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Complementing Your Health Communication Efforts to Maximize Impact


I Introduction
II Social engagement
III Behavioral economics
IV Community-based social marketing
V Conclusion
VI Resources
VI References

--submitted by Sophie Rosa, PHO Health Communication Field Support Specialist

I Introduction

A well planned and executed health communication campaign can increase awareness about a health issue, sway attitudes and perceptions, correct misconceptions, or support advocacy efforts. When it comes to behavior change, health communication can make the case for a lifestyle shift, provide a prompt for action, or illustrate a positive behavior. However, facilitating the movement from knowing, to agreeing, to doing and finally, to maintaining a new behavior, depends on more than just creating the perfect health communication campaign. For sustained change to happen, a campaign must be deployed with complementary behavior change strategies such as social engagement, behavioral economics and community-based social marketing. In recent years these strategies have gained considerable momentum and are now being widely recognized as key health communication allies for creating sustainable behavior change.

II Social engagement

Social media can amplify health communication and easily disseminate a variety of tailored messages, while creating ‘chatter’ about a behavior, service or program. Social media can support public health by enabling peer-to-peer discussion, modeling behaviour and providing problem solving and coping strategies. It can achieve this across a wide population with greater efficiency than traditional communication approaches, including static websites. [1, 2, 3] Many studies report that social media is a significant and valued source for encouragement, experience sharing and motivation when it comes to adopting a healthier lifestyle. [4, 5, 6, 7]

Social media does have some drawbacks, including the varying quality and reliability of the overwhelming amount of health information being shared online. This challenge means it is imperative that public health organizations have a strong digital presence to ‘set the record straight.’ Another contentious issue among public health organizations is the social media risk related to privacy and confidentiality. These hurdles, as well as literature gaps, are discussed in a Moorhead et al. review of the uses, benefits and limitations of social media in health communication efforts. [8] Moorhead et al. identify the need for more evidence about the effectiveness of social media tactics and platforms for influencing positive behavior change. The review also notes that there is a lack of evidence about how specific audiences (e.g., age and gender groups) and cultures react differently to social media.

There are many resources available about how to complement a health communication campaign with social media. Some examples are noted below:

III Behavioral economics

It’s far easier to claim intention to change, than to follow through on it. When making a health behaviour change, a broad range of spontaneous and subconscious judgments come into play. In the end, most people simply end up going for the easier unhealthy choice despite their best intentions and knowledge. Behavioral economist Richard Thaler explains that most people place a far greater value on the present and struggle with decisions for which consequences are in a distant future – unless there is an immense future reward to make the present sacrifice worthwhile. [9]

Behavioral economics is an examination of how to address these unhealthy decision biases by manipulating the environment in a way that leads to optimal choices. In other words, behavioral economics offers public health practitioners a conceptual roadmap to nudge an individual towards the healthy choices, and bypass this paradox.

The human brain gives preference to default options even when another option is appealing. This bias is called the endowment effect [10] or the status quo bias. [11] Just et al. demonstrated that switching the default side dish on the school cafeteria menu to a healthier option, such as a salad, significantly increases consumption of healthier food. [12] Wansink demonstrated that changing the context of how food is presented can significantly affect diet quality and quantity. [13] His research [14, 15] in high-schools demonstrated that simple inexpensive changes in cafeteria design can lead to significant results. Some examples of his findings are presented below:

  • Placing an assortment of fruits in an attractive bowl, rather than a steel pan, doubled fruit sales.
  • Moving nutritious side-orders from the middle to the beginning of the lunch line increased the amount purchased by 10 –15%.
  • Keeping ice cream treats in a non-glass opaque topfreezer significantly reduced sales.
  • Placing chocolate milk behind regular milk led to increased regular milk sales.
  • Implementing a “cash for desert” policy, i.e., not eligible to buy with lunch card or vouchers, resulted in a 71% increase in fruit sales and a decrease in 55% of dessert sales.
  • Moving the salad bar from the wall to the front of checkout register tripled salad sales.
  • Creating a “Healthy Express Checkout Line” for purchases with no unhealthy meals, snacks or deserts doubled healthy sandwich sales.
  • Encouraging the use of trays increased salad consumption by 21% without increasing dessert sales.

