Educational Content and Health Literacy Issues in Direct-to-Consumer Advertising of Pharmaceuticals


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Direct-to-consumer (DTC) pharmaceutical advertisements have been analyzed in many ways, but richer conceptualizations of health literacy have been largely absent from this research. With approximately half of U.S. adults struggling to understand
  Educational Content and Health Literacy Issues in Direct-to-Consumer Advertisingof Pharmaceuticals MICHAEL MACKERT and BRAD LOVE  Department of Advertising, The University of Texas at Austin, Austin, Texas   Direct-to-consumer (DTC) pharmaceutical advertisements have been analyzed in many ways, but richer conceptualizations of  health literacy have been largely absent from this research. Withapproximately half of U.S. adults struggling to understand healthinformation, it is important to consider consumers’ health literacy when analyzing DTC advertisements. This project, framed by the health belief model, analyzed 82 advertisements. Advertisements  provided some kinds of educational content (e.g., drugs’ medical benefits) but typically failed to offer other useful information(e.g., other strategies for dealing with conditions). Issues likely tobe barriers to low health literate consumers, such as nonstandard text formatting, are common. KEYWORDS content analysis, DTC pharmaceutical advertising,health belief model, health education, health literacy  INTRODUCTION The debate surrounding direct-to-consumer (DTC) pharmaceutical advertis-ing in the United States has been vigorous, with Silver, Stevens, and Loudon(2009) providing a recent overview of the history of DTC advertising andresearch. Industry advocates have argued that DTC advertising can educateand engage consumers, increase awareness of diseases, improve patientcompliance to treatment regimens, and prompt doctor À patient discussions(Holmer, 2002, 1999; Royne & Myers, 2008). These proponents state that con-tent keeps patients informed as ‘‘an excellent way to meet the growing  Address correspondence to Michael Mackert, PhD, Department of Advertising, TheUniversity of Texas at Austin, 1 University Station A1200, Austin, TX 78712-0116.  Health Marketing Quarterly  , 28:205–218, 2011Copyright # Taylor & Francis Group, LLCISSN: 0735-9683 print = 1545-0864 onlineDOI: 10.1080/07359683.2011.595639205    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   T  e  x  a  s   L   i   b  r  a  r   i  e  s   ]  a   t   1   7  :   2   2   1   4   J  u  n  e   2   0   1   3  demand for medical information, empowering consumers by educating themabout health conditions and possible treatments’’ (Holmer, 1999, p. 380).These benefits, however, come with the caution that ‘‘confusion arises whencommercially driven promotional information is represented as educational’’(Holmer, 2002; Wolfe, 2002) and can influence patient-provider interactionsin various ways (Abel, Burstein, Hevelone, & Weeks, 2009; Montoya,Lee-Dukes, & Shah, 2008). This conflict is exemplified by some researchpointing out that DTC advertisements rely on emotional appeals and provide vague explanations of benefits (Bell, Wilkes, & Kravits, 2000; Kaphingst &DeJong, 2004; Young, Paterniti, Bell, & Kravits, 2005).The situation is further complicated by the fact that approximately 43 % of American adults aged 16 and older can perform only simple literacy activi-ties (National Center for Education Statistics, 2003), a pressing concern con-sidering the language and information in DTC pharmaceutical materials arebeyond the reading skills of the general public (Kaphingst & DeJong,2004). Indeed, research conducted with lower literate audiences has demon-strated the challenges that these consumers face fully understanding theinformation in DTC pharmaceutical advertisements (Kaphingst, Rudd,Dejong, & Daltroy, 2005). Beyond concerns over general literacy, healthliteracy—the ability to obtain, process, and appropriately act on health infor-mation (Nielsen-Bohlman, Panzer, & Kindig, 2004)—adds an additional layerof complexity. Between one third and half of all patients lack the skills tofollow instructions on prescription medications and patient informationbrochures (Ad Hoc Committee on Health Literacy, 1999; Nielsen-Bohlmanet al., 2004; National Center for Education Statistics, 2003). In conjunction with system and provider issues among others, reduced health literacy con-tributes to the $3.5 billion per year the United States spends on medicationerrors due to the misuses of drugs (Aspden, Wolcott, Bootman, & Croenwett,2006).To enrich the conversation surrounding the educational value of DTCadvertisements, this research introduces two important elements to thedebate, including the application of a multifaceted conceptualization of health literacy. A multifaceted conceptualization of health literacy can alsoimprove the ability of message designers to communicate with low healthliterate audiences and educate individuals. Zarcadoolas, Pleasant, andGreer (2006, 2005) conceptualize health literacy as having four dimensions:  fundamental literacy  (reading, writing, and numeracy), scientific literacy  (understanding technology and the scientific process), civic literacy  (inter-relationship between personal and public health issues), and cultural liter-acy  (understanding different cultures and customs related to health).This model of health literacy could be seen as an improvement on the‘‘obtain, process, and appropriately act on health information’’ definition of health literacy, as it can help message designers consider different kinds of health information that can be present in a particular message. In the context 206 M. Mackert and B. Love     D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   T  e  x  a  s   L   i   b  r  a  r   i  e  s   ]  a   t   1   7  :   2   2   1   4   J  u  n  e   2   0   1   3  of DTC advertisements, this might include the complexity of the text (funda-mental literacy), stating the results of a randomized clinical trial (scientific