Suggested citation: Plourde C, Cook L, Mitchell P, Jennings C. Talk to the Fifth Guy: A Lesson in Social Marketing. Cases in Public Health Communication & Marketing. 2008; 2:11-38. Available from: www.casesjournal.org/volume2.

Abstract

Health officials around the world regard the escalating incidence of avian influenza with concern. This concern led the U.S. Department of Health and Human Services to increase Federal funding for pandemic flu preparedness and prevention messaging in 2004. In Florida, the Department of Health wanted to go beyond the traditional health education model and developed an innovative campaign to change health behaviors related to pandemic flu. Initial market research showed the majority of Floridians did not feel at risk for contracting avian influenza or another pandemic influenza virus and had little or no intention of preparing for the possibility. Formative research identified a widespread stigma attached to unhygienic behaviors that enhance the spread of disease, which became the focus of the campaign. The resulting "Fifth Guy" social marketing campaign targeted hand washing and other prevention behaviors to reduce the spread of flu. The campaign used traditional paid and earned media to increase negative stigma attached to unhygienic behaviors. The campaign also included "new media" such as social networking and video sharing websites. The campaign featured a fictitious character, the "Fifth Guy," with his own name, Ben Mitchell and his own MySpace page where he maintained a blog and posted pictures of himself. An actor playing Ben Mitchell conducted a live media tour. Television ads were uploaded to popular video-posting websites to extend the brand. The "Fifth Guy" became a movement to increase positive flu prevention behaviors by stigmatizing the negative ones.

The Problem

Historically, a pandemic flu happens roughly every fifty years. The Spanish Flu of 1918 was followed by the Hong Kong Flu in 1968. The threat of the next pandemic increases as each year passes without one's occurrence, and public health leaders continue to speculate as to when and how severe the next flu pandemic will be. Most recently, the outbreak of avian influenza, H5N1, in the bird population has raised concern that if a genetic mutation occurred allowing human-to-human transmission, humans would lack immunity to the new strain. With no natural immunity, humans could be vulnerable to an infection rate similar to the 1918 pandemic in which as many as 50 million people died worldwide. Even though avian influenza has not become the next pandemic, it has prompted health officials to establish clear guidelines in case Avian Influenza or another virulent flu strain threatens the United States.¹

Armed with this information, health officials have been asked to develop education initiatives and preparedness plans to inform U.S. citizens of the threat and encourage them to prepare for the worst. In 2004, President George W. Bush allocated $350 million federal dollars to develop preparedness and action plans on both a national and local level. The national strategy, while offering some guidelines, states that preparing for a pandemic is in the hands of individual citizens. Local, state, and federal governments will not have the resources to assist all citizens if and when a pandemic occurs in United States. Since individual preparation is the key to limiting widespread impact, guidelines state that citizens should be actively engaged in the preparation and prevention processes.²

In 2005, the Department of Health and Human Services decided to disseminate information on pandemic influenza to the U.S. The agency developed a series of 70 general messages on pandemic influenza preparedness.³ In addition, the World Health Organization, the Centers for Disease Control and Prevention, each state health department, the American Public Health Association (APHA) and many others developed fact sheets, campaigns and web pages, some with blogs, including helpful tips for preparation and prevention of pandemic influenza.⁴ However, most of these resources required a general public who was actively seeking out the information, making accidental exposure rare and reaching a limited population.

The education campaigns were enhanced by heightened media attention. The percentage of media stories including information on pandemic flu in the U.S. grew from 12% to 21% in one year.³ In addition, a made-for-television movie depicting the horror of a pandemic aired on national television. One Harris Poll reported that 65% of adults said they were at least slightly familiar with pandemic influenza, an increase from 2005, when only 47% of adults reported familiarity with pandemic flu. The same poll also reported that 68% of adults were concerned, an increase up from 51% reported the year before. However, in a 2006 survey conducted by the Harvard School of Public Health, 64% did not believe that a pandemic would threaten the United States, citing this as the top reason they were not preparing.³ In the absence of clear direction and specific solutions, risk perception remained low.

Social Marketing: A New Media Approach

Given the presidential directive to develop a pandemic flu preparedness plan, the Florida Department of Health wanted to narrow the focus to create citizen awareness without inducing panic. The agency's aim was to develop a useful, effective, and sustainable campaign. The Florida Department of Health enlisted the assistance of Marketing for Change (M4C).

