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4

OUT OF SIGHT, OUT OF MIND?

Addressing Unconscious Brand Awareness in Healthcare Communication

Laura Crosswell, Lance Porter, and Meghan Sanders

On June 8, 2006, the FDA approved the world’s first preventative vaccination for the human papilloma virus (HPV). Eager to initiate public discussion and perhaps activate consumer demand, Merck Pharmaceuticals quickly launched a national print, television, and online advertising campaign for the Gardasil(R) vaccination (Petersen, 2006). Prior to receiving FDA approval, however, Merck joined forces with nonprofits Cancer Research & Prevention Foundation and Step Up Women’s Network to raise awareness for HPV through an unprecedented, three-tiered social marketing campaign.

While the HPV vaccination presented a hopeful defense against cervical cancer, Merck’s early release of awareness messages sparked debate over corporate intentions. Reports characterized the social marketing campaign as “a commercial effort” that “primed the market” for Merck’s new vaccine (Serono, n.d.). Critics also suggested Merck strategically engineered the awareness push to gain market lead, as GlaxoSmithKline was working on alternative inoculation developments (Herper, 2012). Though Merck insisted, “This campaign is part of a broad and longstanding public health commitment to encourage education about the disease” (Merck representative K. Dougherty in Schwartz, 2006), the pre-released messages prompted accusations of deceptive marketing agendas. Siers-Poisson (2007) further suggested that by “partnering with non-profits, especially non-profits that appear to have patients’ health and women’s issues as their primary concern, Merck reach[ed] audiences that may have rightly been suspicious of the motivations of a pharmaceutical company” (p. 32).

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Current health communication research indicates the level of consumer trust in vaccination advertisements influences information seeking behaviors (Nan, 2012; Manika, Ball, & Stout, 2014). Therefore, it is important for researchers, medical practitioners, and marketing professionals to understand the relationship between pharmaceutical branding and consumer trust in public awareness health campaigns. Following the argument that “we should at least pause and think about what is happening when companies use social responsibility as an advertising strategy” (Pardun, 2009, p. 175), this work attends to the greater implications of corporate-driven healthcare messaging by framing the ways in which commercial interests threaten awareness efforts. In the following analysis, we focus on the disconnect between conscious and unconscious brand awareness as it relates to public trust in healthcare communication.

Commercializing Social Awareness

In 1969, Kotler and Levy coined the term “social marketing,” arguing that macro-market scholarship did not adequately account for nonprofit fieldwork within business frameworks (Bolton, Cohen, & Bloom, 2006; Andreasen, 2012). Responding to the call for a broadening of industry terms, the American Marketing Association formally extended the term ‘marketing’ in 2007 to include “the activity, set of institutions, and process for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, marketers, and society at large” (AMA, 2012). While AMA’s new definition provides insight to changes occurring throughout the field of marketing, social marketing lacks such structured operationalization (Thackeray, 2012). Ambiguously interchangeable, the term is often applied to nonprofit activities, as well the overall social impact of marketing (Kotler & Zaltman, 1971; Lazer & Kelly, 1973). Further, social marketing is frequently misused as an appellation for social media/network marketing (Andreasen, 2012).

Today, most literature reflects variations of the notion that social marketing endorses “the design, implementation, and control of programs calculated to influence the acceptability of social ideas” (Andreasen, 2001, p. 71). Such definitions do not account for profit incentives or endorsement motives, limiting the term to philanthropic contexts. As a consequence of conventional standards and unclear definitions, researchers often overlook the canons of social marketing as a means for examining corporate campaigning. While the benefits of social marketing in the healthcare industry include an overall increase in consumer awareness, patient education, and medical discussion, questionable promotional efforts pose a threat to message reception and communication efficacy (Liang & Mackey, 2011). Davidson and Novelli (2001) support such a notion, explaining,

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Society expects and accepts that business will promote its goods and services toward the end of making a profit. It is confusing and skeptical, however, when business ventures into the area of social marketing to promote the improvement of social good by changing behavior. This leads to an increase in the already worrisome level of cynicism about, and distrust of, business.

(p. 90)

The recent rise in media capabilities, combined with the extensive latitude of corporate liberties, make the commercial increasingly indistinguishable from the non-commercial (McChesney, 2000). These blurred boundaries bring into question our current understanding of public awareness campaigns, nonprofit messaging, and corporately sponsored cause-related marketing.