lit-eracy), or the interrelationship between the personal health and publichealth benefits of a vaccine (civic literacy). Due to the distinctions this modelmakes among kinds of literacy, it can be useful both in evaluating messagesand designing messages (Zarcadoolas et al., 2006, 2005).The other major contribution of this study to the debate on the edu-cational value of DTC advertisements is a theoretical grounding via the healthbelief model (HBM). While other studies have introduced the use of theory (such as social cognitive theory) to the analysis of DTC pharmaceuticaladvertising (Cline & Young, 2004; Young & Cline, 2005), application of theHBM presents a new and valuable contribution to research in this area by examining persuasive-message features likely to influence behavioral out-comes. The HBM is consistently used in a health communication contextto examine why individuals undertake or cease health behaviors (Glanz,Rimer, & Lewis, 2002). Given the arguments of advocates that DTC drugadvertisements can serve an educational function for healthcare consumers,the HBM provides a useful framework for evaluating these promotionalcampaigns.The HBM attempts to explain and predict behavioral outcomes follow-ing exposure to a persuasive message. It also accounts for individual beliefsabout the protective behavior recommended in the message and the healthproblems that the suggested behavior is intended to prevent or control (Janz,Champion, & Strecher, 2002; Becker, 1974; Janz & Becker, 1984). Four mainconstructs comprise the framework: perceived susceptibility, perceivedseverity, perceived benefits, and perceived barriers (Janz et al., 2002). Allof these input variables, which come together in a web-like combination,contribute to the final likelihood of taking a recommended protective healthaction (Figure 1).The model suggests consumers are likely to adopt message-promotedbehavior(s) when feeling threatened by the condition and perceiving per-sonal benefits that outweigh compliance barriers (Logan, 2004). Knowledgeis an essential element of individual perceptions of health risks and benefitsof preventive action (Duerksen et al., 2005). Likewise, repeated media mes-sages can contribute to individuals’ understanding and prompt protectiveaction (Duerksen et al., 2005). Given this, the HBM could provide a usefulframework for the designers of pharmaceutical advertisements—increasingknowledge of a condition and a potential treatment (the advertised medi-cation) would ideally lead to adopting the drug and continued compliancein taking the medication.This content analysis introduces important elements to the study of DTCadvertisements by comparing the content to a known persuasive model anda richer conceptualization of an essential variable in individual understand-ing of health information. The purpose of this study was thus to enrich the  Education and Health Literacy in DTC Advertising  207    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   T  e  x  a  s   L   i   b  r  a  r   i  e  s   ]  a   t   1   7  :   2   2   1   4   J  u  n  e   2   0   1   3  debate around the educational benefit of DTC advertisements, framed withinthecontextoftheHBMandhealthliteracy,toguidefutureresearchinthisareaand highlight opportunities to improve the design of DTC advertisements. Assuch, this research sought to address two primary research questions:  RQ1 : How does the persuasive content of DTC advertisements match with the elements of the HBM?  RQ2  : How do DTC ads present health literacy challenges to consumers,according to the health literacy conceptualization of Zarcadoolaset al. (2005, 2006)? METHODS  Advertisements were collected from the top 10 U.S. magazines based oncirculation according to the Magazine Publishers of America (2009) andthe Audit Bureau of Circulations 2005 rankings, the most recent publicly available annual circulation numbers at the time study advertisements werecollected. For the purpose of broadening the sample, an equal number of culturally focused and other specialty publications were used in the analysisas well; these additional publications were widely read English-languagemagazines whose intended audiences are ethnical or racial minorities (e.g.,  Jet, Latina ) or groups that were underrepresented in the top ten magazinesbased on circulation (e.g., Sports Illustrated, Cosmopolitan ). FIGURE 1 Health belief model.208 M. Mackert and B. Love     D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   T  e  x  a  s   L   i   b  r  a  r   i  e  s   ]  a   t   1   7  :   2   2   1   4   J  u  n  e   2   0   1   3  Similar to the sampling strategy of Kaphingst, Dejong, Rudd, and Daltroy (2004), advertisements were selected from the January  À March 2007 issues tocreatea‘‘snapshot’’ofadvertisementsataparticulartime.Duringthesamplingperiod, 82 unique advertisements (  N  ¼ 82) ran 293 times. Table 1 lists themagazines and the number of advertisements from each publication, andTable 2 provides the frequency of advertisements by drug category.  TABLE 1 Advertisements by PublicationMagazineNumber of advertisements AARP Bulletin a 0 AARP Magazine a 3Better Homes and Gardens a 29Cosmopolitan 7Ebony 9Family Circle a 0Good Housekeeping a 24Hispanic 1 Jet 5Ladies’ Home Journal a 24Latina 0National Geographic a 6Newsweek 47Oprah 6People 25Prevention 20Reader’s Digest a 27Sports Illustrated 14TV Guide a 19 Woman’s Day  a 27 a Top 10 U.S. magazines based on circulation.  TABLE 2 Advertisements by Drug Category Category Number of uniqueadvertisementsCardiovascular 19Respiratory 10Central Nervous 9 Analgesic 9Reproductive, contraception,obstetrics = gynecology 6Urinary 5Gastrointestinal = digestive 4Musculoskeletal 4Endocrine 4Immunology 4 Allergic 4Infection 2Neoplastic 2  Education and Health Literacy in DTC Advertising  209    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   T  e  x  a  s   L   i   b  r  a  r   i  e  s   ]  a   t   1   7  :   2   2   1   4   J  u  n  e   2   0   1   3
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