Qualitative Research Methodology and Findings

To understand their target market, M4C conducted focus groups statewide to uncover Floridians' knowledge, attitudes, and beliefs regarding pandemic influenza. Focus group questions were designed to elicit responses to understand: 1) the current public perceptions and overall awareness of pandemic influenza, 2) the information sources Floridians used to learn about current affairs, and 3) whether national pandemic campaign messages had been internalized. The discussion also included a mock "newsbreak" scenario and a series of questions to measure participants' reactions to existing pandemic influenza being reported in the media. M4C conducted a total of four focus group sessions in the three most prevalent population segments: general population (Caucasian and African American), Hispanic/Latino, and Haitian. Each focus group consisted of eight participants who were 21 years of age or older.⁵

The focus group research found that most individuals were not able to distinguish between pandemic influenza, West Nile Virus, and Avian Influenza. The fact that many people did not understand the concept of a pandemic illuminated the barriers to preparing for such an event. Furthermore, most participants were unaware or unsure of how the virus was transmitted. People received their news and information through prime time media. Since the information was irregular and inconsistent, citizens did not feel pandemic influenza was an imminent threat in the U.S.⁵

Proximity to infection and outbreak seemed to influence the individual's perception of threat. Focus group participants reported that their concern would increase when cases appeared in the U.S. and were likely to grow even more concerned if cases surfaced in Florida. The participants all said they would like to obtain more information regarding a pandemic when the threat was imminent, but premature preparation was too tedious and costly. Most participants did recognize the simple steps to prevent seasonal flu or other sickness like staying home when sick and covering coughs. In addition, Floridians recognized that stocking up on food and medicines would allow them to care for loved ones at home during a flu pandemic.⁵

The focus group moderators asked participants to identify ways to strengthen materials and messaging and to identify the communication channel they believed to be most effective. Common suggestions included using catchy graphics, including a list of symptoms of Avian Influenza, using simple language, including narratives, and ensuring that messages were culturally sensitive. The participants ranked checklists, web pages, television ads and posters as the best communication channels. In addition, participants were asked to add any media outlets or channels to the list that they used to receive information. Many suggested using pop culture including current music, movies, media icons as well as church groups, and radio commercials to reach the target audience with preparedness messages.⁵

Other emerging themes not related to pandemic flu included participants' overwhelming aversion to being socially ostracized for behaviors perceived as outside the norm. Discussion turned to various common behaviors deemed by mainstream society as "normal" and focus group participants identified strongly with the themes of "fitting in" to society in all aspects from health to wealth.⁵

In short, the research showed that Floridians did not seemed threatened by the possibility of a pandemic because it was not imminent. While the audience research found Floridians to be unfamiliar with the idea of preparing for a pandemic, they could recognize behaviors that would prevent seasonal (and pandemic) influenza including:

• Increasing hand washing
• Covering coughs or sneezes with a sleeve or tissue
• Staying home when sick
• Stocking up on supplies (similar to hurricane preparedness)⁶

Quantitative Research Methodology

M4C conducted quantitative research to determine how often Floridians covered their coughs, stayed home when sick, washed their hands, and stockpiled for emergencies. Since many of the preventive behaviors outlined by scientific and health organizations were not new or complex, M4C wanted to learn more about Floridians' practice and knowledge of each. M4C conducted a pre-test random-digit-dial survey of 800 individuals across all regions of the state, capturing a representative sample by gender and ethnicity.

The quantitative research aimed to determine how frequently the sample engaged in hygienic (and preventive) behaviors and their perception of peers' behavior. More specifically, M4C wanted to determine the percentage of respondents who actually believed these behaviors inhibited germ spread (not limited to pandemic influenza). Survey questions were worded to uncover the social norms surrounding these key behaviors. The survey consisted of 30 questions: a combination of 4-point Likert Scale, yes or no questions, and open-ended questions.⁷

An analysis of the survey results revealed that 35% of participants believed they were at least somewhat at risk of Avian Influenza or another pandemic flu. Hurricane preparation was also a strong theme. Most respondents stated they would likely prepare for a hurricane since the threat is always imminent during a Florida summer.⁷

