Looking to the Future of New Media in Health Marketing: Deriving Propositions Based on Traditional Theories

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  • This article was downloaded by: [University of Windsor]On: 29 September 2014, At: 08:33Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

    Health Marketing QuarterlyPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/whmq20

    Looking to the Future of NewMedia in Health Marketing:Deriving Propositions Based onTraditional TheoriesLindsay J. Della a , Dogan Eroglu b , Jay M.Bernhardt b , Erin Edgerton b & Janice Nall ba Department of Communication , University ofLouisville , Louisville, KYb National Center for Health Marketing at theCenters for Disease Control and Prevention ,Atlanta, GAPublished online: 17 Oct 2008.

    To cite this article: Lindsay J. Della , Dogan Eroglu , Jay M. Bernhardt , Erin Edgerton& Janice Nall (2008) Looking to the Future of New Media in Health Marketing: DerivingPropositions Based on Traditional Theories, Health Marketing Quarterly, 25:1-2,147-174, DOI: 10.1080/07359680802126210

    To link to this article: http://dx.doi.org/10.1080/07359680802126210

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  • Looking to the Future of New Mediain Health Marketing: Deriving

    Propositions Based onTraditional Theories

    Lindsay J. DellaDogan Eroglu

    Jay M. BernhardtErin EdgertonJanice Nall

    ABSTRACT. Market trend data show that the media marketplacecontinues to rapidly evolve. Recent research shows that substantialportions of the U.S. media population are new media users. Today,more than ever before, media consumers are exposed to multiplemedia at the same point in time, encouraged to participate in mediacontent generation, and challenged to learn, access, and use the new

    Lindsay J. Della, PhD, is affiliated with the Department of Communi-cation University of Louisville, Louisville, KY.

    Dogan Eroglu, PhD, Jay Bernhardt, PhD, Erin Edgerton, and Janice Nallare affiliated with the National Center for Health Marketing at the Centersfor Disease Control and Prevention, Atlanta, GA.

    Address correspondence to Lindsay J. Della, Department of Communi-cation, University of Louisville, 310 Strickler Hall, Louisville, KY 40292.E-mail: LJDell01@louisville.edu

    This publication was made possible through a cooperative agreementbetween the Association for Prevention Teaching and Research (APTR)and the Centers for Disease Control and Prevention (CDC), award numberU50/CCU300860; its contents are the responsibility of the authors and donot necessarily reflect the official views of APTR or CDC.

    Health Marketing Quarterly, Vol. 25(1/2) 2008Available online at http://hmq.haworthpress.com# 2008 by The Haworth Press. All rights reserved.

    doi: 10.1080/07359680802126210 147

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  • media that are continually entering the market. These media trendshave strong implications for how consumers of health informationaccess, process, and retain health-related knowledge. In this articlewe review traditional information processing models and theories ofinterpersonal and mass media access and consumption. We makeseveral theory-based propositions for how traditional informationprocessing and media consumption concepts will function as newmedia usage continues to increase. These propositions are supportedby new media usage data from the Centers for Disease Control andPreventions entry into the new media market (e.g., podcasting, virtualevents, blogging, and webinars). Based on these propositions, we con-clude by presenting both opportunities and challenges that publichealth communicators and marketers will face in the future.

    KEYWORDS. Information processing, interpersonal, mass media,public health, new media, Web 2.0

    INTRODUCTION

    In the 1980s the proliferation of personal computer use reinventedthe processes by which information is created, shared, and communi-cated, spawning the Information Age. The moniker itself suggestedthat information was a scarce resource and that its creation and dis-semination were valued products and services. The accelerated paceof change in information technology occurring today indicates thatthe computer world is poised for another revolution. Whether itis termed new media, participatory media, or Web 2.0, the way inwhich information is created, shared, and disseminated is changingdramatically. Wikipedia (2007) defines new media as:

    . . .new forms of human and media communication that havebeen transformed by the creative use of technology to fulfillthe same basic social need to interact and transact. . . [It is] alsoclosely associated with the term Web 2.0 which refers to aproposed second generation of Internet-based services suchas social networking sites and wikis that emphasize online col-laboration and sharing among users. (New Media webpagewithin Wikipedia)

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  • Whereas this information exchange used to be the privilege of thefew, it is now available and accessible to the masses in the form ofblogging, podcasts, social networks, wikis, really simple syndication(RSS) feeds, multi-player online games, and more. In this paper, weexplore how traditional information processing models and theoriesof media access and consumption can be applied to new media,and we discuss the implications that these theories and models holdfor communicating and persuading Americans to enact preventivehealth behavior.

    Proliferation of Internet Use and New Media

    New media usage is increasing exponentially, and more technologyusers are relentlessly connected (Castells, 2007). According to thePew Internet & American Life Project, nearly three-quarters (70%)of American adults are online (Pew Internet & American Life Study,2006) and even more are cell phone users (73%) (Horrigan, 2007a). Intotal, the Pew group estimated that nearly 85% of American adultsare using digital technology in the form of the Internet or cell phones(Horrigan, 2007a). Another survey conducted by the Pew researchgroup shows that the tendency to use wireless connectivity to accessthe Internet is quickly becoming routine for many. In its survey, arandom-digit dial of 2,373 adults ages 18 and older, the Pew Internet& American Life Project indicated that a third (34%) of its surveyrespondents reported having logged on to the Internet using a wire-less connection (either at home, at work, or at some other location)(Horrigan, 2007b).

