type of evaluation is particularly important to help explain how an intervention was implemented, identify mechanisms of change, and provide context for interpreting the results of the intervention (43). It is no longer acceptable to simply provide evidence that an intervention did or did not have the intended effect; intervention research will advance when process evaluation is incorporated and analyzed in a way that sheds light on the often unknown, or the ‘black box’, of intervention effects (44, 45). Once we have a better understanding of how obesity prevention interventions work, we can begin to more widely disseminate them and better replicate successful outcomes in a greater number of settings.

A key strength of this review was the combination of a systematic review with content analysis to code qualitative information as well as quantitative data and to analyze a large number of studies. Even though we investigated interventions that did not self-identify as social marketing, the National Social Marketing Centre's benchmark criteria provided a robust, broadly applicable framework for determining the extent to which an intervention is consistent with the principles associated with the social marketing approach (17). Furthermore, we examined interventions for underlying intervention design concepts and processes rather than the explicit labels associated with social marketing. The process helped identify important gaps in applying methodical planning and evaluation processes, such as social marketing, which should inform future research efforts in in early care and education settings.

In addition to these strengths, this review had some limitations. First, it should be noted that we could only code for benchmark criteria based on what was reported in published material. Time and space limitations of journals may have prohibited the full description of intervention development and evaluation and would thus limit the evaluation of the full scope of included benchmark criteria. However, the process for identifying articles did try to identify both protocol and outcome related publications so that the set of articles related to an intervention could be assessed as a whole. Second, interventions were given credit for the presence of benchmark criteria when at least one subcomponent of the criteria was reported but there was no attempt to assess the quality with which criteria were applied. This liberal practice may have obscured relationships between use of benchmark criteria and intervention effectiveness. Lastly, interpreting the effectiveness of interventions to change children's nutrition and/or physical activity behaviors or anthropometric measures was complicated by the fact that many different types of measures were conducted over varying periods of time. Consistent measures across studies would allow for more meaningful interpretation of the effects of interventions and allow for generation of evidence-based recommendations.

A large number of children around the world are at risk for overweight or obesity, and more effective interventions are needed that support obesity prevention efforts. Social marketing provides a systematic approach for the planning, execution, and analysis of programs designed to influence voluntary behaviors of target audiences that influence weight status. Few interventions in early care and education settings have applied social marketing to the development of programs aimed to influence children's diet and activity, and thus it is still unknown how a social marketing approach influences behaviors of children who attend early care and education centers. This review highlighted several opportunities for researchers to incorporate social marketing concepts into interventions to create programs that cater to the specific needs of those whose behavior they seek to change. Social marketing could be an important intervention design approach for early childhood obesity prevention efforts, and thus future research to investigate the effects of purposeful application of the social marketing process to nutrition and physical activity interventions in early care and education settings is warranted.