As a result of lax policies and regulatory oversight, corporate agencies often assume social marketing approaches to product promotion (Pardun, 2009). Such methods of consumer messaging increasingly surface throughout media airways, introducing an element of deception to the public health domain (Davidson & Novelli, 2001). As Jaramillo (2006) suggested, “The strategies that have defined such corporations as Nike and Disney have now been co-opted by the pharmaceutical industry. The actual pill is peripheral to the lifestyle that is being built and promised to consumers, not patients” (p. 271). Because people turn to various media sources when health concerns arise, it is necessary for stakeholders to recognize the internal, interpersonal, and mass mediated influences that shape healthcare decision-making.

Message Processing and Consumer Trust

Health awareness campaigns encourage message reception and behavior replication by relaying the information, knowledge, and skill necessary for goal attainment (Lundgren & McMakin, 2004; Lee-Wingate, 2006). In order for public health messages to have impact, however, receivers/audiences must process the information in some fashion. As D’Silva and Palmgreen (2007) note, “PSAs are created with the intention that the audience would at some point in the future respond positively to the information. Hence, apart from attention, encoding and recall become an integral part of developing appropriate messages” (p. 67). Health communication is more likely to be received if message senders are representative of targeted publics, modeled behaviors align with audience values, the information is constructed and relayed in a manner capable of being processed by the audience, and message design attracts viewer attention (Bandura, 1997).

Siefert, Gallent, Jacobs, Levine, Stipp, and Marci (2008) explain, “Cognitive-affective neuroscience clearly suggests that the brain processes information differently depending upon how information is presented and perceived” (p. 427). Tenets of social cognitive theory reflect such notions, emphasizing the importance of attention measures in information processing and decision-making. Though the effect may not be consciously recognized, the “mere association of a product with a positively evaluated stimulus such as an attractive picture. . .may be sufficient to alter attitude toward the product without any ‘rational’ belief change preceding the effect” (Rossiter & Percy, 1983, p. 112). Given that industry practices base message development and campaign implementation on the foundation of carefully orchestrated design, we can reason there lies a certain power in brand placement and sponsorship integration in public health messages.

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Established research continually underscores consideration for message exposure, attention, comprehension, and retention in evaluating persuasive texts (Russell & Roskos-Ewoldsen, 2005; Bandura, 2001). Consumer scholarship indicates perceived trustworthiness heavily influences viewer identification with campaign communication and subsequent consumer behavior (Austin et al., 2002). Chatterjee and Chaudhuri (2005) found that trust significantly influences advertising efficacy through increased viewer attention, ad saliency, and brand recall. Studies also show that viewer skepticism negatively correlates with ad appeal, message reception, viewer attendance, and consumer responsiveness to the message (Obermiller, Spangenberg, & MacLachlan, 2005). Therefore, an ad’s perceived trustworthiness largely determines message efficacy. In health communication, source credibility can also increase message efficacy by influencing beliefs, attitudes, and behavior (Pornpitakpan, 2004). Rhetorical scholarship suggests source credibility, a construct based on the believability of a communicator, derives from the perceived trustworthiness and expertise of the source (O'Keefe, 1990).

Value judgments regarding trust and credibility stem from “perceptions of knowledge and expertise; perceptions of openness and honesty; and perceptions of concern and care” (Peters, Covello, & McCallum, 1997, p. 2). We surmise that brand detectability may influence perceptions of openness and honesty, therefore influencing perceived trust and credibility. By deconstructing cases of commercialized health communication, scholars and practitioners can more effectively consider the means by which corporate agencies construct certain realities for healthcare consumers.

Semiological frameworks stress the power of corporate branding, promoting the notion that “the viewer is a knowledgeable, even masterful, decoder, moving skillfully from signifier to signified” (Bordwell, 2012, p. 44). Therefore, though it may not be a conscious thought process, corporate sponsorship in nonprofit health campaigns may influence viewer perception of campaign credibility and trustworthiness. As such, Merck’s involvement in the HPV health awareness campaign, which eventually escorted audience members to a product promotion, may impact ways in which viewers perceive campaign credibility and trustworthiness. Our study compares implicit micro-level behaviors with explicit self-reported measurements to investigate the “hidden” effect of corporate sponsorship in health messaging.

