Challenging Dogma - Spring 2011

Friday, May 6, 2011

Using Marketing Models and Principles to Maximize Success of a Print Social Marketing Campaign: A Critique of the Get Healthy Campaign – Ignacio De La

Since 1985 obesity rates have crept up at an alarming pace, and obesity has become a significant national and local public health problem (1). In 2008, around 68% of Americans over the age of 20 were overweight or obese (2). The problem has spilled over to the youth, with 18% of adolescents aged 12-19 years, 20% of children aged 6-11 years, and 10% of children aged 2-5 considered obese in 2008 (2). This dramatic increase in obesity has been tied to poor eating habits and a sedentary lifestyle (3).
In order to address this growing problem, local public health boards across the nation have started programs which seek to reduce the factors that lead to obesity. In line with this trend, The Get Healthy Campaign is an initiative of the Boston Public Health Commission whose mission is to “raise awareness about four key behaviors that contribute to a healthy lifestyle” (4). It consists of a series of print advertisements which inform and invite the readers to learn more about the campaign and ways to stay healthy on its website: gethealthy/Pages/Home.aspx (4). The four behaviors which the Get Healthy Campaign focuses on promoting are eating healthy foods, drinking healthy beverages, walking more often, and turning off the television.
This initiative is faced with an uphill battle. Very few Americans adhere to healthy lifestyle habits and the number of those who do have been decreasing over the years (5). The food industry annually invests billions of dollars into marketing unhealthy foods to consumers and in 2002 alone it spent 1.6 billion dollars in advertising to children (6). This has translated into 8 commercials selling unhealthy foods for every 10 minutes of television (7). The combined amount of money invested by the nation’s public health offices does not even begin to match the vast amount of resources at the disposal of the corporations, even less so the Get Healthy campaign. In this context, public health practitioners must make use of all the arsenals available to them, including social behavior principles which more accurately account for how people go about changing behaviors.
An important principle to keep in mind when attempting to shape people’s behaviors is the principle of psychological reactance. When people believe that their ability to behave as they freely choose, their autonomy, is being threatened they “experience reactance, a motivational state aimed at restoring the threatened freedom (8).” Psychological reactance is an important principle to keep in mind; it leads the individual to more strongly uphold their freedom by doing the opposite of what they are told to do, thereby defeating the purpose of the advertisement.
The framing effect has been heavily researched and is often used to great advantage by marketing firms (9, 10). A frame is “the decision maker’s conception of acts, outcomes and contingencies associated with a particular choice. The frame that a decision-maker adopts is controlled partly by the formulation of the problem and partly by the norms, habits, and personal characteristics of the decision maker.” Using the correct way of framing the issue can thus bolster the chances of the social marketing influencing a person’s opinions and of having the desired behavior change effect.
The lessons that the concept of ownership can bring to the designing of social marketing campaigns is often overlooked. Once you own something you value it disproportionately to its actual value. This ownership effect is not only felt for objects, but also for their unhealthy behaviors. People will not easily give up unhealthy habits, thus the alternative that you offer them must be made to appear better and more attractive to them.
Psychological reactance, the framing effect, and ownership are just a few of the social behavior principles which more accurately account for how people go about changing behaviors. It is principles such as these that inform my critique of the Get Healthy Campaign which follows.
Critique 1: Reliance on the Health Belief Model and Rational Choice
The Get Healthy Campaign is predicated upon the health belief model. As such, a critique of the approach taken by the Get Healthy Campaign must include a discussion of the health belief model and its inherent flaws.
The theory’s main assumption is that behavior is a result of a person’s reasoned decision. The health belief model has been shown to have had very limited success in helping initiatives accomplish behavior change, such as occurred with the 5-a-Day For Better Health campaign (11, 12). In fact, it has even been used by the tobacco companies in order to increase smoking rates in adolescents. This was accomplished through the implementation of smoking prevention programs which were constructed under the health belief model, such as the Talk: They’ll Listen campaign (13).