    Still, not everyone is online; demographic differences persist. Accord-ing to data from the Pew Internet & American Life Project (2006), 83%and 82% of individuals between the ages of 1829 and 3049, respec-tively, are on the Internet. Adults over age 50, however, use the Internetmuch less frequently. The Pew group also reported that Caucasiansoutnumber their ethnic counterparts on the web: 72% of Caucasianrespondents report having used the Internet while only 58% of non-Hispanic Black Americans and 69% of English-speaking Hispanicsreport having used the Internet in 2006. Adults with at least somecollege education access the Internet more than those without a collegeeducation (84%91%, some college or college versus 36%59%, less than high school or high school). Statistical variationsalso reflect economic realities. Adults with higher incomes use the

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  • Internet significantly more than those earning incomes below $30,000annually (Pew Internet & American Life Study, 2006).

    Not surprisingly, adolescents are even more receptive to techno-logical change in their lives; they consistently post higher wiredstatistics than do adults ages 18 years and older. In 2006, nearly93% of tweens and teens (ages 1217) report being online, up from73% in 2000 (Lenhart and Madden, 2007). Similarly, the portionof adolescents accessing the Internet daily has increased from 42%to 61% within the same time frame. Moreover, of the 61% of teen-agers accessing the Internet on a daily basis in 2006, one third(34%) report using the Internet multiple times in one day (Lenhartand Madden, 2007).

    Todays Americans are not only using the Internet more, they alsosimultaneously access multiple media, such as television, cell phones,mp3 players, and personal digital assistants. Papper et al. (2004)observed media usage habits among adults and reported that nearlyone quarter (24%) were using at least two media at the same timeduring the day. Statistics on teens multitasking behavior are evenmore dramatic. In a recent study conducted by the Henry J. KaiserFamily Foundation, over three-quarters (81%) of teens report thatthey use multiple types of media simultaneously at least 25% of thetime (Foehr, 2006). Given that the Kaiser Family Foundation alsoreported that American adolescents age 1518 spend an average of6.5 hours using media, the statistic on multitasking represents animportant trend among users (Rideout et al., 2005). There can beno mistake: multitasking means that Americans are accessing moremedia in less time (i.e., media exposure far exceeds media usage).For instance, Papper and associates found that adults report spend-ing an average of 11.7 hours per day accessing media. However, whenmedia multitasking time was taken into account, the total jumped to15.4 hours per day. Likewise, in the Kaiser study, researchers esti-mated that teens were actually squeezing in 8.5 hours of mediaexposure during their 6.5 hours of media usage time. Indeed, thesedata may well indicate that multitasking has become the norm amongmany adolescents.

    Health Information in the Age of New Media

    As Internet access and connectivity increases, Americans also areturning to Internet sources more frequently for health information.

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  • An estimated 68% of Americans report reading the health section ofa newspaper or magazine in the last year; 72% report watching ahealth report on television, barely outpacing the 65.4% who indicatethat they access health information on the Internet (Department ofHealth and Human Services, 2005).

    Other data also attest to the Internets growing popularity as aconduit for health information. The surge in online health infor-mation queries and usage is matched by the growth of options amongonline information sources. According to comScore Media Metrix, adigital market research company, the first quarter of 2007 witnessedan overall 12% growth in the online health information category ascompared with first quarter 2006 (Lipsman, 2007). The comScorestudy of consumer online health information usage showed that thehealth information category had reached an average of 55.3 millionvisitors per month in the first quarter of 2007, a number accountingfor approximately one third of all U.S. Internet users. Among theleading online sources of health information, WebMD Health wasmost frequently visited with an average of 17.1 million unique visitorsduring each month of the first quarter of 2007. This average was anincrease of 25% over the same time period in 2006. The official web-site of the National Institutes of Health, NIH.gov, followed WebMDand averaged 9.8 million unique visitors per month for the first quar-ter of 2007, an 8% increase over its numbers for first quarter 2006.

    The surge in online health information queries and usage ismatched by the growth of options among online information sources.For example, MedicineNet.com, exemplifying this trend, now offers36 general health and medical RSS feed channels and over 1,000 spe-cialty health and medical feed channels (Retrieved from Medicine-Net.com June 5). Personal health experiences recorded on blogs, orWeb logs, are also popular despite the fact that their authors maylack credible medical authority. In December 2006, Fox Newsreleased its a top ten list of Best blogs: Health Web sites worth aclick, and the list ranged from the highly personalized The AmazingAdventures of Diet Girl and Diabetes Mine to scientific topics likeGenetics and Health (Alvarez, 2006).

    Not only is the variety of health information expanding on theInternet, but this digital health information is becoming increasinglymobile. For example, Apple.coms iTunes, an online media store,provides free podcast sessions from numerous health informationsources, including the Centers for Disease Control and Prevention,

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  • the Mayo Clinic, Harvards School of Medicine, the World HealthOrganization, the Public Broadcasting Service and HealthBeat, andThe Johns Hopkins Bloomberg School of Medicine (http//www.apple.com/itunes/). Many of these large health institutions are alsooffering podcasts and RSS feeds directly to their users from theirrespective websites.

    New Media at the Centers for Disease Control and Prevention

    The Centers for Disease Control and Prevention (CDC), in fulfil-ling its mission to protect and promote the health of all Americans,recognizes the importance of using new and emerging communicationchannels to reach the public. Under the leadership of the NationalCenter for Health Marketing, CDC is responsible for researching avariety of media that can be used to communicate health infor-mation, encourage healthy behavior, address long-term public healthneeds, and respond to urgent health threats. Ongoing activitiesinclude the creation and evaluation of podcasts, electronic greetingcards, blogs, interactive games, webinars, and full scale usabilitytesting of all of its products.

    Demonstrating the possibilities for using new media in publichealth, CDC now offers several podcasts that can be downloadedfrom both the CDC.gov website and iTunes. To date, CDC has cre-ated more than 250 different podcasts, translating some into Spanish.As of February 1, 2007, CDCs podcasts (including audio, video, andtranscripts) had been downloaded more than 180,000 times, clearlyindicating that these eHealth products are fulfilling a niche demandfor mobile audio public health information.