Such changes in ‘choice architecture’ can nudge people to make decisions that are in their best interests and are more aligned with their aspirations for a healthier lifestyle. Another way to achieve this is to increase the ‘attractiveness’ of certain choices. For instance, in a study conducted by Wansick et al., selection of healthy hot vegetable side dishes went up 99% in five elementary schools for a period of two months simply by labeling the side dishes with compelling names – X-ray Vision Carrots, Power Punch Broccoli, Silly Dilly Green Beans and Tiny Tasty Tree Tops. [16]

For other practical examples of behavioral economics for healthy eating, visit

IV Community-based social marketing

Community-based social marketing is about how the social context determines behaviors. Community-based social marketers aim to remove barriers, exploit enablers and foster community level involvement. There is evidence to suggest that this comprehensive approach, along with an eye-catching health communication campaign, and basic behavior change tactics such as commitments, prompts, norms and incentives, can work together to change behavior. [17, 18, 19, 20]

The use of commitments in community-based social marketing is based on the premise that individuals want to behave consistently and, more importantly, they want to appear as if they do. As such, once an individual publicly commits to a small request or action that commitment will easily grow to include larger actions simply because people want to appear consistent. [17] Pallak et al. reported that public commitments led to a reduction of approximately 10 to 20% in energy consumption, while private commitments led to insignificant changes compared to the control group. [21]

Visible, easy to understand prompts in proximity of where a behavior usually occurs can lead to behavior change, even without changes in beliefs or attitudes. [17] Austin et al. noticed a 17% increase in recycling on a university campus by putting prompts about acceptable recycling material several meters away. That number increased to 54% when the prompts were moved even closer. [22] In a pilot study in the United Kingdom, placing life-size cut-outs of doctors and nurses with a healthy food choice message in a dialogue bubble in the fresh produce and frozen fruits sections resulted in an increase of 18% and 11% of sales respectively. [23]

The development or the reinforcement of favorable social norms can also boost the effectiveness of behavior change campaigns. Many people overestimate the prevalence of an unhealthy behavior, and unfortunately, they allow this biased perception to influence their lifestyle choices. [24, 25] Communication campaigns can motivate change by highlighting the true prevalence of an unhealthy behavior. This works by adjusting the perceived social norm that people are naturally motivated to comply with. [26] In instances where a small behavior change can lead to immediate results, adjusting the social norm can be more cost-effective than regulatory efforts. [27] In situations where significant behavior change is required, changing social norms can effectively complement communication and other health promotion approaches, such as policy development. [28, 29, 30] Fast food marketing tactics nurture a culture of convenience and acceptance of unhealthy food choices. Recent efforts to curb these tactics involve combinations of policy change and communication campaigns that focus on adjusting social norms, such as the Informed Dining Program in British Columbia or the New York City Soda Ban [31] Other initiatives, such as the Obesity Awakening campaign from Live Well Colorado, take aim at the widespread misperceptions about obesity. [32]

The use of incentives can also facilitate behavior change. Research by McKenzie-Mohr, [17] suggests that incentives are most effective when the behavior and the incentives are highly relevant to one another, and that positive incentives surpass penalties. The use of incentives is particularly effective with low-effort and transient behavior change, such as disease screening and immunization [33]. There is also evidence suggesting that incentives can encourage smokers to quit and remain smoke-free for longer periods of time. [34] When choosing incentives, it is important to consider the type of incentive and the extent to which it will resonate with the target audience. Some incentives may attract individuals already engaging in healthy behaviors rather than those who are not. Socioeconomic status is also a determining factor in incentive success. Individuals with a high socioeconomic status are twice as likely to adhere to an incentive-based program then those with a low socioeconomic status, [35] making conscientious design of incentive programs that much more critical.