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While previous research has documented high recall for vaccination messages (Kobetz, Kornfeld,Vanderpool, Rutten, Parekh, O’Bryan, & Menard, 2010) and accounts of consumer apprehension toward the drug company advertisements (Shafter et al., 2011), there are few, if any, studies that investigate the potential influence of brand image in awareness campaigns. Given the lack of prior research in this area, we chose to conduct an inductive analysis. As such, we proposed the following research questions:

RQ1: Do consumers fixate on for-profit corporate sponsorship?

RQ2: Are participants able to recall for-profit corporate sponsorship?

In order to examine the ways in which different levels of brand awareness influence message reception, we first needed to determine brand discoverability. Physiological measures are often used as indicators of unconscious awareness and other responses that individuals may not think to or be able to articulate (Stern, Ray & Quigley, 2001; Potter & Bolls, 2012). Researchers can infer from physiological measures differences in individual’s cognitive approach to media messages in regard to attention span and order in which information is seen and considered. Accordingly, the following research questions also guided this work:

RQ3: Do physiological measurements of corporate sponsorship fixation correlate with brand recall?

RQ4: Does physiological awareness of for-profit corporate sponsorship affect viewer perceptions of campaign credibility?

RQ5: Does physiological awareness of for-profit corporate sponsorship affect viewer trust in Merck Pharmaceuticals’ social marketing campaign?

RQ6: In what ways does brand identification influence consumers’ perceived effectiveness of the Gardasil vaccination?

Method

Consumer research heavily relies on specialized studies that dig into the psyche and behaviors of targeted audiences. Pre-conscious and unobtrusive data collection provides an advanced approach to modern advertising research (Briggs, 2006). Advanced measuring systems and calculations facilitate the evaluation of advertising effectiveness by revealing insight to the perceptual and cognitive processes that influence consumer decisions (Duchowski, 2007). Eye-tracking measures lend themselves to both qualitative and quantitative data analysis, offering researchers opportunities to interpret findings through illustrative mapped visualizations and/or statistical measurements of eye movement (Rosbergen, Pieters, & Wedel, 2004).

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Maughan, Gutnikov, and Stevens (2007) argue eye-tracking techniques “put the study of consumer response to marketing and advertising materials on a firm scientific footing” (p. 342). Given the method’s ability to obtain objective measures of attention and reliable indicators of consumer awareness, our eye-tracking analysis delivers a quantifiable assessment of brand influence in Merck’s multi-phased campaign. By joining biometrics with survey responses, we offer a complex analysis of participant attitudes toward pharmaceutical branding in health communications.

Equipment and Materials

We monitored eye movement patterns using the Tobii T60, an eye-tracking device that resembles a regular computer monitor. Because tracking hardware is embedded in the monitor, head-mounting devices did not restrain participants. Therefore, subjects viewed Merck’s social marketing campaign in a natural environment on what appeared to them to be a regular computer monitor.

Viewers watched a total of four broadcast messages aired in connection with Merck’s roll-out campaign; including the two health awareness messages aired prior to FDA’s approval of Gardasil (“Make the Connection” and “Tell Someone”) and two post-FDA approved product commercials (“One Less” and “I Chose”). We used a 20-item pre-test questionnaire to measure previous awareness and knowledge of HPV and the Gardasil vaccination. We then used a 35-item post-test questionnaire to probe participant perceptions of each of the four commercial messages, their attitudes toward Gardasil, and any future vaccination intentions.

Procedures

We designed the pre-test questionnaire to gauge pre-exposure awareness and knowledge of HPV, cervical cancer, and the Gardasil vaccination. To prevent a priming effect, the survey addressed various other health issues (including influenza, the rotavirus, herpes simplex, colon cancer, lung cancer, skin cancer, heart disease, and alcoholism). Study guidelines also required the participants to complete the pre-test survey three to fourteen days prior to experiment participation.

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During the second phase of the study, participants watched four of the HPV awareness campaign messages in the order in which they were released to the public (“Make the Connection,” “Tell Someone,” “One Less,” “I Chose”). To avoid perceptual expectations and altered visual attention, participants were not given a specific viewing task, nor were they directly told that their eye movements were being tracked. Each participant viewed all four commercials without interruption and then completed a post-test questionnaire at a nearby computer station. The questions assessed participant demographics, as well as viewer recall, involvement, knowledge and exposure, and general attitudes toward the vaccine. We awarded students extra credit toward a mass communication course upon completing the second part of the study.

