Challenging Dogma - Fall 2009

Tuesday, December 15, 2009

The Boston Public Health Commission’s “Got” Campaign: The Failed Understanding of a Successful Marketing Strategy – Sean Lunde

The “Got milk” campaign is repeatedly lauded by advertising agency executives for its innovative, cost effective solutions to increase milk consumption (1). The simplicity of the slogan is only a small portion of the campaign’s advertising strategy. Deprivation, cultural competency and strategic partnerships are a few of the strategies that were utilizes to make the campaign successful.
The Boston Public Health Commission’s current campaign attempted to apply the
“Got” campaign to the influenza virus. The series of four posters stated:
“Got a cough? Cover it.”
“Got a pulse? Get a flu shot.”
“Got a fever? Stay home.”
“Got hands? Wash them.”
However, in their advertisements, the BPHC fails to integrate any of the strategies that made the “Got Milk” campaign successful.

Lecturing Will Not Work

Public health practitioners may disagree on the exact approach to be used, but all would agree that at least one model explaining human behavior should be used when developing a public health messaging campaign. Every poster in the “Got” campaign fails almost every test of effective public health messaging.

One of the posters suggests everyone with a pulse should get a flu shot. Unfortunately, not everyone has access to the flu shot. Even if flu vaccines were available to anyone at no cost, there is often a lack of supply. This flu season, there is a shortage of both the seasonal and H1N1 flu vaccines (2-3). This poster is meant to produce the action of all who see it to obtain a flu shot.
This poster may actually discourage individuals from seeking to obtain a flu shot. The theory of Rational Behavior states that individuals are likely to perform behaviors within their abilities (4). Given the known shortages of flu shots, this poster could actually discourage individuals from seeking a flu shot.

Most People Don’t Understand the Flu

The most disturbing aspect of the BPHC’s “Got” campaign is that it fails to include any apparent use of behavioral health models. Effective public health campaigns must use at least an individual model of predictive behavior, such as the Health Belief Model. Preferably, they would include aspects of group level theories. The intervention seeks for people to change behavior and adopt new habits, but does not appear to consider how those behaviors become commonplace habits in a society.

The Health Belief Model, while somewhat antiquated, still deserves consideration within the context paper. When combined with alternative, group-level models, the HBM helps to explain the complete failure of this intervention to address human behavior. Since it has been around for over 40 years (7), it seems logical that any public health professional would at a minimum consider the health belief model. The model attempts to explain various factors contributing to an individual’s health-related decision.

The model accounts describes four major factors an individual uses when making a health-related decision: perceived susceptibility, perceived severity, perceived barriers, and perceived benefits (8). Susceptibility is not addressed. None of the posters describe how common the flu is and that it can be easily spread. A recent Fox News poll actually found that Americans are equally as scared of the swine flu as they are of the swine flu vaccine (9). In a survey conducted by the Harvard School of Public Health, less than half of respondents are even somewhat concerned that they will get the swine flu within the next 12 months (10). Individuals also have no idea where the swine flu comes from. A third of the survey respondents believe they could contract swine flu through contact with pigs, adding unnecessary precaution when dealing with farm animals (10).

Also, there is no discussion of the severity of the flu. By not providing information, individuals viewing the posters are forced to rely on word of mouth or other, possibly less credible sources.
Barriers to treatment are also are not addressed, even though there are many perceived barriers that should be considered. Concerning the swine flu, two-thirds of individuals surveyed believe that there is no vaccine (10). Finally, there are no apparent perceived benefits associated with the any of the recommended actions in the poster.

The intervention is not framed in a social context

Each of the posters in the BPHC’s “Got” campaign depicts an individual performing a desired individual task. However, this is not how any of these activities occur in everyday life. Health related activities are almost universally part of an interconnected community web. Individual behavior change likely will not occur when the communities surrounding the individual discourage behavior change. Rather than focus on one specific theory, the lack of appropriate ecological principles that guide all social ecological health program designs will be examined (11).

The hand-washing poster encourages anyone that has hands to wash them. Health professionals, who surely know that hand washing is an effective method of disease transmission, such as the flu, still fail to wash their hands on a regular basis. External social and group-level forces can often make it difficult to supply with a simple task such as hand-washing. Physicians are often busy and may see hand washing as another tasked imposed upon them by a hospital administrator (12). Food service workers may face external forces such as arriving at work late and then worry about being reprimanded for taking additional time to wash there hands. Inner-city youth riding the bus to school may not encounter a hand washing facility, although they interact with dozens of people before they have a bathroom break.

Long-entrenched beliefs also guide behavior. From a simple activity perspective, midwives have discussed that ctg monitoring is still a standard activity among seasoned professionals. During their education, they were taught that ctg monitoring should be a part of their everyday process. Although routing use is no longer clinically indicated and the standard practice is not taught in educational programs, the practice is still common. It has been entrenched into the professional culture of midwifery (12).

