Which message will likely hold the most influence when two messages are provided to an audience back to back?

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Healthcare marketers aim to meet the wants, needs, and interests of consumers when developing campaigns to sell health services. Designing campaigns customized to consumer profiles can seem daunting and costly as the wants, needs, and interests of consumers vary greatly. But healthcare marketers need only turn to emerging social marketing literature for insight on maximizing resources and effectively reaching potential consumers.

According to Kelly Brownell, author of Food Fight and director of Yale University’s Rudd Center for Food Policy and Obesity, in 2001 Coca-Cola and PepsiCo spent $3 billion promoting their products in the United States alone. That same year, the “5 A Day” fruit and vegetable campaign from the National Cancer Institute operated with a mere $2 million advertising budget. The largest amount of money that had ever been dedicated to a national antismoking effort – the American Legacy Foundation’s “The Truth” ads – was only $185 million. For health communication campaigns, competing against high-volume advertisers like the soft-drink and tobacco industries means creating quality messages that effectively and efficiently influence the thoughts, feelings, and behaviors of a targeted audience. To this end, many social marketing researchers have found that customizing messages to a particular audience maximizes their strength and influence.

Two methods to customize health messages are particularly prominent in health communication research. Message targeting customizes messages to shared characteristics of population subgroups, such as lifestyle factors like recent college graduates in emerging careers in small cities or physically active retirees living in the suburbs. Message tailoring, in contrast, fits messages to individual characteristics, such as personality factors like coping styles or preferences for thinking extensively about choices. This article reviews psychographics and matched messages as specific strategies for targeting and tailoring messages, respectively. Particular attention is given to optimizing resources and effectiveness when using these strategies in developing health communications to market health services.

Message targeting involves defining a subgroup of a population based on common characteristics and providing information in a manner consistent with those characteristics. This approach assumes that if group members possess enough similar characteristics and motivations, they will be influenced by the same message. Knowledge of the subgroup’s characteristics, obtained through the process of audience segmentation, allows message developers to allocate campaign resources economically and strategically by targeting their relevant audience.

Variables currently used in consumer market research to segment audiences range from demographics such as age, gender, education, and income, to behavioral characteristics such as loyalty to products, brands, or services. Although these audience segmentation methods are frequently employed for their convenience, Michael Slater of the School of Communication at Ohio State University and his colleagues contend that these basic methods are too broad and therefore not very effective. They argue that the needs, wants, and interests of the consumers are not always taken into account by simple, one-dimensional variables.

For example, in healthcare marketing audiences are sometimes segmented by disease condition. According to Slater, because of the substantial variability among individuals with the same disease, marketing campaigns targeted towards this subgroup will unlikely be successful. Consider two individuals with spinal cord injuries. Peter has a lumber level (i.e., lower back area) spinal cord injury that did not result in a complete laceration of the spinal cord. Peter can ambulate independently with a cane but experiences some lower limb numbness and urinary incontinence. Sam has a cervical level (i.e., neck area) spinal cord injury that completely severed his spinal cord. Just like Christopher Reeve, who had a similar type of injury, Sam uses a power wheelchair as his primary mode of mobility, has limited hand use, and uses a urinary catheter. Although Peter and Sam both have clinically diagnosed spinal cord injuries, their health care and assistive device needs are quite different, thus requiring different focal points within a marketing campaign.

Clearly, understanding and accounting for variability among members of segmented subgroups is critical for influencing consumers. This is particularly true for health behaviors. Physical activity participation, for example, is influenced by demographics but is also guided by culture, geography, income, family, personal preference, and a host of other interconnected variables.

Psychographics is one emerging field that offers a more complex method for audience segmentation. Broadly construed, the term psychographics refers to any system that uses psychosocial variables beyond simple one-dimensional characteristics, like income or gender, to describe consumers. These variables include the personality, lifestyles, attitudes, opinions, and interests of consumers. Psychographics have been used predominantly in general consumer marketing by firms like Claritas, Yankelovich Partners, and SRI Consulting Business Intelligence (SRIC-BI).

In consumer marketing campaigns, companies use psychographics to measure psychological variables of their targeted audience with the goal of identifying individuals who will be most receptive to their advertisements. The theory underlying psychographics is that understanding why individuals make certain choices, rather than simply understanding their general demographic background, is more effective in developing marketing campaigns.

The psychographics research service offered by Claritas, for example, helps companies determine the preferences, interests, and lifestyles of their audience in order to target those segments most likely to purchase their products or services. The Claritas program PRIZM uses a census to identify households whose residents are more likely to fit certain lifestyle profiles and use certain channels of message delivery (e.g., TV stations, mail, etc.). This demographic, psychological, and social profiling provides a richer understanding of audience subgroups who likely share comparable reasons and motivations for purchasing a product or engaging in a particular behavior. Claritas then advises companies in the creation of messages that are more relevant to the particular audience segments.