Participants

During the fall of 2013, we solicited participants through a subject pool at a midsized southern university. Though Merck’s social marketing campaign largely focused on targeting women’s healthcare behavior, men are often involved in medical decisions affecting female family members (i.e. daughters, wives, mothers). Beyond that, men are members of our consumer culture and actively participate in word of mouth marketing. Therefore, we did not issue gender-specific guidelines for participation. We collected information on sex, age, ethnicity, level of sexual activity, and vaccination status for categorical purposes after ensuring participant anonymity.

In total, 117 participants contributed to data collection. Three times as many females (65.8 percent) than males (21.4 percent) participated in the study. 12.8 percent of participants chose not to identify their gender. Ages ranged from 18–34, with a mean of 20.2 years. The majority of participants identified themselves as white, non-Hispanic (75.2 percent). Other races identified included African-American (11.1 percent), Hispanic (3.4 percent), Asia-Pacific Islander (1.7 percent), and Native-American (0.9 percent). 7.7 percent of participants did not report a race. Prior to the study, 70.9 percent of participants had heard of the Gardasil vaccination, 13.7 percent reported no prior awareness, and 2.6 percent were unsure. 12.8 percent of participants did not indicate their level of previous awareness.

Those who reported prior knowledge of the Gardasil vaccination most frequently identified commercial advertising as the source of initial awareness (58.1 percent), followed by physicians, (47.9 percent), friends/family (41 percent), and web sites (10.3 percent). 5.1 percent of participants reported “other,” with sources including university health facilities, university faculty, and magazine advertisements.

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Coding Procedure

For each of the four advertisements, we identified scenes in which Merck’s branding appeared in the commercial spot. We then drew a rectangular area of interest (AOI) around any for-profit, nonprofit, or product branding that appeared in the defined scenes. Figures 4.1–4.4 illustrate the areas of interest (AOIs) for eye fixation data collection. The AOIs facilitated data analysis by tracking the number and length of participant fixations within each labeled area. In this study, a fixation was defined as directed gaze within an area of 35 pixels that lasted for at least 250 ms.

Although fixation data for these AOIs can be expressed in a number of ways, “the number of fixations and the cumulative dwell time of fixations recorded in each AOI have been reported as the most useful” (Hallowell & Lansing, 2004, p. 23). As such, we collected the time it took for participants to first fixate on AOIs, fixation count, visit duration, fixation duration, and total fixation duration as our physiological awareness measurements. Table 4.1 provides an overview of the different tracking metrics used for statistical analysis.

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Measurement Items

Fixation Metrics

We based our fixation data on the standardized Tobii gaze measurements defined in Table 4.1. Fixation count reflects the number of times participant gaze landed in a particular area of interest, whereas cumulative dwell time, or total fixation duration, reflects the sum of the gaze time devoted to all areas of interest (AOIs). To prepare for further analysis, we dichotomized fixation count measurements by separating participants that fixated on Merck branding at least once throughout the study from those who never established eye gaze within a Merck branding AOI. We also performed a mean split on the total fixation duration on corporate branding throughout the campaign (M=1.13 seconds, SD=1.11 seconds); therefore low durations represented fixations ranging from the lowest duration time to the mean viewing length (.00 –1.13), and high durations ranged from the mean time to the maximum total dwell time (1.131–6.53; M=1.4, SD=.49). We followed the same procedure for branding fixations (M=1.4, SD=.50), with low fixation values ranging from .00 to 3.52 seconds and high fixation values ranging from 3.521 to 6.73 seconds.

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While fixation times may seem low, the average is relatively large in comparison to branding airtime. Advertising regulations do require pharmaceutical companies to acknowledge message involvement through some degree of brand presence; however, industry research does not offer average fixation lengths for branding metrics in broadcast advertisements, nor does the FDA offer specific requirements for brand saliency in sponsored awareness campaigns (Code of Federal Regulations, Title 21). As such, we reference the average length of an eye blink to frame the subtleness of Merck’s branding throughout the awareness campaign. Though reports vary, the average eye blink typically ranges from 0.1 to 0.4 seconds (Schiffman, 2001). In the pre-FDA messages, Merck’s logo received roughly 2.406 seconds of airtime per message. Given the location, size, and limited air presence of the for-profit company branding, it is likely Merck managed to meet basic regulations and slip past viewer identification, in essentially, the blink of an eye.