Individuals reported engaging in the behaviors more often than they reported others engaging in the same behaviors with hand-washing presenting the largest gap in self-report vs. peer report. Ninety-four percent of individuals surveyed reported that they wash their hands every time they use the restroom but said others do not engage in the same behavior as frequently (only 48.7% were perceived to wash every time). Survey questions about the other preventive behaviors also produced similar variations between self-report and perception of peers' behavior. Thus, Floridians were doing one of two things: engaging in healthy behaviors that will likely limit the spread of pandemic influenza or over-reporting their own behavior to fit their perception of social norms. M4C concluded that since most individuals reported washing their own hands, but accused their peers of unhygienic behavior, hand washing was a social norm. In all cases, there was room to increase the preventive behavior and the perception of strong social norms.⁷

[Please refer to Appendix A for the full survey findings]

The Plan

The qualitative and quantitative research showed that Floridians were largely unconcerned by the threat of a flu pandemic. M4C determined that focusing a campaign on preparing for an actual pandemic would not yield positive behavior change. Furthermore, the difference between self-reporting of basic preventive behaviors (washing hands, staying home when sick, and covering cough) and the perceptions of others engaging in the same behaviors presented an opportunity. This finding became one of the major platforms for the campaign - the idea that others are not as hygienic as one's self. Established observational research by major health organizations had found that 80% of people (4 of 5) wash their hands after using the restroom. Therefore, the team decided to use this behavior as the crux of the campaign.⁸

Using its own research and the qualified observational studies, M4C's objective became increasing Floridians' participation in hygienic behaviors and strengthening social norms around these behaviors. The goal of the campaign would become the backbone of the state's pandemic preparation efforts by encouraging individuals to engage in preventive behavior. To elicit behavior change, M4C brainstormed creative taglines and messages to make the audience perceive the behaviors to be fun, simple, and necessary. The benefit of engaging in the behavior had to outweigh the consequences of not engaging in it. Clearly, the threat of pandemic influenza was not an adequate consequence, so based on the focus group finding that adherence to social norms was an important motivator, M4C decided to focus on the concept of "fitting-in," or fear of becoming an "outlier."⁸

M4C chose the workplace as the setting for the ads, as this setting resonated with the majority of Floridians. Playing off the observational studies about hand washing, the team coined the term "Fifth Guy" as the outlier who does not wash his hands after using the restroom. To put a human face on the messages, a fictional character, Ben Mitchell, was created to represent the "fifth guy." The taglines, "Germs are Getting Stronger" and, "Can Someone Talk to the Fifth Guy" created a sense of urgency accompanied by a simple call to action: do not be the "Fifth Guy." M4C believed that a person who saw the ad would empathize with Ben Mitchell's co-workers and recognize a Ben Mitchell in themselves or their workplace. The hope was that people would make a small change in their own behavior to avoid similar social stigmatization.

M4C also wanted to connect the hurricane preparedness behaviors, in which Floridians were already engaging, to preparation for a flu pandemic. The campaign was launched in the late spring and early summer 2007, a few months before Florida's hurricane season. Some ads listed items citizens should stockpile for pandemic flu preparedness, which were similar to those for hurricane preparedness.

Mock-ups of possible graphics and proposed taglines were created and pilot-tested with focus groups to determine message efficacy [see Appendix B for originals]. The ads and print media showed Ben continually breaking all the hygiene rules by not washing his hands, going to work when sick, and coughing or sneezing into the air. Emphasis was placed on the disgusted reactions of Ben's co-workers toward their colleague. After pilot-testing the originals, the results reinforced the preliminary research linking the desired behaviors to current social norms. Hand washing was considered a social norm, so the campaign focused on targeting the outcasts who were not maintaining proper hygiene.