Since they have used this model as the basis of how people change their behavior, the Get Healthy Campaign believes that by providing facts and about how the four lifestyle behaviors that they will get people to adopt them. It views people as rational, and as such provides them with information about their health. However, human psychology is such that rational decision making doesn’t always play central role in determining behaviors (14, 15).
Two examples of how the human mind fails at rationality are the fundamental attribution error and the effects of stereotype priming. The fundamental attribution error illustrates the importance of context and how people tend to overlook it when they explain the behaviors of others. Rather, people tend to attribute a person’s behavior to that person‘s personality. An often cited experiment which illustrates this phenomenon was conducted by John M. Darley at Princeton Theological Seminary. As opposed to what most people would have predicted, the main predictor of whether the subjects helped out a stranger depended on whether or not they were late, the context, and not on their personalities (16).
Under the effects of stereotype priming, a person’s behaviors are significantly affected when faced with stereotypes which apply to them (17, 18). A study which examined this effect gave a group of American female Asians the Graduate Record Exam. Those females primed by gender did worse, and those primed by race did better off, when compared to the group which was not primed (18). Wholly rational beings would not be swayed by such priming. Another study looked at the effects of age-stereotype priming on memory abilities of older adults. They found that older adults’ memory performance suffered when they were reminded of their age (17).
Another flaw of this model is the way in which it views the link between thought and behavior. Informing people of the facts and statistics does not necessarily bring about change in behavior, and often people are already aware of the negatives which are associated with their unhealthy behaviors (19). People are motivated by differing values and beliefs. Rather than brush them all with the same stroke, the target audience should be broken up and catered according to their experience and values (20). This is especially relevant in a city as diverse as Boston, in which over 140 languages are spoken and foreign born residents make up over 25% of its population (21).
As the preceding paragraphs make evident, using the health belief model will not maximize the potential of the Get Healthy Campaign. Rather than using a model which relies upon the rational choice as its linchpin, the print social marketing campaign would benefit from relying upon other social behavior constructs.
Critique 2: Triggering Psychological Reactance
A large problem with the Get Healthy Campaign is the way they phrase their messages. From the title of the print social marketing campaign down to the advertisements they put out, the language used is one of ordering the target audience to eat healthy or turn off the television. The advertisements all include messages which command people to do a health behavior: “Turn it off .” “So walk the extra block to the store. And take the stairs instead of the elevator.” (22)
These statements, which are telling people to change behaviors, impinge on their freedom of choice of behaviors. Instead of convincing the audience to follow the healthy behaviors being touted, all that the messages are doing is triggering psychological reactance (23). In the end, this type of message is leading people to strengthen the unhealthy behaviors which the commands were hoping to change.
Other messages used in the campaign come off as derisive: "Is your TV babysitting your kids? Turn it off (22)." "Those who think they have no time for healthy eating will sooner or later have to find time for illness (22).” These strong and direct messages invoke confrontation and lean towards accusations of being in denial; neither of which are not taken well by the target audience (24). Rather than causing them to take up the planned healthy lifestyle behavior, they directly lead to the target audience wanting to display and reaffirm their freedom of choice through strengthening their unhealthy behaviors (25).
Several studies have been conducted which provide proof of psychological reactance and flesh out its theoretical underpinnings (26-31). One of the studies, while trying to determine whether reactance could be measured, conducted two parallel experiments in which they showed participants two versions of a message that advocated flossing and urged students to limit their alcohol intake (30). The messages varied in the degree to which they posed threats to the freedom of behavior of participants, with the high threat message being phrased similarly to Get Healthy Campaign messages. As would be predicted through the use of psychological reactance theory, the high threat version elicited the highest level of psychological reactance.
