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1. Healthy Lifestyle Promotion: How Brands Work in Public HealthPresented byDoug EvansRTI InternationalPresented atConversations on Social MarketingNovember 5, 2007 • Washington, DC 701 13th Street, NW ■ Suite 750 ■ Washington, DC 20005 Phone 202-728-2058 Fax 202-728-2095 E-mail devans@rti.org RTI International is a trade name of Research Triangle Institute

2. Outline • Lessons from commercial branding • Branding in public health • Case studies of public health brands • Evaluation of public health branding • Evidence from branding evaluations • Future of branding

3. What I’ll Tell You • Brands in the commercial and public health (PH) sectors add value to the relationships between products and consumers • PH brands can be differentiated from commercial brands by their purposes (changing health behavior), value exchange between brand and consumer, and outcomes (health behavior change) • Brands can apply “upstream” – such as to organizations and government policies – and “downstream” to individual behavior • Branding is a global social marketing strategy that has demonstrated evidence of effectiveness across cultures, country settings and topics • More research is needed on how public health brands work, and more brands should be developed in the public health sector

4. Lessons from the commercial sector:Brands are like reputations • Marlboro, BMW, and Virgin Atlantic – Great brands have a clear cut identity and value proposition • Marlboro’s identity: “All-American; hardworking/ trustworthy; rugged individual, man’s man (experienced, sure of self, confident, in charge, self-sufficient, down to earth, cool/calm, get the job done); admire his strength.” • Desirable, masculine reputation promotes associations with the brand for Marlboro consumers

5. Just having a little fun…

6. Basic Brand Features • Relationship between consumer and product or service (marketing focused on the consumer and building the brand-consumer relationship) • Value (customer and otherwise defined) added to a product or service • Exchange (cost and benefit) between product or service and consumer • All brands promise value, great brands consistently deliver it

7. Brands and Brands of Brands • Organizations can brand themselves – establish reputations that affect all their offerings • Virgin’s brand of brands transcends any one product • Modern, funny, hip, cool & maybe even “green” • Every Virgin brand benefits from the organization’s promise and delivers in its own sector

8. Virgin Media – “Proper Telly”

9. Persuasive Mechanisms • Aspiration to an appealing external ideal • Modeling of a socially desirable good • Association with idealized imagery • Successful brands promise an external ideal for consumers, and then deliver (mostly) on the promise

10. “The Ultimate Driving Machine”

11. How do brands work? • Why does that image work so well? How does it communicate so much when it “says” so little? • Positive associations – brand promotes them based on strategic marketing objectives • Images inspire aspiration – I want the promised external ideal • The individual aspires to close the gap between his or her own self-image, and the external idealized image • “Social imagery” (i.e., my perception of the external ideal) can also explain health behaviors

12. What is Public Health Branding? • Commercial brands are associations that enhance the value of products and services for consumers • Branded products or services project socially desirable models & idealized imagery for consumers • Public health brands are associations that enhance value of health behaviors for an audience (better life as a nonsmoking, physically active, condom user) • Public health brands are about healthy lifestyles

13. Healthy Lifestyle Promotion • Public health brands offer behavioral alternatives to health risks, promote healthy choices as socially desirable • Identify audience motivations & barriers: • Example audience motivations: • Independence, personal control, social status • Example barriers: • Competing messages, low self/outcome efficacy • Appealing social images (cool kids are physically active) promote aspiration to promoted lifestyle • Competition with unhealthy behaviors/marketing

14. Overarching Strategy • Brands present a call to action • Social Movement against tobacco use or promoting condom use as socially responsible • Brand promise • Ohio’s stand tobacco countermarketing brand — “Make a difference in the lives of important people around you by Standing Up against tobacco use” • Vaccination or inoculation from health risks (condom use as protection from HIV/STDs) • Result is a replacement or alternative lifestyle

15. Theoretical Basis • Social cognitive theory (Bandura, 1986): Modeling a positive, nonsmoking lifestyle encourages emulation • Social images projected by truth® are of coolness and popularity of non-smoking lifestyle (Evans et al., 2005) • Evidence for branding effectiveness across most modifiable behaviors (Evans et al., forthcoming) • Additional evidence on public health brands: • Hornik et al. (2003): ONDCP anti-drug campaign • Huhman et al. (2005): VERB physical activity campaign

16. Branding as Mediator Brand Equity MessageExposure Health Behavior (smoking, diet, etc.) Moderators(other media,demographics,etc.)