Similar to market researchers, health educators recognize the importance of audience segmentation as a means of reaching the neediest members of a population. Michael Slater, with colleague June Flora, observed that health behaviors are so embedded in individuals’ social relationships and environment that changing even one health behavior may require a significant change in lifestyle. Psychographics, which offers lifestyle analyses, seems to be a good fit for guiding health communication practices. Unfortunately, to date, psychographic variables have been used almost exclusively in consumer marketing approaches. Relatively little empirical research exists on the effectiveness of psychographics in changing lifestyle patterns such as eating healthy, quitting smoking, getting routine health exams, and exercising. Even the rich body of lifestyle research conducted by companies like Claritas and The Segmentation Company (a division of Yankelovich, Inc.) provides little insight into how individuals will respond to campaigns that target lifestyle change.

Research using psychographic approaches (also referred to as lifestyle analysis) is, however, beginning to emerge in the health communication literature. In a 2000 American Journal of Health Behavior article, Melinda Forthofer and Carol Bryant reported a study that used audience segmentation to inform a social marketing strategy for increasing regular mammography screening. They segmented audiences using assessments of demographics, health attitudes, and perceptions of the risks and benefits of clinical breast exams. (These factors resemble variables Claritas’ PRIZM uses to define consumers by their lifestyles, attitudes, and opinions, if they were adjusted to focus on mammography screening.) Using these psychographic-like variables in their mammography study, the researchers successfully identified two segments of the population representing the majority of women not getting breast exams: women not aware that annual screening was necessary and women who were aware. Campaign resources then were allocated efficiently to create messages targeting each segment.

Healthcare marketers and educators can use the extant health behavior communication literature to more easily find and serve relevant subgroups of their intended audience. Indeed, studies using lifestyle analyses have shown that certain lifestyle clusters predict a variety of health behaviors including seatbelt use, vitamin C use, and self-report attention to health information (work by Michael Slater provides useful examples). For example, if the goal of a marketing campaign is to encourage women in a community to get screened for breast cancer at a specific hospital, it is important to know the key barriers preventing women from getting mammograms and which factors play into their decisions for selecting a hospital (e.g., some women may choose based on television advertisements, others may listen to recommendations from friends and relatives).

Campaign resources are used most economically when population segments are identified in a systematic and meaningful way. Unfortunately, the initial cost of a targeted health communication campaign is often a prohibiting factor for using psychographics to segment audiences. The expenses are two-fold. First, in order to create meaningful population subgroups, it is necessary to communicate directly with community representatives from neighborhoods, churches, schools, and so forth. In their 2006 Health Psychology article, Robert Ruiter and his colleagues argue that it may even be necessary to interact directly with individuals to determine their attitudes, lifestyles, needs, beliefs, and motivations. Second, the organization must develop differentiated materials for each segment. Rather than using one generic message for each segment, as is done with messages that target demographics, the organization must develop multiple sets of materials to target subgroups of individuals with similar beliefs or attitudes. While the initial task of collecting psychographic information and creating messages at this level can be a costly and daunting enterprise, the end result is a communication campaign that effectively reaches the greatest potential audience.

Message tailoring is another method of customizing health communication messages. While message targeting involves aiming a message at a subgroup of people, health communication experts Matthew Kreuter and Celette Skinner describe message tailoring as a process that “fits” the message to the individual, much like a tailor would a suit. Fitting a message to meet personal needs and characteristics, rather than targeting group criteria, may be more effective for influencing health behaviors. This process requires an assessment of the individual.

The message tailoring approach is motivated by a psychological theory that describes how individuals process and respond to information contained in persuasive messages. The Elaboration Likelihood Model, developed and tested extensively by psychologists John Cacioppo and Richard Petty, posits that individuals will be most persuaded by personally relevant messages because they are more likely to pay attention and process more thoroughly the information these messages contain.

The most basic approach to tailoring is personalization, which involves identifying and incorporating into messages characteristics of an individual such as the person’s name or age. Tailoring by personalization may be viewed as analogous to targeting by demographics—both offer customization, but only superficially.

More sophisticated approaches to tailoring are comparable to psychographic targeting. These approaches, which assess and integrate into messages more detailed information for the recipient, may be more appropriate for complex health behaviors. One way we have done this in our laboratory at Yale University is by matching messages to the ways individuals process incoming health information. This approach is guided by the social intelligence theory of personality, developed by psychologists Nancy Cantor and John Kihlstrom, which posits that variations in information processing styles may differentiate individuals even more so than personality traits. Moreover, tailoring messages to information processing styles tend to be based on more static (rather than dynamic) psychological characteristics and, as a result, may use resources more efficiently. Messages tailored to a relatively constant characteristic of the person do not need to be modified as often as those tailored to characteristics that may change over time.

We have focused on four information processing styles: coping style, need for cognition, health locus of control, and regulatory focus. These are described in Table 1. In a series of field experiments, we tested the effectiveness of tailoring messages to each of these health information processing styles for promoting mammography use and fruit and vegetable consumption. In these studies, participants completed a short baseline survey to determine their information processing style and then were assigned randomly to receive a message that was tailored (or matched) to their processing style or one that was not tailored to their style. Data collected during follow-up interviews (ranging from several weeks to several months after message delivery) showed that messages matched to an individual’s information processing style were generally more persuasive in affecting behavioral change than mismatched messages. (This work is reviewed in more detail by Latimer and colleagues in the 2005 Journal of Health Communication.)