Recall Metrics and Attitudinal Measurements

To examine the correlations between physiological fixation and self-reported awareness, we dichotomized self-reported awareness items and composite recall measurements. For each of the commercials, participants were asked to list any organizations/companies they recalled sponsoring the message. Unprompted recall indicators separated participants unable to identify Merck in any of the four prompted recall items from those who recalled “Merck” at least once. After completing all four of the unprompted awareness items, participants were asked to think back to specific messages and identify any of the listed sponsorships they recalled in specific advertisements. All aided awareness lists included the same items: Pfizer, GlaxoSmithKline, Merck & Co., Johnson & Johnson, Women’s Step Up Network, American Cancer Society, Susan G. Komen Breast Cancer Foundation, and the Cervical Cancer Foundation. We then created an additive measurement score for total prompted awareness by adding together the amount of times “Merck” was correctly identified as a campaign sponsor. Our semantic differential scale stemmed from an adapted version of MacKenzie and Lutz (1989) and Priester and Petty’s (2003) brand-related information processing measuring instruments. We used the five-point, six-item scale listed in Table 4.2 to survey participant perception of Merck’s commercial messages. The survey questions provided a single sentence review of each commercial and asked participants to rate the specific message based on the dichotomous adjectives listed in Table 4.2. Participants rated their perceptions of each of the four commercials. Certain items were reverse coded to prevent participant disengagement. Because we wanted an attitudinal index for the overall campaign, not per commercial, we conducted factor analysis for each item, collapsing the item across the four campaigns in order to construct our index.

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Findings

RQ1: Do consumers fixate on for-profit corporate sponsorship?

Findings indicated most viewers did fixate on corporate sponsorship AOIs (M=.87, SD=.33). There were no significant differences between the ads.

RQ2: Do consumers consciously recall for-profit corporate sponsorship?

Findings showed 87 percent (n=101) of participants fixated on Merck’s branding at least once, yet only 10.4 percent were able to identify or recall Merck as a corporate sponsor. Figures 4.5 and 4.6 illustrate areas in which participants fixated most, showing a moderate to heavy amount of traffic on Merck sponsorships. These examples highlight the dissonance between conscious awareness and physiological response.

Figure 4.5 illustrates the areas in which participants fixated most. Red coloring indicates areas that received longer and more frequent viewer fixations.

Figure 4.6 illustrates participant fixation counts.

RQ3: Do physiological measurements of corporate sponsorship fixation correlate with self-reported measurements of brand awareness?

As outlined earlier, physiological awareness is a measurement of viewer focus on corporate branding. Results indicated brand fixation and aided awareness are positively correlated, r(114)= .18, p< .01, suggesting the more often individuals fixate on Merck’s logo (fixation count), the more likely they are to recall Merck’s involvement in the awareness messages. The duration of fixations also demonstrated a positive correlation to corporate recall, r(114)= .29, p< .001. More simply, these numbers demonstrate that viewers became consciously aware of corporate sponsorship if they focused on Merck’s branding long enough and/or frequently enough.

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As indicated earlier, our pre-test gauged prior awareness and knowledge of HPV, cervical cancer, and the Gardasil vaccination. A positive correlation remained between recall and fixation duration even after controlling for previous awareness, r(82)= .326, p= .001. Table 4.2 provides an overview of the significant correlations among brand fixations and recall measurements.

RQ4: Does physiological recognition of for-profit corporate sponsorship affect viewer perceptions of campaign credibility?

Those with low fixation counts (M=.22, SD=.98) rated the campaign as significantly more credible than those with high fixation counts (M=-.33, SD=.94), F(1, 103)= 8.10, p<.01. Findings also demonstrated that participants who spent less time fixating on for-profit sponsorship perceived Merck’s campaign to be more credible (M=.15, SD=1.03) than viewers with longer corporate sponsorship fixation durations (M=-2.6, SD=.91), F(1,103) = 4.32, p<.05. In other words, as brand focus increases, perceived credibility decreases.

RQ5: Does physiological recognition of for-profit corporate sponsorship affect viewer trust in Merck Pharmaceuticals’ social marketing campaign?

Brand discoverability (as measured by time to first fixation) and viewer trust in the campaign messages demonstrated a positive correlation, r (99)= .30, p < .01. This finding suggests that those who focused on corporate branding faster perceived the campaign to be less trustworthy than those who took longer to establish focus on corporate branding. Tests of variances showed neither brand fixation metrics nor recall measurement significantly influenced viewer trust in campaign messages. Table 4.3 outlines significant attitudinal and physiological correlations.