V Conclusion

The gap between awareness and behavior change can be closed when evidence-based health communication is combined with a variety of other behavior change tactics such as those described above. As branches of the same tree, the complementary approaches of social engagement, behavioural economics and community-based social marketing, share the common goal of creating social change.

VI Resources

Resources on community-based social marketing include the Tools of Change website ( and the Fostering Sustainable Behavior: Community-Based Social Marketing website (

The site is an organization led by Dr. Brian Wansick, one of the foremost experts on behavioral economics.

Public Health Ontario (PHO) Social Media suite of consultation and training services offered by the Health Promotion Capacity Building team at PHO:

VII References

  1. Chou WY, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the United States: implications for health communication. J Med Internet Res 2009 Nov;11(4):e48 [FREE Full text] [CrossRef] [Medline]
  2. Kontos EZ, Emmons KM, Puleo E, Viswanath K. Communication inequalities and public health implications of adult social networking site use in the United States. J Health Commun 2010 Dec;15 Suppl 3:216-235 [FREE Full text] [CrossRef] [Medline]
  3. Takahashi Y, Uchida C, Miyaki K, Sakai M, Shimbo T, Nakayama T. Potential benefits and harms of a peer support social network service on the internet for people with depressive tendencies: qualitative content analysis and social network analysis. J Med Internet Res 2009 Jul;11(3):e29 [FREE Full text] [CrossRef] [Medline]
  4. Chou WY, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the United States: implications for health communication. J Med Internet Res 2009 Nov;11(4):e48 [FREE Full text] [CrossRef] [Medline]
  5. Hwang KO, Ottenbacher AJ, Green AP, Cannon-Diehl MR, Richardson O, Bernstam EV, et al. Social support in an Internet weight loss community. Int J Med Inform 2010 Jan;79(1):5-13 [FREE Full text] [CrossRef] [Medline]
  6. Takahashi Y, Uchida C, Miyaki K, Sakai M, Shimbo T, Nakayama T. Potential benefits and harms of a peer support social network service on the internet for people with depressive tendencies: qualitative content analysis and social network analysis. J Med Internet Res 2009 Jul;11(3):e29 [FREE Full text] [CrossRef] [Medline]
  7. Sanford AA. "I Can Air My Feelings Instead of Eating Them": Blogging as Social Support for the Morbidly Obese. Communication Studies 2010 Nov 2010;61(5):567-584.
  8. Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A New Dimension of Health Care: Systematic Review of the Uses, Benefits, and Limitations of Social Media for Health Communication. J Med Internet Res 2013;15(4):e85. URL: doi: 10.2196/jmir.1933. PMID: 23615206
  9. An Economic theory of self-control.  Richard H. Thaler and H. M. Shefrin. Journal of Political Economy. Vol. 89, No. 2 (Apr., 1981), pp. 392-406. Published by: The University of Chicago Press. Article Stable URL:
  10. Thaler, Richard H. (1980) “Towards a Positive Theory of Consumer Choice.” Journal of Economic Behavior and Organization, Vol. 1, pp. 39-60.
  11. Samuelson, William, and Richard Zeckhauser. (1988) “Status Quo Bias in Decision Making.” Journal of Risk and Uncertainty, Springer, Netherlands, Vol. 1, No. 1, pp 7-59.
  12. David R Just, Lisa Mancino, Brian Wansink. Could Behavioral Economics Help Improve Diet Quality for Nutrition Assistance Program Participants? Economic Research Report No.43, 34 pp, June 2007