Critique 3: Ignoring Relevant Core Values
Marketing campaigns extensively research their target populations (32). This allows them to get a better hold on what they relate to and how they react to various versions of their advertisements. Coined as formative research, it is the cornerstone of successful marketing campaigns (20). Despite its wide practice by marketing firms, many public health social campaigns still fail to incorporate it. That the Get Healthy campaign falls into this camp is evidenced by the core value which it mainly targets.
The core value that its advertisements are molded around the most is health. The advertisements, and the whole campaign, is built around the promise that if the target audience picks up eating healthy food, drinking healthy beverages, walking more, and watching less television their health will improve. The support which backs up this promise are the claims backed up by scientific evidence which can be found on the campaign website.
In contrast, their successful competitors use support of a different kind to back up their promises. Just searching for food commercials on illustrates this gaping difference in approaches. The “I Am Man - Burger King” commercial never once tells its audience to buy food at Burger King. Rather than use scientific evidence or throw numbers at the audience, it visually ties eating at Burger King with the identity of being a man (33). The producers of this commercial have done their research well, and have decided to target the core value of identity which is held by their audience.
Health is not as strong a core value in the target population (20). Focusing on health is a big loss in opportunity, especially considering the advertisements that the Get Healthy Campaign is up against. According to Jeffrey J Hicks, an employee of the firm behind the “truth” campaign, the “truth” advertising campaign was so effective in part because their message in tune to their target population’s core values (32).
Proposed Intervention:
My proposal would be to shift the approach of the campaign away from the health belief model. Instead, marketing theories and principles that do not rely on the rational choice theory would be used to inform the creation of the advertisements. Specifically, this means making use of formative research, psychological reactance, the framing effect and ownership to inform the creation of the Get Healthy Campaign advertisements.
Before creating advertisements, the Get Healthy Campaign would go about assessing what exactly each target demographic holds as their core values. Once the research had been conducted, advertisements which have been molded around target audience’s core values would be tested in sample groups of the target audience. This would allow the advertisements to be tested for the amount of psychological reactance which they inspire with the hope of reducing.
An example could illustrate the shift from the current framework used by the Get Healthy Campaign to the one in which I propose. One of the behaviors which the campaign is pushing is to get people to eat more healthy foods. One of the advertisements which they have put out promoting this goal consists of the message, “Fruits & Vegetables. No prescription required (22).” It covers about a third of the real estate, and below that there is a short message about the health benefits of eating fruits and vegetables, preceded by the command to “Eat your fruits and veggies (22).” The promise is that if you eat five cups a day you will be healthy. This is a message that any rational person would heed, but which only 26% of Americans were following in 2006 (5).
Instead, an alternative would be to access the core value(s) of our target audience. Hypothetically, let’s say that our target is young adults and their core value is sex. The ad could display an attractive young couple in the middle of preparing a healthy, visually pleasing meal full of vegetables and fruits. The message could be something like, “Fruits and vegetables, providing you with the energy you need to go strong throughout the day and night.” The first print advertisement focuses on telling people to change their behaviors in order to improve their health to. The second print advertisement focuses on trying to get people to believe that being by adopting the new behavior they will obtain something that they already value. Improved health ends up being a side effect.
Defense 1: Using Proven Marketing Tools
Corporate campaigns which seek to influence the behaviors of consumers are successful precisely because they masterfully put to use the tools of marketing theory and social principles such as framing. Apple is able to sell electronics at much higher prices than other companies because it appeals to consumers’ ideals of community and identity.
The “truth” campaign is an example of a public health campaign which used these marketing tools to successfully reduce adolescent smoking rates in the state of Florida during the late 1990s (32, 34). In the early stages, they realized that the campaign would “need to address the tobacco issue in a way and with a tone that reflected how youth viewed tobacco (32).” After several months of formative research, they realized that their target audience’s core values were control and rebellion. With this insight the people behind the “truth” campaign were able to frame their entire campaign in terms of teenagers, the target audience, rebelling against the tobacco industry.