    Additionally, CDCs activities also include innovative uses ofblogs, RSS feeds and interactive games. On July 13, 2006, CDClaunched the Health Marketing Musings blog on its Health Market-ing website, providing a forum for health marketing professionalsto openly discuss relevant communication and marketing issues.The health marketing blog, one of the first in the U.S. Departmentof Health and Human Services to be accessible to the public,addresses topics ranging from global health communication and mar-keting to new media strategies. The Health Marketing Musings bloghas been accessed thousands of times and has more than 3,000 sub-scribers to its GovDelivery e-mail subscription service. The blog isalso available for RSS feed summaries, which allow interested readers

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  • to receive a summary of the Directors updates so that they do nothave to personally visit the site everyday to look for new content.

    As part of a comprehensive communication strategy promotingNational Influenza Vaccine Week (NIVW) in November 2006,CDC stepped into the virtual world of Whyville, a massive multi-player online role-playing game, with over two million players. Manyplayers are teens and pre-teens who play educational games withinWhyville to earn virtual currency (not connected with the real-worldeconomy) and increase their virtual social standing. In order tosupport NIVW and encourage Americans to get their influenza vac-cination for the 20062007 influenza season, CDC introduced Why-flu to the virtual game world. During the six weeks the Why-fluwas active, there were 134,421 visits to the vaccination room and19,572 unique Whyvillians virtually vaccinated.

    Finally, CDC has spent several months over the last year usingbest-practice research methods and user-based testing to develop aWeb 2.0-compatible CDC.gov website. The site features a rotatingflash highlight box at the top of the page that emphasizes importantand=or immediate health topics. The improved site also includes Web2.0 elements that will help promote broader distribution of CDCsresearch and recommendations. For example, RSS feeds (a new sitefeature) help facilitate the process by which other web publishersand information service sites link with and receive updated CDChealth information. Additionally, the new site boasts a tag cloud(see Figure 1), which allows users to visually ascertain the popularityof specific search terms other visitors have used when searching thesite for health information. For example, in June 2007, the mostpopular searches were: AIDS, bird flu, body mass index (BMI),and chlamydia. Thus, by looking at the tag cloud, new website userscan see what other visitors have searched, and, in theory, use thesetags to generate their own successful search string.

    MODELS OF INFORMATION PROCESSINGAND CONSUMPTION

    It is obvious that relentless connectivity to digital information isshaping the way in which health information is created, shared,and disseminated, as well as the way in which health information issought, accessed, and consumed. What is not clear, however, is

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  • how all of these changes impact consumer information processingand what, if any, implications these changes may have on the creationof health messaging and content development. What may be mostimportant to recognize is the fact that new media engender a muchstronger participatory element than the simple exchange of email andchat room conversation. In this sense, new media contain elements ofboth interpersonal communication (i.e., the ability to deliver individ-ualized messages to one person at a time) and mass communication(e.g., the ability to deliver one message to many different people atone time). That is, new media allow communicators (whether theybe publishers, broadcasters, or consumers) to develop, send, anddeliver unique messages to many different people all at the same time.Given this paradigm shift, it may be worthwhile for health communi-cators to revisit the foundations of communication in both theinterpersonal and mass media in an effort to identify and adoptthe characteristics of each medium that generally result in moreeffective communication. The next section of this paper will review

    FIGURE 1. Tag Cloud on the Centers for Disease Control andPreventions Recently Improved Homepage

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  • information processing models and theories of persuasion from boththe mass and interpersonal communication literatures.

    Mass Media Models of Information Processing and Persuasion

    In assessing how people encounter, attend, process, learn, andretrieve information from the mass medium, communicationresearchers have espoused the adoption of prominent theoreticalframeworks: selective process theories and dual process theories.Both of these frameworks recognize that consumers are inundatedby media messages and that human information processing capacityhas limits. They acknowledge that while the number of media mes-sages we encounter continues to grow, our information processingcapacity remains static, forcing us to make decisions about whichmessages we want to attend to, process, and learn.

    Selective process theories describe a situation in which mediaconsumers attend to, cognitively process, and retrieve media mes-sages that are consistent with their own beliefs and attitudes. Inthese instances, consumers frequently overlook or ignore messagesand media outlets that are perceived to be incongruent with theirbeliefs and attitudes. In this way, the media consumer confirmshis personal viewpoints while preventing his own exposure to newor opposing information (Atkin, 1985; Sanbonmatsu et al., 1998).Dutta-Bergman (2004b), in a study of health information seekingbehavior, found that selective exposure and processing not onlyoccurs when consumers encounter television, radio, or print media,but that it also occurs in online contexts. In his study, individualswho reported being highly involved in health issues or very healthconscious (i.e., held strong beliefs about health, engaged in healthyactivities) actively sought out more health information on the Inter-net than individuals who said that they were less involved withhealth and health issues.

    In reflecting on his findings, Dutta-Bergman (2006) noted that theInternet, with its inherent searchable nature, supports selectiveprocess theories in that users are able to actively select and attendto websites that align with their information or entertainment needswhile ignoring online content that does not align with their under-lying media usage motivation. Evidence of selective processing onlinepresents a strong challenge for health marketers. Not only do healthmarketers need to ensure that health conscious or health oriented

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  • individuals (those who actively seek out health information) encoun-ter and process their content, but they also need to find a way to com-municate with less health conscious Americans.