  13. Mindless Eating: Why We Eat More Than We Think (2006), Brian Wansink New York: Bantam-Dell. ISBN 0-553-80434-0.
  14. Brian Wansink, David R. Just, and Joe McKendry. Lunch Line Redesign. The New York Times, October 21, 2010,
  17. Wansink B, Just DR, Payne CR, Klinger MZ. Attractive names sustain increased vegetable intake in schools. Preventative Medicine. 2012 Oct;55(4):330-2.
  18. McKenzie-Mohr, D.; Smith, W. Fostering Sustainable Behavior: An Introduction to Community-Based Social Marketing; New Society Publishers: Gabriola Island, BC, USA, 1999.
  19. Pfeiffer, J. Condom social marketing, Pentecostalism, and structural adjustment in Mozambique: A clash of aids prevention messages. Med. Anthropol. Q. 2004, 18, 77–103.
  20. Johnston, C.E. Developing sustainable behaviors through community-based social marketing. In Examining the Confluence of Environmental and Water Concerns: Proceedings of the World Environmental and Water Resources Congress 2006, Omaha, NE, USA, 21–25 May 2006; Graham, R., Ed.; American Society of Civil Engineers: Reston, VA, USA, 2006.
  21. Kollmuss, A.; Agyeman, J. Mind the gap: Why do people act environmentally and what are the barriers to pro-environmental behavior? Environ. Educ. Res. 2002, 8, 239–260.
  22. Pallak, M.S.; Cook, D.A.; Sullivan, J.J. Commitment and energy conservation. In Applied Social Psychology Annual; Bickman, L., Ed.; Sage: Beverley Hills, CA, USA, 1980; pp. 235–253.
  23. Fostering Sustainable Behavior: Community-Based Social Marketing. The Use of Prompts in Increasing Recycling in Academic University Departments; 2009 Available online:
  24. Healthier Choices Pilot Report. Damian Edwards, National Obesity Forum, United Kingdom, 2013
  25. Schultz P.W.; Nolan, J.M.; Cialdini, R.B.; Goldstein, N.J.; Griskevicius, V. The constructive, destructive, and reconstructive power of social norms. Psychol. Sci. 2007, 18, 429–434.
  26. Borsari, B.; Carey, K. Descriptive and injunctive norms in college drinking: A meta-analytic integration. J. Stud. Alcohol. 2003, 64, 331–341.
  27. Schultz P.W.; Nolan, J.M.; Cialdini, R.B.; Goldstein, N.J.; Griskevicius, V. The constructive, destructive, and reconstructive power of social norms. Psychol. Sci. 2007, 18, 429–434.
  28. Carlson, A.E. Recycling norms. Calif. Law Rev. 2001, 89, 1231–1300.
  29. Vandenbergh, M.P. Order without social norms: How personal norm activation can protect the environment. North Western Univ. Law Rev. 2005, 99, 1101.
  30. Vandenbergh, M.P. The individual as polluter. Environ. Law Rep. 2005, 35, 10723–10744.
  31. Dernbach, J.C. Harnessing individual behavior to address climate change: Options for congress. Virginia Environ. Law J. 2007, 26, 107–157.
  32. Erin P. Hobin, David G. Hammond, Samantha Daniel, Rhona M. Hanning, Steve R. Manske. The Happy Meal® Effect: The Impact of Toy Premiums on Healthy Eating Among Children in Ontario, Canada. Can J Public Health 2012;103(4):244-48.
  34. See e.g. Adam Oliver, “Can Financial Incentives Improve Health Equity?” (2009) 339 Brit Med J 705; Theresa M Marteau, Richard E Ashcroft & Adam Oliver, “Using Financial Incentives to Achieve Healthy Behaviour” (2009) 338 Brit Med J 983.
  35. Kevin G Volpp, “Paying People to Lose Weight and Stop Smoking”, online: (2009) 14:3 LDI Issue Brief <>
  36. Harald Schmidt, Andreas Gerber & Stephanie Stock, “What Can We Learn from German Health Incentive Schemes” (2009) 339 BMJ 725 at 727.