1. PART I - LITERATURE OVERVIEW
The first part of this project is a critical review of the relevant literature followed by the
conceptual framework and a statement of the objectives of this research. Theories and
concepts reviewed here, although do not fully cover all the relevant literature on the topic,
are those that I have used to frame my research question and those chosen because they -in
a way- challenge, support or confirm my own hypotheses, findings and arguments.
1.1 Public Communication Campaigns
Public communication campaigns are “communication efforts to improve the lives of
individuals and the fabric of our society” (Paisley & Rice, 1981: 7); very commonly used to
reach and inform the ‘mass’ audience about important social issues, they are called public in
the sense of excluding no one from their messages (Stappers, 1983: 142) and also in the
sense of addressing the audience as citizens, as an ‘active public’ who have to choose to be
persuaded to take action on a (social) problem (Roser & Thompson, 1995: 103). Paisley
(1981: 23) argues that reform is a unifying principle of all public communication campaigns
whether the structure of society itself is affected (promotion of collective benefits) or only
the lifestyles of individuals (promotion of individual benefits) (Paisley, 1981: 24).
McAlister (1981: 91) argues that communications that aim at influencing complex and
persistent behaviours of the audience (like smoking) must perform three functions: inform
audiences about these behaviours and their consequences, persuade audiences to cease or
avoid those behaviours and finally, train audiences in skills necessary to translate intention
into action. The media, he continues, offer economy and uniformity in mass distribution that
make them highly attractive options for communicators wishing to influence widespread
behaviour change.
1.1.1 Public Health Communication and Social Marketing for Health Promotion
Public communication campaigns have been used broadly for the promotion of healthy
attitudes and behaviours. The majority of citizens of the developed world are familiar with
public health communication efforts, communicated mainly via television advertisements -
known as Public Service Announcements or PSA’s. “Myriad of studies have explored the
efficacy of such public service announcements” (Beaudoin, 2002: 124) that have often
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caused controversies and public discussion about their appropriateness and efficacy. Some
of the studies argue for their positive results (McAlister, 1978; Moscowitz, 1973; Goldman &
Glantz, 1998); however, others have found that PSAs are not an effective means to promote
and maintain healthy behaviours as they have little or no effect on audiences (Wallack,
1990b).
Public Service Advertising is a highly visible communications strategy used to promote health
and other issues of public interest and concern; “ the pervasiveness of advertising makes it
seem powerful and useful for health promotion” (Dorfman & Wallack, 1993: 716). Health
promoters turn to a number of disciplines (communication theory, social psychology and so
on) in order to make best use of the media (Hastings & Haywood, 1991) and thus, promote
health to a mass audience more effectively; recently, much has been written about
commercial marketing as yet another source of insight for more effective campaigns for
social issues and especially public health promotion (Hastings & Haywood, 1991: 135).
Often the term social marketing is used synonymously with advertising or mass media
campaigns for health promotion or for shaping attitudes on other social issues (Hastings &
McDermott, 2006; Chapman et al, 1993). The first formal definition of social marketing was
that of Kotler and Zaltman (1971: 5):
“Social marketing is the design, implementation and control of programs calculated to
influence the acceptability of social ideas and involving considerations of product
planning, pricing, communication, distribution, and marketing research.”
Andreasen (1994; 110) proposes a revised definition that seems better suited for the
application of social marketing to public communication campaigns:
“Social marketing is the adaptation of commercial marketing technologies to programs
designed to influence the voluntary behavior of target audiences to improve their
personal welfare and that of the society of which they are part.” Marketing
technologies - used heavily by the tobacco industry itself to ‘sell’ smoking as fun,
stylish, cool- are this time being used to ‘sell’ healthy behavior and good health or selfempowerment
becomes the product advertised and promoted” (Hastings & Haywood,
1991: 140).
Perhaps the most useful perspective social marketing gives to public health communication
campaigns is the focus on the audience; as Hastings and Haywood (1991: 144) say:
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“To communicate successfully we have to understand our audience's point of view, we
have to climb into their skins and walk around in them. The consumer orientation that
underpins social marketing is a good starting point for doing this.”