These same techniques can be applied to other public health campaigns; including the Get Healthy Campaign. The first lesson which can be applied from these examples is that the Get Healthy Campaign would frame the issue in terms that would draw the attention of the target audience. In order to do this, their core values would be used to create an appealing message.
Another lesson gleaned from these examples is to present issue as something the target audience is affected by; as an issue that they can identify with. The target audience needs to see itself as having ownership of the campaign. One way to foster this sentiment would be to host videos of people talking about their journey to living a healthy lifestyle. The participants could elaborate on the ways in which their lives improved. They could also pass on encouragement to those on the road to healthy living. The videos would avoid using fear appeals and delivering negative stories so that the target audience may accept it more easily (35, 36).

Defense 2: Limiting Psychological Reactance
Social marketing campaigns can sometimes lead the audience to behave in the opposite manner of what they intended by triggering psychological reactance (8, 25, 28). Advertisements have to be able to make the target audiences relate to their message in order to maximize the chance of persuading the target to change behavior (8, 35). The current campaign advertisements are just simple sketches of healthy food, a spoonful of sugar, a leg, and a television. Instead, of health facts and admonishments the Get Healthy Campaign would put out advertisements that show people who are similar to the target audiences doing the healthy behaviors which are being promoted.
Another way that psychological reactance would be limited would be to the target demographic test run the several versions of the advertisements in order to gauge which one inspires the least amount of psychological reactance. This is used with success by various public health campaigns and has been shown to be a fairly valid practice for predicting psychological reactance (28). Advertisements should be built upon the beliefs of the target audience which will smooth acceptance (20).
Defense 3: Accounting for Core Values
A very important step which the Get Healthy Campaign seems to have overlooked is analyzing the core values of its target audience. By first conducting formative research on each demographic, the core values of the target audience would be known. Below is a table modeled in the style of a core value table presented in the book “Marketing Public Health: Strategies to Promote Social Change” (20). Freedom, control, and identity are three core values held by teenagers.

At that point, rather than attempting to ingrain the target audience with new core values, their established core values would be used to shape the messages that the campaign projects. The advertisements would create a frame which illustrated eating healthy, drinking healthy, walking, and limiting the amount of television in such a manner as to make them natural extensions of the target audience’s values and beliefs.
The Get Healthy Campaign is predicated upon the health belief model. There are three flaws which are hindering this public health intervention: Its reliance on the health belief model and the rational choice paradigm, its triggering of psychological reactance in the target audience, and its overlooking of core values held by its target audience. In order to increase the success of its messages, the Get Healthy print social marketing campaign should instead use social behavior principles which more accurately account for how people go about changing behaviors. The elements of such an intervention would have a greater chance of causing a shift in the way that healthy lifestyle behaviors are viewed by its targeted audience, giving a chance for other interventions to build upon its effects. The campaign would be a practice run for a new way of planning health interventions in which the old paradigm of the rational decision maker is replaced with that of the predictably irrational person.

1. National Center for Health Statistics. U.S. Obesity Trends. Hayattsville, MD: National Center for Health Statistics.
2. National Center for Health Statistics. Obesity and Overweight. Hayattsville, MD: National Center for Health Statistics.
3. Eagle TF, et al. Health status and behavior among middle-school children in a midwest community: What are the underpinnings of childhood obesity? American Heart Journal 2010; 160:1185-1189.
4. Boston Public Health Commission. Get Healthy Now Campaign. Boston, MA: Boston Public Health Commission.
5. King DE, Mainus AG, Carnemolla M, Everett CJ. Adherence to healthy lifestyle habits in US adults, 1988-2006. American Journal of Medicine 2008; 98:2229-2236.
6. Federal Trade Commission. Marketing Food to Children and Adolescents: A Review of Industry Expenditures, Activities and Self-Regulation. Washington, DC: A Report to Congress, 2008.