    Dual process theories of cognitive function present similar chal-lenges for health marketers. Briefly, dual process theories posit thatthinking or cognitive processing occurs in either a systematic or apassive manner. The heuristic-systematic model (Chaiken, 1980)and the elaboration likelihood model (Petty and Cacioppo, 1981,1984) both propose this dichotomy. The Chaiken model claims thatindividuals encounter, evaluate, process, assess, and learn new infor-mation in an organized, analytic, detailed manner that easily transfersfrom one new situation to another. Under Chaikens systematic pro-cessing model, a person must have both the motivation and thecapacity to think in a logical, organized, and comprehensive mannerabout a given topic. When either motivation and=or intellectualcapacity is lacking or exists at a low level, a more passive approachmay be utilized. Then heuristics, or mental short cuts, are used toprocess the information encountered. Such short cuts might includeappearance elements such as source likeability, source credibility,and=or the number of persuasive arguments present (Petty andCacioppo, 1984).

    Dutta-Bergman (2003b) showed that ones level of involvement inInternet usage (e.g., searching versus surfing) can significantly impactattitudes and intention toward particular health issues. Although hisstudy was unable to confirm some tenets of the elaboration likelihoodmodel, his study was conducted in a highly controlled environment(i.e., a college computer lab) where it was difficult for participantsto multitask. Thus, it seems likely that the dichotomy between passiveand active cognitive processing may become much more pronouncedif some consumers solely search the Internet for health informationwhile others casually encounter it while using or accessing othermedia simultaneously.

    Health marketers often hope that their audiences will concentrateon and fully process (or elaborate) their messages because elaborationhas been shown to lead to attitudes that are more persistent overtime, more resistant to counterarguments, and more predictive ofbehavior (Petty and Cacioppo, 1984). However, health marketersmust also acknowledge that a great deal of information processingoccurs in a more passive (or peripheral) manner via heuristics or isavoided altogether. Thus, health marketers often set a primary goal

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  • of encouraging people to seek out and subsequently elaborate on amessage, but they underpin it with a secondary goal of creating anenvironment conducive to positive attitude change through heuristicsshould elaboration fail. To address the first goal, Petty andCaccioppo (1981) found that people elaborate on messages of highpersonal relevance. Thus, health marketers are prudent to try to evokea sense of personal relevance among their audiences. Techniquesdeveloped to foster a sense of personal relevance include personalizingmass mailings, using audience segmentation strategies, and tailoringmessages to specific audiences. Acting upon research findings thatheuristic cues have a greater impact if recipients are in a positive stateof mind (Blackwell et al., 2006), traditional health marketers havedeveloped techniques to capitalize on these findings. These techniquesinclude product placement in movies and popular television shows,the interjection of comic relief within an advertisement itself, andcorporate sponsorships of popular sporting=leisure events. In newmedia, health marketers should look for similar opportunities.

    While the study of attitude formation via cognitive informationprocessing principles is essential to all mass media communicators,the analysis and understanding of decision-making behavior in themarketplace is equally important for marketers and advertisers.Decision-making and attitude formation are inextricably linkedbecause people either act in accordance with their attitudes, or theyadjust their attitudes to fit their behavior. Rothschild (1987), basedon early research by Howard (1977) and others that identified differ-ent approaches to problem solving (e.g., routinized response beha-vior, limited problem solving, and extensive problem solving),differentiated between high and low involvement decisions in themarketplace. Rothschilds research confirms that health marketersneed to recognize that the line of demarcation between high andlow involvement decision-making is set by the consumers percep-tions of the importance of the problem rather than by the communi-cators perception of its importance or immediacy. For example,cancer screening may be a very important health behavior to a healthmarketer, but a consumer may only engage in extensive problem solv-ing behavior if she believes it to be an important decision. Moreover,it may take something as drastic as a positive diagnosis for herself ora family member for her to become involved in the topic.

    Health marketers must recognize that the more passive the context,the more important it is to reach consumers where they are rather than

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  • expecting them to seek out health information. They must also recog-nize that it is increasingly important for receivers (i.e., consumers) toencounter information while in a positive state of mind and that theymust create communications that receivers will perceive as personallyrelevant. Consequently, developing a channel strategy that focuses onmedia vehicles or media features with which audiences are comfort-able or which they use frequently may help a communicator gainacceptance with a more passive target audience and ensure exposureof his message.

    In lower involvement decisions, health marketers may also needto provide a stimulus that breaks through existing and competingstimuli in the mass media environment to gain the attention of theiraudience. Blackwell and colleagues (2006) provide several strategiesfor doing so: using human attractiveness, employing movement,developing distinctive attributes (e.g., unique packaging), makingthe message entertaining, and using a well-known brand and brandimage. The caveat for health marketers, especially those engagedin promoting public health, is that a balance must be struck. Thestimuli cannot be allowed to overwhelm the primary communicationmessage.

    Overall, based on both mass communication and marketingresearch, there are several important points for health marketers toremember in this age of new, participatory media. First, personalinvolvement in health topics will vary from one individual to another.Individuals who are highly involved in a topic will likely seek outinformation on their own initiatives (Dutta-Bergman, 2004b). Thisassociation is illustrated by the popularity of online support groups.For instance, Goggins et al. (1998) reported on an evaluation of theJohns Hopkins Pancreatic Cancer website (http://www.pathology.j-hu.edu/pancreas). The evaluation found that the number of peopleaccessing the website far outweighed the number of postings thatmight be expected based on the number of patients diagnosed withpancreatic cancer. Many of the support group participants wererelatives of patients who undoubtedly sought out support andinformation of their own accord. This example demonstrates why itwill continue to be important for health marketers to place theirinformation in popular communication venues, keeping in mindthat current research shows that new media (e.g., blogs, wikis, andvideo=photo sharing websites) are possible channels for informationflow to and from these individuals.