[Please refer to Appendix B for billboard and poster graphics]

Implementation

To reach the multilingual Florida population, campaign materials were translated into Spanish and Creole. To ensure cultural sensitivity and accurate translation, the messages were tailored by native speakers within the organization. Campaign elements included humorous television and radio spots (15, 30 and 60 seconds) and billboards, posters and stickers (English and Spanish). Network and cable airtime was purchased and radio spots aired on Hispanic and English television stations. Publix stores, a popular Florida grocery store chain, placed ads on approximately 30 grocery carts in half (332) of their Florida stores. "Fifth Guy" print advertisements appeared in the Orlando Sentinel and Tallahassee Democrat.⁹

[Please refer to Appendix C for detailed media outreach information]

Herrle Communications, M4C's sister company, assisted with media relations for the duration of the campaign. Print stories from earned media appeared in the Lakeland Ledger, and The Ft. Myers News Press. Internet-based stories appeared on brandchannel.com, HoutLust (blog), scaryideas.com, oliviermermet.com, ETTF.net, and eMaxHealth.com. Herrle Communications hired an actor to play the role of "Ben Mitchell" and launched a media tour of tour the state. "Ben" conducted radio and television interviews over a four-week period. He always carried the signature urinal featured in the print and television advertisements.⁸ M4C created a website as an informational and interactive tool for the target audience (http://www.5thguy.com). In addition, "Ben Mitchell" developed a page on the popular social networking website, MySpace.com, (http://www.myspace.com/5thguy) where he maintained a blog and posted pictures of himself touring Florida with his urinal. The television advertisements were featured on popular video-posting websites including YouTube,Yahoo, Daily Motion, VSocial, Vimeo, Funny or Die, Google, Grouper, Vidilife, and JibJab to increase brand recognition.⁹

Evaluation

The Florida Department of Health had a $1.4 million budget to run the campaign in ten media markets and three languages, allowing the campaign to air for about nine weeks. Campaign evaluation was included in the initial budget. The same survey instrument used during the formative research process measured change in behavior and attitudes following implementation. M4C distributed the survey to 800 randomly selected individuals two weeks after the final airing of the campaign TV ads. The survey included additional questions to evaluate brand recognition of the campaign. Twenty-nine percent of respondents in Florida recognized the "Fifth Guy" brand and taglines. To evaluate brand recognition, the survey employed both aided and unaided recall. More than two-thirds of those who recognized the "Fifth Guy" brand did so unaided, the "gold standard" in advertising.⁹

The 5thguy.com website attracted over 17,000 unique visitors. Monthly web view audits counted well over 100,000 "hits" to the Website over the course of the campaign. The website was recognized by broadchannel.com, a leading website which reviews content on the Web, calling it, "a site that's not just catchy, but contagious."

The survey found a statistically significant increase in the targeted healthy behaviors among respondents. In addition, the results showed that people strongly agreed with the clear link between hand washing, staying home when sick, and covering one's cough and prevention of germ spread. Most questions about behavior required participants to report on the last 24 hours or less. In general, more individuals reported covering coughs, washing hands more frequently, and staying home when sick. Markets with heavier exposure to campaign materials reported larger increases in positive behavior change.

Finally, an interesting phenomenon was observed in post-test results. Just as in the pre-test, individuals reported engaging more often in healthy behaviors than their peers, but now reported that peers were engaging less often than before.⁹

[Please refer to Appendix A For full pre- and post-test results]

Discussion

The campaign was an example of how to use so-called "new media" to gain free exposure and virally spread a health campaign's message. Websites like YouTube generated thousands of video views by the general public and the MySpace.com profile attracted the attention of people across the country.

Materials (posters, stickers, billboards) all directed consumers to the interactive webpage that had links to all these Internet sources. The websites were easy to navigate, informational, and fun. Before long, the "fifth guy" ads were being forwarded between groups of friends across communities. Internet postings of the ads had a larger viewing population and reach than the paid media placements in the Florida markets. This illustrates the power of the online world and highlights its usefulness for the world of public health. It allows individuals and organizations to access and impact target audiences more efficiently and cost effectively.

While the evaluation illustrates the value of this campaign in changing attitudes, there are limitations that should be noted. The "Fifth Guy" campaign was run with a $1.4 million budget, a large budget for a state-funded campaign. Unfortunately, most state departments could not allocate funds of this magnitude to a health campaign, making replication difficult. However, given the campaign's large focus on advertising, the budget was not large enough to buy long-term ad airtime and placement. If a greater budget existed and more media time could be purchased, M4C would have a better idea of the long-term impact of the campaign on the target health behaviors. If budget allowed, it would have been interesting to do a follow-up study of the same market six to twelve months after the campaign to see if the messages were internalized and if desired behaviors increased, decreased, or remained the same. One could hypothesize that during the first follow-up, the survey captured individuals before they had a chance to implement the healthy behaviors and were still contemplating change. Message internalization and action could have occurred months later and thus were not captured. It can also be hypothesized that over-reporting of the target behaviors on the pretest created a deceptively large change between pre- and post-intervention behavior.¹⁶

There were also environmental factors that were not addressed during the planning and implementation phases. The launch occurred during the spring and summer months, a time when cold and flu rates are usually lower and media attention is focused elsewhere. An evaluation to see what impact the timing had on campaign success would help determine whether such external factors as season had influenced the results. An interesting follow-up would be to run the ads during cold and flu season to see if the usual awareness regarding seasonal illness would increase the frequency of the preventive behaviors targeted.