Another poster instructs individuals to stay home if they have a fever. This poster fails to account for the fear of stigmatization an individual may fear for skipping a day of school or work from having the view. Stigmas can exist within a variety of dimensions. Since the transmission of the flu can often be traced to unsanitary conditions, a person may be viewed as dirty or unsanitary if they call in. Also, when the flu affects a certain population more than another, that person’s social environment can be stigmatized. Individuals without the flu will naturally tend to stigmatize a sick person by attributing a characteristic different from their own. This phenomenon is the basis of the fundamental attribution error, which is subconsciously present among all humans in social settings (14).

Recommending that anyone with a pulse should get a flu shot not only lacks any use of social theories, but also may create group resistance to flu shots and could be seen as unethical. For example, an immune suppressed should not get the flu shot (15). It is easy to imagine what could happen if a contraindicated person blindly followed the poster’s advice. After receiving the flu shot, the individual could become very sick and maybe even die. Others that share or perceive they to share similar characteristics with that individual may be discouraged from getting a flu shot. Just as social learning theories can be used to effect a desirable change, thy can also be used have negative effects if a social context is not applied when designing public health interventions.

Cultural competency is not apparent

Each of the posters presented do not target the emotions and values specific population groups. The “Got Milk” campaign’s advertisements were so successful because the situations they depicted were carefully crafted so the emotions they elicited could be generalized (1). Not having milk to consume with an Oreo cookie crosses cultural, age and gender boundaries. The posters in the BPHC flu campaign do identify common physical traits of all humans. Of course, we all have hands and a pulse. However, these are not emotions, they are physical traits.

The BPHC’s flu campaign distributes posters in English, Spanish, Vietnamese and Chinese (5). The thoughtless translation of advertising messages can easily result in undesired effects. The “Got milk” campaign experienced the problem with translation after realized that “Got milk?” means “Are you lactating” when translated to Spanish. The effects of multiple-language marketing are also unclear. A survey of various studies found that while some Hispanics prefer Spanish-language advertising, others either prefer English or are indifferent (6).


The Boston Public Health Commission is so flawed that it is difficult to critique it using the social sciences. Lecturing people will not work. If lecturing worked, everyone would be model citizens and not have any health problems. The Health Belief Model was examined due to the fact that it provides at least some insight into how individual choices are made. It also provides a starting point for where further, more advanced social-behavioral models can be applied. While linguistic translation may also be helpful in reaching target populations, it must be used with caution.

Whether or not the intervention could constitute paternalism should also be examined from an ethical standpoint (. As a public health professional, all interventions should be examined to see if they are forcing an intervention on a person that is not completely voluntary. While the effort to impede spread of disease may outweigh the individual’s right to refuse treatment, this is a serious infringement on individual liberties and strict examination of the issue is warranted.

Proposed Intervention: An Integrated Approach to Reducing Influenza Infections

A simple poster will not help reduce the spread of influenza. However, a multi-faceted approach will. From an ecological perspective, the individual, family and social and cultural influences should be taken into account (17). The integrated flu prevention approach improves the outcomes of individual planned behavior and educates groups from multiple spheres of influence.

Hand Sanitizer Converts Planned Behavior to Action

Hand sanitization, traditionally through hand washing, is the best way to stop the spread of communicable diseases. Even though most people know this, sanitization often occurs infrequently (18). Hand sanitizers offer a convenient alternative when made easily available to users. They are actually so effective that the Food and Drug Administration has found that alcohol-based hand sanitizers actually have meet performance standards that exceed those of standard hand washing (19).

While hand washing has long been promoted by as the gold standard for preventing disease transmission, the Theory of Planned Behavior helps to explain why hand washing may not be completely effective (20). Humans may plan to conduct an activity, but outside influences might prevent that action from becoming a real behavior. In school settings, children are not always able to go to the bathroom whenever they think they need to wash their hands. During a five minute break between classes, few students would choose going to the bathroom to wash their hands over catching up with friends. Even though they may plan to wash their hands, an opportunity to chat with the attractive girl from biology class may be much more appealing.
This idea goes beyond the classroom as well. In the workplace, multiple individuals consistently spread germs through multiple items such as a copy machine or a coffee pot. However, a chat around the proverbial water cooler is more likely to occur than an individual going to wash their hands after using the copy machine. Bathrooms are likely just far enough that an individual cannot integrate this practice into his or her daily routine.

Case-controlled studies have proven the advantages of alcohol-based sanitizer over hand washing. A variety of studies have used a control group that was taught proper hand-washing techniques and an intervention group that has alcohol-based sanitizer made available to them. Where alcohol-based sanitizers are available, the incidence of illness related absence days decreases by 30-50% when compared to control groups (18-19).