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  • On the other hand, many people will not be highly involved inhealth topics. Because these individuals are less likely to seek outinformation on their own initiatives, embedding attention-gettingmessages in media that these individuals are using and in contexts thatengender a positive mind-set (e.g., social networking websites, digitalgames, podcasts) offer greater potential to reach this group. Placingpersuasive health messages in these media as compared with onlinenews sites or organizational websites could be more effective at reach-ing this less involved group. Finally, regardless of the strategies used,if health marketers succeed in prompting their audiences to processhealth information in a more comprehensive manner, audience mem-bers will need the ability to do so. Thus, persuasive health messaging,when communicated through new media channels, should be writtenin the appropriate format for both the channel and the audience, con-sidering such elements as health literacy levels, language issues,numeracy abilities, and the impairment of cognitive function.

    What may be most critical in this age of new media exposure, how-ever, is the need for research-based communication plans. Prudenthealth communicators need to be wary of jumping on the tech-nology bandwagon and must continue to base their strategic com-munication and marketing decisions in audience research and mediaselection research. Today, more than ever, new digital media allowfor the capture and analysis of an infinite amount of valuable audi-ence and consumer information that can be used to form evidence-based communication and marketing strategies.

    Interpersonal Communication Theory in Computer-MediatedEnvironments

    While Internet technologies are inevitably compared to mass mediainnovations (e.g., printing press, radio, television), the interpersonalelements of todays participatory new digital media distinguish themfrom their mass media predecessors. That is, individuals can now cre-ate and share online content, even their own health histories andexperiences, as they never could before. In this sense, participatorynew media has shifted the online communication paradigm. Ratherthan a simple one-to-manymodel, newmedia communication patternsrange from one-to-one, one-to-many, to a complex many-to-many-to-many model (Crosbie, 2006). Consequently, health marketers wouldbe prudent to ground their new media communications in a solid

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  • understanding of interpersonal models of communication and infor-mation processing, as well as a thorough comprehension of massmedia approaches.

    During its developmental stage, some researchers panned computer-mediated communication (CMC) as a poor, less than desirable, formof communication (Short et al., 1976). In the 1980 s, they remainedcritical, decrying its lack of visual cues normally associated with otherforms of nonverbal communication (Sproull and Kiesler, 1986) andclaiming its very nature inhibited message personalization (Daft andLengel, 1984). Put succinctly, under several major models of interper-sonal communication (e.g., social presence theory, media richnesstheory) which researchers proffered in the 1970s and 1980s, CMC faredvery poorly.

    In the early 1990s, however, communication researchers began toexplore an alternate explanation of how interpersonal relationshipsare constructed and managed in a computer-mediated environment.Specifically, Walther (1992) formalized the social information pro-cessing theory of CMC, which recognizes that individuals adapt theircommunication style to the constraints of the medium within whichthey are communicating. Moreover, Walther contended that peoplewill use any communicative cues available to them at the time to con-nect with others and develop relationships. Walther asserted thatCMC needs to be approached from a relational or interpersonal per-spective. He claimed that a relational perspective suggests that func-tional and social factors should be examined and that messagesdeveloped from this perspective will differ from those developed froma channel-effects view alone (p. 81).

    According to research conducted on the social information pro-cessing theory, communicators use nonverbal substitutes such as tex-tual cues in a computer-mediated environment to convey informationthat nonverbal cues transmit in a face-to-face environment (Witt,2004). In many instances, these substitutes have proven as effectivein establishing relationships and communicating relational infor-mation in a computer-mediated environment as their nonverbalcounterparts in face-to-face communication (Walther and Burgoon,1992; Walther et al., 2005). By utilizing self-disclosure techniquesand asking personal questions to learn more about others anddevelop interpersonal impressions, communicators in CMC environ-ments can develop a variety of cues during their interactions to helpperpetuate a sense of relevance and familiarity between themselvesand their recipients (Tidwell and Walther, 2002).

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  • Consumers employing verbal immediacy cues such as expressionsof participation (e.g., we, us, and our as opposed to you)and proximity (e.g., heres an idea, this project as opposed tothose ideas) can be especially effective when visual elements areabsent, as would be the case in blogs, text messages, podcasts, tags,and more. Research indicates that individuals who regularly com-municate using immediacy cues in computer-mediated environmentsidentify with others more quickly and develop a more cohesive senseof relational or social closeness with other users than their counter-parts who do not regularly employ immediacy cues (Witt, 2004). Thisdifference ultimately impacts individuals perceptions of the effective-ness of the communication message and medium (Witt, 2004). Finally,use of iconic cues such as emoticons (e.g., using keystrokes to conveya smile : )), lower case typing, and punctuation use (e.g., !!!!!!!)can help foster social relationships in text-based computer-mediatedcommunication. Utz (2000) found that iconic cues such as emo-ticons significantly predicted the development of social relationshipsin the online gaming environment. Years before, Carey (1980) hadnoted the same phenomenon: when faced with an interpersonal com-munication situation in which face-to-face nonverbal cues wereabsent, communicators compensated by relying on a variety of iconiccues (e.g., animated use of punctuation, nonstandard spelling ofwords such as 4 UR info, vocal surrogates such as yuck andhumm).

    In a health context, several studies have found that despite the lackof face-to-face nonverbal cues, empathy (the ability to interpretanother individuals feelings) can still be fostered in an online environ-ment (Preece, 1998; Preece 1999; Preece and Ghozati, 2001). Recently,Preece and Ghozati (2001) reviewed 100 online social support groupsand found that 81% of the online support groups contained empa-thetic messages. Given that there is a strong relationship betweenempathy and other characteristics of strong interpersonal relation-ships (e.g., similar interests, common experiences, shared understand-ing) (Colvin et al., 1997), it follows that empathy helps create a senseof group cohesion and identity. Thus, identifying nonverbal methodsfor becoming accepted as part of the group, will be important forhealth marketers as participatory media continue to evolve.