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RQ6: In what ways does brand identification influence the perceived effectiveness of the Gardasil vaccination?

An analysis of variance did not show any significant relationship between fixation duration F(1,115)=1.296, p=.166 and consumer perceptions of Gardasil vaccination efficacy, (M=4.26, SD=.78) or fixation count F(1,115)= 1.335, p= .140 and consumer perceptions of Gardasil vaccination efficacy.

In summary, while most individuals did see the branding at least once, only a very small percentage could report having seen it. The presence of sponsorship seemed to reach conscious awareness the more often and longer a person saw the branding. Given the brief duration of the sponsorship’s presence in the message, it is very possible that for most people, awareness was not present enough to increase trust and credibility in the message.

Discussion

So what is the effect of corporate branding in social marketing campaigns? We found that most people focused their attention on corporate branding at some point while viewing this campaign. At the same time, however, participants largely did not identify the campaign with Merck. So where is the disconnect? What are the implications of audiences not comprehending the source of direct-to-consumer advertisements that are produced to resemble public service announcements? This difference in physiological fixation on branding and recall ability highlights the significance of Merck’s off-label, promotional activities. While increased fixations can lead to more aided awareness, the awareness may not rise to the level of consciousness. Our findings present an opportunity to operationalize what we are calling unconscious awareness. We define unconscious awareness as one’s sub-conscious, physiological response to visual indicators of corporate branding.

Other scholars have put forth similar accounts of what we describe as ‘unconscious awareness,’ coining terms such as “attentionless unconscious cognition” (Greenwald, 1992). However, as Jacoby, Lindsay, and Toth (1992) note, such notions “inherit the problem of ensuring that attention has been fully eliminated in supposed demonstrations of unconscious influences” (p. 806). More simply, the authors question the reliability of traditional measurements that claim to test ‘automatic processing’ through older, psychoanalytic methods (such as task dissociations, process dissociation procedures, and word-stem-completion tasks). Eye-tracking technology seemingly resolves prior limitations, offering a ‘process-pure measurement’ of unconscious awareness through physiological indicators.

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In reviewing a series of studies in current psychology, Norman (2010) examined properties of ‘the unconscious,’ noting variations in operationalized indicators of the term. The author suggested theoretical assumptions stem from a wide range of experimental designs, specifically noting differences in subjective and objective measurements. Our study offers a new approach for measuring and defining ‘unconscious awareness’ by merging both qualitative and quantitative indicators. Norman’s analysis also suggested empirical findings refuted traditionally dichotomized understandings of consciousness and unconsciousness, suggesting “the existence of intermediate states of conscious awareness” (Norman, 2010, p. 193). Our study supports modern interpretations, as we propose unconscious awareness occurs during a vulnerable stage of message processing—the interim between attention and retention.

Bandura suggested message processing involves attention, retention, production, and motivation. While attention requires the viewer to focus on, discern between, and extract information from relayed messages, retention entails rearranging the information into categories that the memory preserves. During the production phrase of message processing, the viewer relates the memory’s impressions of communication efforts to specific actions, which results in behavior formation (Bandura, 1991). Our findings indicate unconscious awareness may result from incomplete message processing of stimuli stuck between stages of attention and retention.

We submit that brief brand fixations (physiological attendance) promote information recall at a subconscious level. Seemingly, the production phase of message processing incorporates biometric impressions that influence subsequent attitudes and behaviors. The physiological indices of viewer interaction with brand suggest that though viewers may not report any awareness of corporate involvement in a public awareness message, they oftentimes may still connect with the brand at a more implicit level—and perhaps at a lower degree of cognitive involvement.

Scholarship in visual persuasion confirms that unconscious considerations of ad elements (such as color patterns, ad copy, informative value, brand appeal, and exposure) motivate the nature of viewer response (Maddock & Fulton, 1996). Results from this study address the notable influences underlying branding strategies in health awareness campaigns. Our findings speak to source significance, indicating that the faster viewers noticed Merck branding, the less likely they were to perceive campaign messages as credible. Risk communication scholarship often highlights the power of information source when assessing message credibility. Regardless of communication presentation, consumer trust and source credibility heavily mediate successful communication (Ruth & Eubanks, 2005). Therefore, communication efficacy largely depends on how trustworthy the viewer perceives the source to be.