Social marketing proponents argue that their programs include the development of skills,
consumer participation and activism (Chapman et al., 1993: 117) and that all such programs
are oriented toward “empowering people to change threats to their health and well-being
(including economic and social deprivation, objectionable advertising of health-compromising
products, and environmental degradation)” (Chapman et al., 1993: 117). However, not all
scholars share the same enthusiasm about the potential of social marketing for more
effective and audience/public-centered public communication campaigns. Contrary to the
opinion of many scholars-advocates of the application of social marketing to health
promotion (like Kotler, Lefebvre, Hastings & Haywood, to name but a few), others are very
skeptical about the ability and power of a practice like marketing -used for many years in the
service of consumerism and individualism- to address the audience as a public for a social
issue of paramount importance like public health and are also concerned about its ethical
dimensions.
Health promotion expert Lawrence Wallack (1990b: 157) identifies several limitations of the
application of social marketing to health communication and promotion efforts: first of all, its
close correspondence to more general advertising and marketing practices makes it an
approach open to criticism as being manipulative and ethically suspect. Many see social
marketing efforts as a form of social control and stress the importance of social responsibility
even when it is for people’s ‘own good’. Moreover, social marketing faces the difficult task of
reducing the psychological, social, economic and practical distance between the consumer
and the behavior (here smoking cessation) and as Wallack argues the limited success of
previous health promotion campaigns does not leave room for much optimism (Wallack,
1990b: 158). More importantly, Wallack argues that marketing in any form reflects
commercial values and interests and promotes consumption as a way of life (Chapman
Walsh et al, 1993); social marketing is promoting single solutions to complex health
problems, downplaying or completely ignoring the social conditions that give rise to these
problems in the first place2.
2 Instead of a social marketing approach Wallack argues for a more active role of the media and for campaigns
that aim directly at policy makers. He uses the term media advocacy to refer to the strategic use of mass media
for advancing a social or public policy initiative aiming at reframing public debate, increasing public support and
at more effective policy level approaches to public health problems. According to Wallack media advocacy has 3
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1.2 Fear appeals:
Appeals are widely used in public health communication campaigns and are “a useful social
construct for examining anti-smoking television advertisements” (Beaudoin, 2002; 126);
emotional appeals in particular, are prevailing in public communication campaigns (DeJong &
Atkin, 1995). Recent campaigns aimed at smoking cessation as well as smoking prevention
in the United States, the United Kingdom and other countries all around the world have used
fear-arousing, hard-hitting images, as have campaigns for road safety, prevention of
HIV/AIDS, breast self-examinations, exercise promotion and so on (Hastings et al, 2004;
961; Witte & Allen, 2000; 591).
A large body of research has tried to provide answers as to whether and in what way, if any,
threat or fear appeals can persuade the audience to change their health behaviors (Hastings
et al, 2004). Some studies recommend against their use (Austin, 1995), while others
suggest that fear arousal is integral to persuasive health messages (Witte, 1995). Other
studies have investigated the amount of fear evoked in parallel with the resulting amount of
attitude or behavior change (Hastings et al, 2004) and have reached different conclusions:
some argue that the more fear the more the ‘desired’ effect is achieved while others argue
that moderate rather than high levels of fear can actually be more effective.
Apart from the diversity of views regarding their effectiveness, fear appeals, used almost
always along with an underlying health campaigns’ emphasis on personal responsibility, have
also raised concerns about the ethical dimensions of their use. Fear appeals are rejected by
many who according to deontological or duty theory believe that causing anxiety and
distress in order to persuade is fundamentally wrong regardless of the cause you are trying
to serve or the ultimate societal consequences (Hastings et al, 2004; 973). According to this
view, fear appeals should be used to the extent that they allow for personal choice and
autonomy. Others, express their ethical concerns regarding the design of health messages
that make use of fear appeals in parallel with direct reference to personal responsibility and
an implication of culpability if one does not follow the recommended practice; they point out
their concerns about the potential of such messages to elicit a negative self-image and
functions: it recognises the agenda setting role of the media, it reframes media explanations of social issues
away from individual blaming, responsibility and individual solutions and it advances public policy solutions to
create what Wallack calls ‘healthy environments’. (Wallack, 1990)
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