    In approaching the new media environment, health marketers needto revisit the foundations of interpersonal communication, leveragingmethods for reducing uncertainty, enhancing immediacy, fosteringempathy, and utilizing affective icons to maximize customer=audience

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  • relationships. Mehrabians (1981) approach-avoidance theory state-ment, People approach what they like and avoid what they dontlike (p. 22) may have been simplistic, but if health communicatorsattend to this maxim and employ key constructs in interpersonal com-munication theory, their messages may be perceived as more likable,and as a result, more approachable in an age of new media.

    Despite the pervasiveness of new media in their lives, someAmericans may continue to feel that it is inappropriate, and poten-tially dangerous, to develop social relationships and=or friendshipsonline or via digital media. In fact, Utz (2000) found that skepticismtoward online social forums friendly capacities significantlyimpeded the development of digital, online relationships for someusers. Utzs early work on multi-user online gaming clearly indicatesthat users accessed the same medium for different primary purposes(i.e., gaming versus role-playing versus chatting). Utzs work under-scores the hazard of assuming that all new media users are pursuingthe same goals simply because they are using or downloading the samemedia. Nor can it be assumed that all new media users will respond tosocial inquiries or friendly requests in a similar manner. Thus, inaccepting research findings on computer-mediated interpersonalcommunication and adopting strategies which proved successful inthese studies (e.g., use of emoticons, use of frequent verbal immediacycues), health marketers should also strive to promote a sense of per-sonal relevance among new media audiences. Moreover, exploringusers motivations for accessing new media and tailoring their mes-sages with the appropriate interpersonal cues should increase successrates. In summary, Walthers observation is still relevant:

    . . .what is needed is research on communication technologyguided by the theoretical underpinnings regarding communi-cation functions in any context. From this perspective differ-ences due to channel attributes will become more precise,interesting, and may possibly be employed with greater discre-tion and utility. (1992, p. 8182)

    New Media Uses and Gratifications

    Studying media consumption habits could help traditional healthmarketers reach unmotivated health information consumers. Earlier,

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  • we noted that Dutta-Bergman (2004b) had found that healthconscious individuals were significantly more likely to use or seekout online health information than less health-conscious individuals.In his study, participants who failed to report health consciousness oran orientation toward health and healthy activities, also failed to regu-larly seek out health information on the Internet. Dutta-Bergmansfindings suggest that creating repositories of online health infor-mation that can be searched and mined (e.g., informational websitessuch as WebMD.com, CDC.gov, and cancer.org) may primarilyserve to help health-conscious individuals confirm their beliefs abouthealth or answer their health-related questions.

    A separate study by Dutta-Bergman (2003a) one year earlierrevealed insights into how health marketers might reach those lessinvolved in health issues. In this study, Dutta-Bergman found thatan individual with unhealthy eating habits was more likely to watchspecific genres of television (e.g., comedy programs) and more likelyto have sought out entertainment-based Internet content than indi-viduals with healthier eating habits. Additionally, a simultaneousmedia usage study conducted by BIGresearch confirmed this corre-lation between health consciousness and media preference. Specifi-cally, Schultz et al. (2006) identified consumer audience segmentswithin a population of high media users. Not surprisingly, none ofthese high media usage segments were significantly associated withexercise or physical activity behavior (as measured by self-report ofswimming, playing sports, exercise, jogging, snow skiing, and more).In contrast, when snacking behavior (as measured by soft drink,snack foods, and frozen food consumption, as well as eating out)was correlated with these high media usage segments, some associa-tions did emerge. The segment most likely to report snacking beha-vior was the old school segment that reported their purchasedecisions were strongly influenced by mass media (TV, magazines,newspapers) and minimally influenced by online search media. Fol-lowing close behind the old school segment, ravenous media con-sumers also engaged in snacking behavior, although the associationfor this segment was only a directional relationship (i.e., not statisti-cally significant). The ravenous segment reported being highly influ-enced by all media types and engaging in the most media multitaskingor simultaneous media usage compared with all of the other segmentsidentified in the study. Data also showed that the ravenous segmentconsumed large amounts of network, print, and electronic media. In

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  • contrast, the independents segment was inversely related to snack-ing behavior. Although this inverse relationship was only directional,it helps illustrate the link between health habits and media screen timebecause independents consumed the fewest hours of media whencompared with the rest of the segments. Not surprisingly, this groupalso reported that their consumption decisions were primarily influ-enced by online search media.

    These three studies demonstrate the need for collaborationbetween message developers and media planners. By and large, someof the most important potential public health audiences (e.g., thosewho do not engage in physical activity, those who have poor nutritionhabits) are unmotivated health information consumers. As a result,traditional efforts to create accessible and usable, but static, reposi-tories of health information on the Internet will most likely fail toreach less health oriented individuals. In the future, it will becomeincreasingly important for health marketers to learn about mediausage habits and motivations so that they can infiltrate media thatapathetic consumers are using. A strong basis for understandingmedia usage motivations stems from the functional perspective ofmedia use. Functional media use theories posits that users choosespecific media to satisfy a specific communication need or functionand that the purpose of the media may vary based on the character-istics of the user (Perse and Courtright, 1993). Within the broaderscope of the functional perspective, both uses and gratificationstheory (Palmgreen and Rayburn, 1982) and channel complementaritytheory (Dutta-Bergman, 2004a) are widely respected.

    Uses and gratifications theory (Palmgreen and Rayburn, 1982)posits that personal motivations for using specific media (i.e., gratifi-cations sought) are influenced by both the belief that the media pos-sess certain characteristics and the subjective evaluation of whethereach characteristic is a positive or negative attribute. This model sug-gests that health marketers could understand more about mediausage motivations by researching: 1) how beliefs about new mediaare being formed and how health marketers might be able to influ-ence the belief formation process, and 2) whether highly valuedbeliefs currently exist.