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Studies suggest that “when people perceive themselves to be at risk, they understand and put into practice only those messages that come from sources they perceive as trustworthy and credible” (Lundgren & McMakin, 2004, p. 25). Therefore, citizen understanding of HPV, cervical cancer, and the Gardasil vaccination are inherently tied to Merck’s ability to effectively communicate risk messages to target audiences. Assuming behavior is learned through observation, imitation, and identification, this analysis explored the means by which Merck Pharmaceuticals and partnering organizations shaped public awareness of HPV and cervical cancer.

While Merck’s vaccination presents promising potential to reduce rates of cervical cancer, inoculation aptitude depends on pervasive acceptance and support for the HPV vaccination (Nan, 2012). The pioneering stages of Merck’s awareness campaign indicate a concentrated corporate effort to mask pharmaceutical branding and conceal message involvement—and with good reason. The Edelman Trust Barometer surveys public trust in institutions, perceptions of source credibility, and specific issues influencing trust in business and politics. Rankings are based on the responses from 33,000 people in 28 different global markets. Findings from the 2016 index indicate trust in healthcare is relatively low, and in the US, the healthcare industry ties second to last with the automotive industry (White, 2016). American trust in pharmaceuticals and biotechnology also declined by two points since 2015. We expect that Merck strategically designed the subtle branding with an understanding that obvious corporate markings might prime viewers to connect the social awareness campaign to the company’s eventual product release.

The suppression of presence is a particularly noteworthy phenomenon in advertising strategy (Perelman & Olbrects-Tyteca, 1971). Merck’s strategic rotation and placement of required brand markings in the pre-FDA awareness broadcasts indicated conscious, active, and involved concern with the location and positioning of corporate markings. However, as our findings indicate, this may not have been the best strategy.

If we accept that “trusting consumers would take the stance that the advertiser designed the ad to be truthful and informative with the intent to lead the individual to an informed and beneficial choice,” we can cautiously infer that skepticism rises when seemingly deceitful marketing tactics penetrate viewer cognitions (Ball & Stout, 2008, p. 4). Therefore, though brand presence often goes largely unnoticed in the realm of immediate consumer consciousness, the subtle corporate sponsorship may still impede communication effectiveness and future health behaviors through subconscious (or physiological) brand interaction. Indeed, our findings suggest commercialized social marketing campaigns threaten message efficacy, posing a potential breakdown in communication efforts and a collapse in public health advancement.

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One of the largest gaps in consumer expectations and how they see healthcare lies in the area of transparency (White, 2016). Public health information becomes increasingly compromised by market motives as public awareness efforts evolve into direct-to-consumer advertisements through disguised social marketing. As indicated at the beginning of this chapter, our research stems from the premise that brand detectability may promote perceptions of openness and honesty, and therefore positively influence perceived trust in the message and source credibility. Accordingly, this research offers well-founded reasoning for regulating the size and visibility of corporate logos in commercialized healthcare messages.

While DTC guidelines required Merck to acknowledge message involvement through some degree of brand presence in the awareness effort, lax and ambiguous guidelines allow for creative (and deceptive) liberties. The early stages of Merck’s campaign provide an excellent example of the pharmaceutical company’s extensive effort to remain unidentifiable throughout the social awareness/product endorsement cycle. Current FDA regulations prohibit the visual presentation of commercial text that interferes with drug risk information. Given the influence of source credibility and transparency, it seems equally important to have regulations that prevent visual interference with corporate branding. Commercial design strategy also largely influences information retention, memory retrieval, and behavioral outcomes. Therefore, much like the guidelines that regulate risk information, the FDA should require full disclosure of any and all incentives related to sponsorships involvement, including corporate associations, compensations, partnerships, investments, and/or profitable opportunities linked to public awareness broadcasts.

America’s aggressive marketing trends, combined with significant gaps in federal policies, reflect a contemporary need for regulation realignment in public healthcare communication. In order to honor citizen responsibility and informed decision making, healthcare consumers need a more accurate account of information realisms. Our proposed regulations level the playing field by providing opportunity for viewers to consciously process corporate involvement and potential message agendas. Such policies satisfy the demands of commercial speech rights and federal antitrust laws, while also protecting the sanctity of public health information.