17. Concept of Brand Equity • Multi-dimensional scale of attributes & associations • Aaker (1996), Keller (1998) developed measures in commercial sector • Evans, et al. (2002; 2005) developed brand equity scale for truth campaign, stand campaign (2007) • Adapted to nutrition & physical activity (Evans, et al. 2007; forthcoming)

18. Public Health Brand Equity Scale

19. What are the Main Components of Public Health Brands? • Subject matter (HIV, tobacco) • Brand development (use of theory) • Marketing execution (channels) • Evaluation (design, data, analysis) • Outcomes (branding, behavior change)

20. Example: LoveLife • African condom use promotion campaign • Promoted condom use as hip and cool, part of modern lifestyle for young adults • Increased positive attitudes toward responsible sex, increased condom use (Stadler & Hlongwa, 2002)

21. LoveLife Message

22. LoveLife Strategy • Promote lifestyle choices: value abstinence, delay initiation of sexual activity, reduce sexual partners among sexually active teenagers & condom use • Reach a number of audience segments (e.g., pre-contemplating, contemplating, sexually active) • Use multiple channels: Mass media, nationwide adolescent-centered reproductive health services, network of youth outreach and support, co-branding

23. Example: truth • Launched in February 2000 • Largest National anti-tobacco campaign (Over $300M) • Encouraged emulation of non-smoking lifestyle by tapping adolescent needs for independence, rebellion, control • Media tracking, evaluation of branding effort, anti-tobacco industry attitudes • High overall brand identification (Evans et al., 2005), reduced smoking associated with brand exposure (Farrelly et al., 2005)

24. Rebellion Against Industry

25. How Can Public Health Brands be Evaluated? • Was the audience exposed to message? • What were audience message reactions (message perceived as credible, likeable?) • What associations were formed by target audience with brand? • Is brand exposure associated with positive reactions and associations? • Are reactions and associations related to intended behavior change?

26. Evaluation Designs • Observational (media tracking studies) • CDC’s VERB tracked tween awareness • Quasi-experiments (natural variation in exposure) • Truth used variation in media buy (Gross Rating Points) as natural control variable • Experiments (RCTs of exposed/non-exposed) • Chicago’s 54321 Go! being evaluated in randomized trial (Evans, Necheles, et al., 2007)

27. Evaluation Measures • Exposure • Self-reported (aided & unaided, or confirmed awareness) • If prompted, does respondent report message exposure (claimed) • If asked to provide description of message, does respondent demonstrate exposure (confirmed) • Environmental (Gross Rating Points, measure of population exposure in media market) • Nielsen media data on time/market audience size

28. Example: truthMedia Evaluation Truth Campaign Exposure by Media Markets (2000–2002)

29. Approximately 22% of total decline in youth smoking attributable to the truth campaign Represents roughly 300,000 fewer youth smokers as a result of truth Portion of Decline in Youth Smoking Attributable to truth

30. Evaluation Measures • Brand reactions (Elaboration Likelihood Model, Petty & Cacioppo, 1986) • Was the branded message credible? Was it likeable? • Predicts subsequent attitudes/associations • Brand associations • Imagery, social norms, attitudes, and behaviors audience associates with brand • Are these associations socially desirable?

31. Branding Measures • Brand association examples • Loyalty (Will you continue with behavior?) • Leadership (Is the brand better than competitors?) • Personality (Do you perceive the brand characteristics as cool?) • Combined associations form brand equity construct (Aaker, 1996; Keller, 1998) • Youth with higher brand equity in Ohio’s stand: • more likely to sustain non-smoking lifestyle, • perceived messages superior to tobacco industry, • perceived brand to have socially desirable personality • (Evans, Renaud et al., 2007)

32. Behavioral Outcomes • Example self-reported health behaviors • Smoking initiation, uptake • Time spent in moderate, vigorous exercise • Food choice, consumption • Condom use • Direct effects of branded message exposure on behavior • Indirect (mediated) effects of reactions and brand associations on behavior

33. Example: Mediated Effects of truth® on Smoking Behavior APEX Uptake -.023 .323* Anti-tobaccoCommitment .157* CFI: .941 SRMR: .052 RMSEA: .044 * p <0.01 -.285* -.305* Industry Manipulation .457* .490* BrandEquity SensationSeeking .143* Source: Evans, Price, Blahut, 2005.

34. Evidence from Evaluations of Public Health Brands? • Social marketing effective, but small effect sizes in 5–9% range (Snyder, et al. 2002) • Limited evidence on targeted message strategies, including branded campaigns • Most effective branded campaigns found in tobacco, nutrition/physical activity, HIV/STDs (Evans, et al. forthcoming): • truth • LoveLife (Africa) • VERB • 5-A-Day • Fighting Fat, Fighting Fit (UK)

35. Evidence of Effectiveness • Farrelly et al. (2005) showed truth campaign was associated with 22% of observed decline in youth smoking prevalence from 1999 to 2002. • Siegel and Biener (2000): 12–13 year olds in MA exposed at baseline less likely to progress to established smoking; no effect on 14–15 year olds or exposure to radio or outdoor ads. • Sly et al. (2002): teens with anti-tobacco industry attitudes promoted by Florida TRUTH were 4 times less likely to initiate smoking & 13 times less likely to become established smokers.