Form Partnerships

Prior to the “Got Milk” advertisements, milk was always shown alone in a glass. The “Got Milk” campaign’s success is heavily attributed to its strategic partnerships. The “Got Milk” slogan was paired with Oreo cookies, rice crispy characters and even Barbie dolls (1). Unfortunately, public health is often reluctant to form partnerships in fear that the message may be diluted.
However, strategic partnerships actually increase the value of campaigns and brands. Discusses the 4 “p’s,” one of which is promotion. A common misconception is that most of the promotion budget is spent on advertising. However, advertising only accounts for 25% of a product’s promotion (21). Strategic partnerships are vital to promotion.

To run an effective campaign, the Boston Public Health Commission does not need to foot the entire bill. When a teacher misses a day of work it will cost the school at least the average daily pay of $100 for a substitute (22). A school board is likely to pay to place plenty of hand sanitizer around the school. The benefits clearly outweigh the costs, making the promotion of hand sanitization more attractive.

Even greater gains could be gained through partnerships with corporations. Human resources divisions are constantly searching for innovative methods to reduce costs. Annual influenza epidemics incur a national economic burden of $87.1 billion (23). Given that employee absenteeism due to influenza is a huge cost for employers, there is a strong business case for providing convenient flu shots to employees.

The theory of planned behavior indicates that individuals may intend to get a flu shot, but may not end up getting one due to inconvenience. Employers can reap additional benefits by making it easier for their employees to get flu shots. This already seems to be an acceptable trend to most people. Today, up to 30% of all flu shots are given in non-traditional settings (24).
Given that “Got Milk” was able to form a partnership with Barbie (1), it makes sense for the Boston Public Health Commission to look for non-traditional partners. Celebrities from sports stars to cartoons could conduct public service announcements in various, culturally competent public service announcements.

Effecting Group Behavior: Herding and Crowd Sourcing

Thorstein Veblen described his observation of the herding instinct of human behavior in his timeless piece: “The Theory of the Leisure Class” (25). The theory explains that individuals tend to want to perform activities and social habits of others in social classes above their own. Elements of Veblen’s theory have been used in more current, theories. The tendency of people to follow those they think are at a class above them is referred to as herding.

When creating new advertisements, targeted ads that encourage positive herd behavior will create success. An appropriate intervention would have different advertisements that were designed specifically for those at the highest risk for flu-related complications. The Advisory Commission on Immunization Practices recognizes the following high-risk groups: children aged 6 month up to their 19th birthday, pregnant women, people over age 50, people with certain chronic medical conditions, people living in long term care facilities and people who live with or care for those at high risk for complications from the flu such as health care workers or school teachers (26).

Unfortunately, the Boston Public Health Commission may not have the budget to hire an advertising professional that is able to effectively target all of the high-priority groups. This potential issue could be solved using the technique of crowdsourcing.

Crowdsourcing uses individuals outside of an organization to in a distributed problem-solving model. Problems are broadcasted to an unknown group of problem-solvers to develop usable solutions. They can also used to tease out the best concepts from a larger base of potential interventions (27).

When designing targeted flu ads, a two-stage model of crowdsourcing would likely be the most useful. The Diffusion of Innovations theory describes individuals likely to participate in helping a community to adopt flu prevention techniques (28).

In the first stage, individuals from the community that are members of the target group will describe what they think would be the most effective intervention. The group that would participate would likely be innovators that constantly develop fresh, new ideas. They would also be the first people in their communities to begin promoting effective methods that limit the spread of the flu.

During the second stage, thought leaders from the area would help to choose the best advertisements and programs generated during the innovation period. While innovators are likely to come up with great ideas, the thought leaders from this group of early adopters would help tease out which advertisements are most likely to achieve success among the larger population (28).

This type of an intervention is a complete departure from the current method the Boston Public Health Commission uses to develop advertisements. The standard practice is for a group of public health professionals to sit in meetings and generate new ideas for interventions. The interventions are then posted around the BPHC office and voted on by the same public health professionals that created the interventions.

Summary: An Integrated Approach Enables Empowerment

This multi-faceted, community-drive intervention empowers communities to become involved in their theory. If public health professionals can admit to the harsh reality that healthcare is a market, the necessity of involving individuals that are a part of the market is apparent (29). This intervention utilizes elements of community level empowerment to its success (30).

Making hand sanitizers easily available helps to make individuals make decisions they believe are their own. Also, by making them ubiquitous and used in common practice, the stigma of being a “germ freak” is reduced. Using crowdsourcing allows individuals to learn skills that improve their ability to exercise individual or group power. The benefits of this type of an intervention will go beyond preventing the spread of influenza. When communities realize that they are able to participate in the promotion of their own health, they will be more likely to be actively engaged in future public health activities.


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