    Gaining insight into usage motivations could help health marketersalign their messages with users expected gratifications within specificnew media channels. Coupled with relevant new media message strat-egies, aligning messages with users expected gratifications might help

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  • health marketers reach unmotivated consumers more successfully.For instance, if an unmotivated consumer expects to use his iPodto unwind from a hard day of work, then health communication pod-casts should be developed to meld with his personal motivation forusing his iPod. In this way, health marketers might become more rel-evant to an uninterested audience segment. Lin (1999) exemplifiedthis idea in her study of online service provision (i.e., shopping, infor-mation, and infotainment services). Her research showed that onlineservice users seek both information and social interaction; hence, shesuggested that online services should be developed to satisfy both theinformational and social needs of users. In a subsequent study (Lin,2001) she demonstrated that expected gratifications actually predictonline service adoption, and she suggested looking at the popularityof the eBay exchange service for an anecdotal success story.

    Over the years, several researchers have proposed models ofmedia-person interactions as ways to categorize important mediagratifications (Katz et al., 1974; McGuire, 1974; McQuail et al.,1972). In fact, Korgaonkar and Wolin (1999), in a factor-based analy-sis of Internet usage motivation, found that individuals who accessthe Internet do so for a multitude of reasons (e.g., social escapism,information search, control over the medium and interactions withinthe medium, and initiation of social interactions). Still, Angleman(2000), in a study of Internet users, found that new media can promptusers to develop new gratification expectations and media usagemotivations. Thus, it becomes increasingly important to study when,where, why, and how unmotivated health information consumers areusing new media. Coupling such knowledge with evidence-basedmessage development strategies may be the formula traditional healthmarketers need to succeed in the new media market.

    Research on channel complementarity between participatorymedia and traditional media could also help health marketers createsuccessful integrated health marketing campaigns. Dutta-Bergman(2004a), in his analysis of the Pew Research Surveys 2000 data,showed that individuals consume media with similar functionalitybased on their interest in a specific content domain, as opposed totheir interest in the medium itself. Thus, media complementaritytheory suggests that people consuming one particular medium togather information in one particular area are likely to consume othermedia that contain information in the specific area (Dutta-Bergman,2004a, p. 48). For example, the theory suggests that a person who is

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  • interested in health issues will likely consume a wide variety of health-related television programs, read the health sections of the news-paper, search for health-specific websites, and perhaps even sign upfor health-focused RSS feeds or establish a health-oriented blog.From the complementarity perspective, it is the underlying interestin a specific topic or domain that manifests itself in a consumerschoice to access and attend to specific media and media content,rather than the actual nature of the media. Thus, as health marketersbegin to explore participatory media, not only will it be important toadapt health messages to the participatory nature of the media, but itwill also be important to study the uses and gratifications of newmedia in the context of traditional media. If the tenets of complimen-tarity theory hold true, researching media usage motivations withinthe larger context of traditional media may help illuminate integratedmedia methods for communicating with unhealthy, more apatheticconsumers.

    DISCUSSION

    In light of traditional theories and models of information process-ing and consumption, Americans growing electronic connectivity is aproverbial double-sided coin. Perceptions of information processingand management will be extremely fluid. To minimize any actualcommunication imbalances that may occur because informationconsumers are, in reality, now poised to play a role as new age healthinformation providers, traditional health information providers willneed to leverage all of the positive attributes of new media, and effec-tively manage its challenging characteristics.

    New Health Communication Content: Created and Consumed

    If health marketers are going to effectively harness the opportu-nities to deliver health messaging via new media, they will also needto create and package new health content that is compatible with theavailable new media options and platforms. More content meansmore informational clutter in the marketplace because other contentcreators and providers (e.g., marketers, philanthropists, politicians,entertainers) will also be competing to deliver their messages via thesenew media channels. Moreover, participatory media now affords

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  • friends, family, strangers, and foes the ability to create, publish, anddisseminate content. The more clutter in the marketplace, thegreater the challenge for health marketers to make contact with theirtarget audiences. It will become critical that health marketers becomeskilled brokers of the information and attention-getting stimuli thatmay serve as gateways to their consumers.

    Sorting through the content overload created by professionalsand amateurs alike will become an even more taxing exercise forAmerican consumers. In theory, selective information processingand attention heuristics will become even more prevalent. As such,familiarity and perceived personal relevance will likely becomeincreasingly important determinants of whether information isattended to or simply unheard amid the noise.

    Perceptions of source and information credibility are also closelylinked with familiarity and personal relevance. If health marketerscan create or develop a heuristic (e.g., a credibility seal, an expertrating system) that can help Americans determine the credibility ofdifferent sources of health information (http://www.hon.ch/), theirmessages may be more likely to be attended to in this new mediaage vis-a-vis those created and disseminated by amateurs. In fact, cur-rent credibility research indicates that Internet users already exploitcognitive heuristics when assessing the credibility of online healthinformation. Fogg et al. (2002) found that Internet users accessinghealth information cite design look (i.e., the look, feel, and layoutof a website) as the most important indication of credibility. In fact,41.8% of participants report using visual cues to assess a sites pro-fessional look and to subsequently make determinations about thesites credibility.

    Unpublished research recently conducted by CDC (Eroglu andLuce, 2007) also revealed that, even when consumers are motivatedto seek and process health information, source credibility continuesto be a pivotal factor in determining the quality of digital infor-mation. Consistent with previous research by Bernhardt and Felter(2004), many focus group participants report triangulating healthdata, commenting that if they are able to find the same informationon three or more websites they assume the information to beaccurate.