Implications

As media changes, so do the ways in which individuals think, manage information, and relate to one another. Health communication operates in a new digital environment as our media industry is in a state of constant creative destruction and flux. Pharmaceutical influence, government policies, political agendas, media coverage, and now, Internet technology, increasingly host the changing nature of health information and communication reception (Kline, 2003). As more voices gain influence, stakeholders increasingly focus on and implement modern induction techniques to encourage target compliance among competing distractions. Advertising and editorial content, once as separate as church and state in traditional media, are now often indecipherable from each other in today’s social media news feeds.

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The American consumer, however, is not often equipped with the skills needed to tackle the foundational science, media framing, or political coloring that inform public health communication (Eysenbach, 2007; Lippman, 1922). Consequently, a steady flow of misinformation and disinformation plague healthcare decision-making and public well-being. The recent surge in social media and blogosphere activity and the rise of so called “fake news” further complicate dynamics driving public trust in healthcare information.

Changes in communication media denote a call for digital literacy. With an influx of messaging outlets and revolutionized notions of source credibility, consumers struggle to identify and navigate arenas of sound information. Studies already indicate information overload (even when useful) hinders audience message reception (Bawden & Robinson, 2009; Eppler & Mengis, 2004; Bawden, Holtham, & Courtney, 1999). However, it is still not clear how our evolving media environment influences notions of trust, credibility, and perceptions of reliable health information (Pearson & Raeke, 2000; Bradford et al., 2005). Mobile apps, social media trends, and digital innovations present complex challenges for healthcare professionals, and time-honored strategies are called into question as industry leaders navigate the evolving nuances of today’s digital environment.

While experts confront the distractions that characterize our new media landscape, it is important for us to consider the social implications of industry tactics and shifts in communication practices. Though we may never know the true agenda driving Merck’s involvement in the pre-released messages, in the long run, it may not matter. Sheila Rothman of Columbia University’s Mailman School of Public Health, suggests, “If societies are just repeating the drug company’s message, they are not really educating. They are blurring the line between educating and marketing” (Stein, 2009). Hybrid marketing strategies become increasingly dubious in light of the far-reaching and widespread messaging capabilities of today’s informational age. Thus, it becomes ever more necessary for both researchers and practitioners in various fields and industries to better understand micro-dynamics of corporate influence on message processing.

Pharmaceutical interests in social awareness campaigns challenge the ethical and legal standards that regulate public health messaging. As Andreasen (2001) suggests, “If it is acceptable for societies to manage some behaviors, then the question to be considered should not be, ‘Is social marketing ethical?’ The proper questions should be ‘What is the ethicality of marketing when compared to education and law as alternative tools of behavior management?’ and ‘Under what conditions will education, marketing and law be most appropriate and most ethical?’” (p. 17). This research promotes further exploration of such issues by introducing a quantifiable approach to examining unconscious awareness and conditioned tolerance of branded communication within the healthcare industry.

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Limitations and Future Research

Merck’s disguised endorsement demonstrates the degree to which corporations are silently setting the agenda within the healthcare industry. The burgeoning and increasingly invisible commercialized structuring of healthcare information presents alarming threats to public well-being. Our study offers preliminary insight to the influence of passive interaction with message sponsorship, and calls into question the dubious practices shaping public health communication. Data visualizations documented involuntary responses to awareness messages, offering opportunities to differentiate conscious brand recall from unconscious awareness of corporate influence. Essentially, participants’ parasympathetic feedback facilitated the conceptualization of “unconscious awareness” as it relates to commercialized health communication. The dichotomy in physiological fixation and recall ability highlights the significance of strategic brand placement in off-label, promotional activities.

This research adds to health communication scholarship by documenting the influence of corporate branding in awareness messages and examining the impact of social marketing through “unconscious” viewer feedback. Because subjects viewed all commercial spots in one sitting, ecological validity was lessened in this experiment, making generalizability difficult. In addition, the effects were self-reported, and the experiment was conducted in a laboratory after the initial campaign was complete. While our work did control for prior awareness, we did not examine the differences in message processing between those who were vaccinated and those who were not. We also did not survey whether or not participants were aware that Merck was a for-profit pharmaceutical company, as we did not want to prime participants during pre-test or post-test surveys. Such limitations provide a strong platform for future research in this area. Further work in this area could serve to expand and confirm our findings.

Though our focus is case-specific, researchers can use similar methodological approaches to examine additional examples of branded health communication as it relates to consumer trust (for example, using biofeedback to gauge the influence of WebMD sponsorships). Additional examples and media platforms should be explored to paint a fuller picture of the phenomenon under investigation.

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