Description of four types of information processing styles. Messages can be tailored to each of the styles for increased effectiveness.

This research highlights an effective strategy for health communication campaigns and also underscores the issue of maximizing resources. That is, although more detailed communication may yield greater behavioral outcomes, it also requires individualized assessment and message distribution, which can be costly. Figure 1 shows how to select health communication strategies based on the content of communication and level of assessment. As the content and assessment become more individualized, the costs of the campaign tend to increase, as well.

Nevertheless, referring back to the spinal cord injury example, it is clear that healthcare marketing campaigns may particularly profit from using individually tailored messages that highlight the benefits of their services for the consumer. Designing a care plan for clients with acute illnesses is just one way that tailored messages could be used in the context of healthcare. The one-on-one contact in doctor-patient relationships provides a perfect setting for determining the type of message that will best serve the consumer’s wants, needs, and interests. Tailoring messages to individuals in this way would require screening tools or surveys to identify cognitive and behavioral factors that make the message more personally relevant to the consumer. While the screening process is more time consuming than simply providing a standard or targeted message, the results of tailoring are potentially greater adherence to healthcare services or health behavior changes.

The choice to use targeting or tailoring depends on a number of factors including the available resources of a campaign, the size of the target audience, and whether the behavior is simple, such as a small one-time purchase, or more complex involving a lifestyle change. Tailoring messages to the characteristics of an individual is usually associated with an increase in costs. Thus, the goal of health communicators is to find a balance between message specificity and the proportion of audience that responds to the message.

A message can be customized to a group or an individual that references any number of characteristics – geographical, psychological, behavioral, or even physical. The question is, how much is enough? In order to predict the level of specificity that a message needs to influence a given behavior, it is important to identify the needs and current situation of the intended audience. Michael Slater suggests that health communicators can determine whether to tailor or target messages by identifying variables that predict behavior change, such as knowledge, beliefs, social norms and values. Examining existing literature on the targeted behaviors is one way health communicators can do this. Yet work by Kreuter and colleagues suggests that, within a given population, the determinants of complex behaviors related to smoking, diet, and physical activity vary widely. Health communication messages and marketing campaigns that are concerned with these types of behaviors, therefore, would be most effective if tailored, as we do by matching messages to an individual’s information processing style. Remember, this approach does require an assessment of the individual.

If there is little variability among the audience in terms of behavior determinants, targeting may be the more appropriate choice. For example, if the key barrier to obtaining clinical breast examinations among certain women within a community is lack of awareness that they should be screened annually, then a message targeting that subgroup of women would be an efficient use of resources. Understanding the lifestyles, attitudes, and values of the community allows health communicators and healthcare marketers to create personally relevant messages that are also general enough to be widely distributed. Healthcare marketers may benefit from assessing psychographic variables to help them understand consumer interests such as women’s preferences for the kind of experience they want to have during a screening for breast cancer.

As illustrated in Figure 2, the best method for creating messages may be to use a combination of tailoring and targeting. In this case, health communicators may benefit from the concept of goodness of fit, which reflects how well the content of targeted messages, taken from composite group characteristics, maps on to the content of tailored messages that are derived from individual traits. Kreuter and colleagues, in their 2000 Health Education Research study, reported that there were no significant differences in participants’ behavioral, cognitive, and affective responses between targeted and tailored messages, provided that the targeted message was a good fit for the individual’s behavioral characteristics.

In a similar vein, it may be possible to use targeted messages, such as those that are culturally relevant to a given population, to produce the same behavioral outcomes as tailored messages. For example, in their 2004 study published in American Journal of Health Behavior, Kreuter and colleagues reported that cancer prevention messages targeted to sociocultural constructs such as religiosity, racial pride, collectivism, and time orientation, performed nearly as well as tailored messages in increasing mammography screening and fruit and vegetable consumption. Targeting subgroups using these sociocultural variables may be just as effective but less costly than tailoring messages to individuals. When applying goodness of fit to health messages, the challenge is to determine which variables will result in good-fitting messages and whether a targeted message that is a good fit results in outcomes similar to individually tailored messages.

Health messages must achieve some level of personal relevance in order to affect behavioral change. For this reason, careful planning is required to find a balance between campaign resources and message effectiveness. While message tailoring requires individual assessment of each audience member and is best for complex behaviors, message targeting is best when the behavior is relatively simple (e.g., a one-time behavior) and if resources are not available to do individual assessment. A combination of targeting and tailoring (i.e., a goodness of fit model), is the ideal communication strategy for message effectiveness and resource efficiency when the behavior is not overly complex. In the end, only extensive research on the behavior and its relationship to audience characteristics can determine whether to use tailored or targeted strategies and produce effective marketing campaigns.