    Clear, consistent, and concise messaging will become increasinglyimportant for health marketers in the new media milieu. Marketclutter and simultaneous media usage suggest that even if traditional

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  • health communicators garner users attention, they may not hold itfor long. Paradoxically, it may become even more challenging forAmericans to obtain a complete picture of health behavior and healthcare recommendations than ever before, despite the unprecedentedamount and availability of health information today. Unless issuessuch as health literacy, language, innumeracy, and cognitive process-ing capacity are addressed and mitigated on a large scale, inequitiesbased on ethnicity, socioeconomic status, age, gender, and educationmay be perpetuated and exacerbated.

    New Technology: Interpersonal and Mass CommunicationTechniques Unite

    Not only does new communication technology allow health mar-keters to create and deliver content via new media vehicles, it alsoallows consumers to identify and specify the mix of content thatuniquely matches their own needs and interests (Crosbie, April2006). From the standpoint of traditional health marketers, thisunique characteristic of Web 2.0 and participatory new mediashould be welcomed news. Health behaviorists have long knownthat personalized, tailored counseling generally yields better beha-vior change results than mass communication alone. If they hadtheir preference, most traditional health marketers would opt toindividually counsel target audience members so that messages couldbe customized and adapted to each persons social, cognitive,environmental, physical, and mental status. In contrast, health mar-keters recognize that mass communication can help keep brandsfamiliar and relevant in the minds of target audiences. Uniting theinterpersonal and mass communication elements in the form ofnew media could prove extremely advantageous for health market-ers, communicators, and behaviorists. To fully capitalize on theadvances and advantages of new media vehicles and technologies,traditional health marketers must move beyond simply repurposingold information for distribution via digital channels. They will needto acquire and continually cultivate expertise in creating content thatmaximizes the interactivity and the user input of new media options,as well as the interplay across complementary media. How this tran-sition can best be accomplished will require additional experimen-tation, research, and evaluation.

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  • CONCLUSIONS

    In this paper we introduced new and participatory media availablethrough Web 2.0 applications. We also looked at simultaneous mediausage habits and trends across the U.S. market, noting that both newmedia use and simultaneous media use is growing rapidly withinmany segments of the U.S. population. We noted that the adventof participatory media and new Web 2.0 technologies provide oppor-tunities for health marketers to disseminate health messages viamultiple new media channels and that private-sector and govern-ment-sector organizations alike are beginning to explore these newchannels. We noted, for example, that the CDC has created blogs,podcasts, RSS feeds, and tag clouds in an effort to maintain its rel-evance to Web 2.0 users and consumers. Also, CDC has also begunusing viral marketing strategies to promote positive health behaviorin social networks and virtual worlds such as Whyville.

    Still, we caution health marketers to recognize that Web 2.0 tech-nologies are not simply extensions of the Internet, within which itwould be appropriate to repackage and redistribute existing healthmessages. Rather, they are hybrid media that integrate and dependupon key constructs from both interpersonal and mass communi-cation theory. To make the most of the opportunities afforded bythese new media technologies, however, traditional health marketersmust make a paradigmatic shift in belief and attitude. Health educa-tors and health promoters (who frequently work with mass media)must study and learn from health behavior counselors and mentalhealth counselors (who frequently work with interpersonal communi-cation). The converse is also true. Only after the individual-focusedand mass-focused disciplines of health communication converge, willpublic health be poised to significantly affect positive health out-comes via new and participatory media.

    For those consumers who are motivated to look for health infor-mation, heuristics, literacy, and relevance may greatly impact cogni-tive message processing. Moreover, technological integration shouldhelp engage and retain consumers. Thus, features such as two-way,real-time communication (via cell phone, voice-over Internet proto-cols, or instant messaging), customizable information delivery (e.g.,RSS feeds, filters, and opt-in options or gadgets1), and compre-hensive health assistance (e.g., credible health information smoothlylinked with online social support groups, photos, topical blogs) are

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  • central to obtaining and maintaining consistent connectivity withmotivated consumers. It seems likely that, in the future, the mosteffective health marketer will be one who can successfully developa personalized virtual presence, where users can subscribe to andcustomize digital health environments to create his or her own com-prehensive personal health digital milieu and then, within thismilieu, seamlessly toggle between a variety of Internet-enabledtechnologies.

    Perhaps equally as important, message developers and mediaplanners must collaborate. The first half of this paper focuses onconstructing relevant messages for new and participatory mediaaudiences, yet messages cannot affect health if they fail to reachtheir intended audiences. Not only is it important to ensure thatmotivated consumers are able to easily access, search, and compre-hend health messages in a new media environment, but it is essentialthat health marketers reach unmotivated consumers, especiallybecause individuals who are not motivated to consume health infor-mation tend to be, on a whole, unhealthier individuals (Dutta-Bergman, 2003a; 2004). Studying new media adoption and usagefrom the vantage points of uses and gratifications theory and mediacomplementarity theory may provide the key to creating integratedmedia campaigns that successfully reach hard-to-reach public healthaudiences.

    Today and in the future, successful health marketing via newmedia requires an integrative tripartite approach to ensure the successof preventive and protective health initiatives. Health marketers needto marry key components of interpersonal communication theorieswith mass communication theories during message developmentand augment these messages with data-based media planning. Ifhealth marketers ignore this approach, their messages are likely tobe overwhelmed by noise and clutter in the marketplace, or worse,viewed as old, irrelevant and outdated or even ignored.

    NOTE

    1. A gadget is a mini application for the Windows Vista desktop or the Windows Live per-

    sonal portal. It is the Windows counterpart of the Macintosh widget. Gadgets are also pro-

    vided by the Google Desktop environment (Nuts & Volts Magazine: Computer Encyclopedia).

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