7. Boston Public Health Commission. Get Healthy Campaign: Turn Off the TV. Boston, MA: Boston Public Health Commission.
8. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
9. D. Kahneman, A. Tversky. Prospect Theory: An Analysis of Decision under Risk. Econometrica 1979; 47:263-292.
10. Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981; 211:453-458.
11. Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.
12. Serdula M, Gillespsie C, Kettel-Kahn L, Farris R, Symour J, Denny C. Trends in fruit and vegetable consumption among adults in the United States: behavioral risk factor surveillance system, 1994–2000. American Journal of Public Health 2004; 94: 1014-1018.
13. Wakefield M, et al. Effect of televised, tobacco company-funded smoking prevention advertising on youth smoking-related beliefs, intentions, and behavior. American Journal of Public Health 2006; 96:2154-2160.
14. Kahneman D, Knetsch JL, Thaler RH. Anomalies: The endowment of effect, loss aversion, and status quo bias. Journal of Economic Perspectives 1991; 5:221-234.
15. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008.
16. Darley J, Batson, CD. From Jerusalem to Jericho: A study of situational and dispositional variables in helping behaviour. Journal of Personality and Social Psychology 1973; 27: 100–108
17. Stein R, Blanchards-Fields F, Hertzog C. The effects of age-stereotype priming on the memory performance of older adults. Experimental Aging Research 2002; 25:169-181.
18. Shih M, Pittinsky TL, Ambady N. Stereotype susceptibility: Identity salience and shifts in quantitative performance. Psychological Science 1999; 10:80–83.
19. McMaster C, Lee C. Cognitive dissonance in tobacco smokers. Addictive Behaviors 2002; 16:349-353.
20. Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd Edition). Sudbury, MA: Jones and Bartlett Publishers, 2007.
21. City of Boston. The New Bostonians Demographic Report. Boston, MA: Mayor’s Office of New Bostonians, 2004.
22. Boston Public Health Commission. Healthy Messages. Boston, MA: Boston Public Health Commission.
23. Brehm SS, Brehm JW. Psychological Reactance: A Theory of Freedom and Control. New York: Academic Press, 1981.
24. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. NY: Guilford Press, 1991.
25. Stewart DW, Martin, IM. Intended and unintended consequences of warning messages: A review and synthesis of empirical research. Journal of Public Policy and Marketing 1994; 13:1-19.
26. Brehm SS, Weinraub M. Physical Barriers and psychological reactance – 2-year-olds responses to threats to freedom. Journal of Personality and Social Psychology 1977; 35:830-836
27. Bensley LS, Wu R. The role of psychological reactance in drinking following alcohol prevention messages. Journal of Applied Social Psychology 1991; 21:1111-1124.
28. Rains SA, Turner MM. Psychological reactance and persuasive health communication: A test and extension of the intertwined model. Human Communication Research 2007; 33:241-269.
29. Grandpre J, Alvaro EM, Burgoon M, Miller Ch, Hall JR. Adolescent reactance and anti-smoking campaigns: A theoretical approach. Health Communication 2003; 15:349-366.
30. Dillard JP, Shen LJ. On the nature of reactance and its role in persuasive health communication. Communication Monographs 2005; 72:144-168.
31. Clee MA, Wicklund RA. Consumer behavior and psychological reactance. Journal of Consumer Research 1980; 6:389-405.
32. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5
33. Burger King. I Am Man. Miami, FL: Burger King Corporation.
34. Bauer UE, et al. Changes in youth cigarette use and intentions following implementation of a tobacco control program. Findings from the Florida youth tobacco survey, 1998-2000. Journal of American Medical Association 2000; 284:723-728
35. Ogilvy D. How to build great campaigns (pp. 89-103). In: Ogilvy D. Confessions of an Advertising Man. New York: Atheneum 1964.
36. Evans WD, Hastings G. Public health branding: Recognition, promise, and delivery of healthy lifestyles (Chapter 1). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford

Labels: , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home