Another potential threat to the validity of the findings was the presence of other hand washing and healthy behavior change campaigns. Although there were no other campaigns with the same messaging launched at the same time, many of the national health organizations and agencies were promoting similar preventive measures. It is possible that Floridians received similar information from their doctors, pharmacists, and/or other health officials. Future campaigns should attempt to monitor and control for this effect.

The "Fifth Guy" campaign used a unique approach to pandemic influenza preparedness. It offers an example of a creative way to influence individual behavior and a model for the use of new media, which may be useful to other public health issues. This campaign took a complex issue with many different angles and targeted three specific behaviors to simplify content, disseminate information, and increase desired behaviors. The campaign made the message desirable, funny, and salient. Given the initial success, there is currently a unique opportunity to take these preliminary efforts and reproduce the campaign on a national level.

References

1. World Health Organization. (2005, August). Avian Influenza. Retrieved June 2007, from Avian Influenza: Assessing the Avian Threat: http://who.int/csr/disease/influenza/WHO_CDS_2005_29/en/
   *World Health Organization. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO, 28 May 2008. Retrieved June 2008, from Epidemic and Pandemic Alert Response: Avian Influenza : http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_05_28/en/index.html.
2. Homeland Security. (n.d.). Federal Planning and Response Activities. Retrieved June 2007, from Pandemicflu.gov: http://www.pandemicflu.gov/plan/federal/index.html
3. MGT of America, Inc. (2006). Assessment of the Public's Knowledge of a Pandemic Flu. Tallahasse.
4. American Public Health Association. (n.d.). Retrieved May 2007, from http://www.getreadyforflu.org
5. Martin, T. (2007). Avian/Pandemic Flu Planning/Development Process Focus Groups' Summary. Tallahassee: Marketing for Change.
6. National Institute of Allergy and Infectious Diseases. (2007, May 28). Influenza. Retrieved June 2007, from http://www3.niaid.nih.gov/healthscience/healthtopics/Flu/default.htm
7. Martin, T. (2006). DOH Pan Flu Pre-Intervention Results. Tallahassee: Marketing for Change.
8. Mitchell, P. (2007). Pre-Pandemic Behavior Change - The Marketing Plan. Tallahassee: Marketing for Change.
9. Mitchell, P. (2007). Pre-Pandemic Flu Behavior Change Campaign. Tallahassee: Marketing for Change.

Appendix

Appendix A. Florida Department of Health Pre-Pandemic Flu Behavior Change Campaign Pre-test Summary Results Chart

Appendix A. (cont.)

Appendix A. (cont.)

Appendix B.

Appendix C. Pre Pandemic Media Buys

Keep Sick @ Home Poster Distribution
Organization Quantity
National Federation for Independent Businesses 1,000
Florida Chamber of Commerce N/R
Florida Retail Federation NO
Department of Business and Professional Regulation 1,500
Department of Education 10
Capitol Building (restrooms, bulletin boards) 40
Tallahassee Chamber of Commerce 1,000
Tallahassee Society of Association Executives 500
Florida Public Relations Association 500
Publix 125
Winn Dixie 125
Florida Restaurant and Lodging Association 500
Florida Association of Realtors N/R
Florida Institute of CPA's NO
Agency for Workforce Innovation NO
Department of Children and Families N/R
Florida Association of Counties will make members aware of poster availability.

Bare Arm Poster Distribution
Group Quantity
Florida After School Alliance 500
Capital Area Healthy Start Coalition 500
Boys and Girls Club 250
Girl Scout Council of the Apalachee Bend 250
American Red Cross 500
The Children's Campaign 250
Hillsborough County Schools N/R
Orange County Schools N/R