36. Review of Branding Evaluations • Nearly all branded campaigns in published literature evaluated (Evans, et al. forthcoming) • Study sample & sample size generally reported • Sample characteristics & response rates usually not described • Observational designs most common • Descriptive statistics commonly reported; multivariate statistics uncommon • Rigorous evaluations relatively rare

37. Subject Areas of Published Branding Efforts

38. Role of Evaluation in Branded Health Communication Programs • Evaluation is integral part of the Health Communication development cycle shown in Social Marketing Wheel (NCI, 2002) • Formative research widely used to developed branded messages • Media tracking used to evaluate exposure, message reactions • Brand associations and effects on behavior used to evaluate outcomes

39. Case Study: Brand Evaluation in CDC’s VERB Campaign • Commercial marketing applied to a public health problem with a branding strategy — organizing principle of entire enterprise (Huhman, et al. 2005) • Conceived VERB brand as supporting each specific campaign strategy: • For example, promoting parks as place to have fun and be active • VERB as behavior + idea • VERB: Physical Activity = fun

40. Example VERB Message

41. Evaluating Branded Campaign Spots: Ohio’s Debunkify • Campaign target: young adults age 18–24 • Objective: Secondary prevention • Paid mass media in markets across state • Main messages: Debunk myths around smoking, smokeless tobacco, and tobacco industry marketing of tobacco • Evaluated brand associations and changes in social norms about tobacco use (e.g., perceived prevalence)

42. Measuring Associations • (Awareness) When you think “debunkify”, you think: Tobacco companies are lying to me. • (Awareness) When you think “debunkify”, you think: breathing secondhand smoke is like smoking cigarettes. • (Loyalty) I’d wear or use a “debunkify” T-shirt or other gear. • (Leadership) Debunkify is for people like me. • (Personality) The people in debunkify don’t get fooled by tobacco companies.

43. stand Awareness and Smoking Uptake • Longitudinal Survey: Time 1 (Y1) - Time 3 (Y3) • Never Smokers at Y1 • Aware of stand at Y1 - Less likely to try smoking at Time 3 • 6.5% vs. 9.5% or • 44% less uptake

44. Example Ohio Debunkify Message:“Game Show Models” • Television advertisement • Aired shortly after “Debunkify” launch in 2006 • Purpose: • Introduce brand & theme: • “Debunk” idea that most people smoke • A non-smoking lifestyle is an acceptable choice • Create buzz around target audience • Drive traffic to debunkify.com website

45. Example Ohio Debunkify Message: “Game Show Models”

46. Example Ohio Debunkify Message: “Secondhand Snakes” • Television advertisement • Aired shortly after “Debunkify” launch in 2006 • Purpose: • Introduce brand & theme: • “Debunk” idea that secondhand smoke isn’t deadly • Understand reasons for promoting and supporting smoke-free establishments • Create buzz around target audience • Drive traffic to debunkify.com website

47. Example Ohio Debunkify Message: “Secondhand Snakes”

48. Future of public health branding • Big issue: Commercial marketers will always have bigger budgets, 24/7 exposure – PH never will • How can PH beat that kind of competition? • How can brands be used strategically to magnify the effects of commercial marketing? • Cooler, hipper, more audience-focused brands • Utilize social trends (e.g., green movement, distrust of authority)

49. Example: Healthy Media Use • Children’s media use is over 8 hours per day (with multi-tasking) and associated with negative health outcomes (e.g. obesity) • Develop branded campaign targeting parents of pre-school (aged 2-5) and elementary (6-11) children • Modify norms about media use, promote parent involvement • Complementary adolescent campaign to promote “smart” media use as socially desirable • Brand interpersonal social engagement as cool (maybe: “virtual dating isn’t even fooling around” – get it?)

50. Innovative Strategies • Co-branding: Social marketers can link their branded messages to other trusted brands (e.g., co-brand a nutrition social marketing message with the Sesame Workshop) • Technology: Internet, handhelds, other media offer opportunities to compete with industry using “viral marketing” and potentially with lower advertising costs, reach youth audiences • Social networking: Place messages in media used by children and adolescents to network, take advantage of potential social diffusion effects (e.g., through MySpace, Facebook, iPods)