EXPLORING SOCIAL MARKETING POLICIES: THE USE OF

POSITIVE AND NEGATIVE EMOTIONAL APPEALS IN HEALTH

ADVERTISING IN FOUR EUROPEAN COUNTRIES

Doctoral Thesis in Business and Management Studies

-Specialisation in Marketing and Strategy

by
Beatriz da Graa Luz Casais

Supervised by
Professor Doutor Joo F. Proena

Porto, August 2014

ii

Authors Biography
Beatriz da Graa Luz Casais was born in Porto, Portugal, on July 9th 1983. She has
taken her higher education pathway at University of Porto with a degree in Journalism
and Communication Sciences at Faculty of Arts (2005), a post-graduation in Health
Communication at Faculty of Medicine (2007), and a MSc. in Marketing at Faculty of
Economics FEP (2009). In February 2011 she finished the curricular course of the
doctorate in Business and Management Studies at FEP, with the approval of the
doctoral proposal in Marketing and Strategy, which made her PhD. candidate.
Beatriz Casais teaches marketing and communication at University of Minho and
Polytechnic Institute of Viseu as teaching assistant. In the past, she collaborated with
Polytechnic Institute of Viana do Castelo, Polytechnic Institute of Porto and Porto
Business School, in the same field. She also did teaching mobility at Tallinn University
of Technology (Estonia) under Erasmus Programme. Beatriz Casais is also Marketing
Manager and Communication Specialist at Five by Five Consulting and Research, Lda.
Between 2006 and 2011, Beatriz Casais was the manager of marketing and
communication at the National Coordination for HIV/AIDS Infection, an organism from
the Portuguese Ministry of Health. In 2011, she integrated, for six months, the
marketing and communication office of FEP. Her professional career started in 2004/
2005, when she was journalist trainee at Dirio Econmico and Rdio Renascena.
Her research interests focus on social marketing, social advertising, health marketing,
public policies and management of non-profit organisations. Beatriz Casais has
published in Health Marketing Quarterly, Journal of Macromarketing and Advances in
Advertising Research. She has presented papers at AMA Marketing and Public Policy
Conference, AMA Summer Educators Conference, Macromarketing Conference,
International Conference in Research in Advertising (ICORIA), European Social
Marketing Conference, International Conference of the International Association on
Public and Nonprofit Marketing and International Colloquium on Nonprofit, Arts,
Heritage, and Social Marketing, a special interest group from Academy of Marketing
where she won the best conference paper award provided by Journal of Social
Marketing and Emerald Group.

iii

Acknowledgments
This thesis is a result of a personal effort and perseverance that would not be possible
without the collaboration of several people to whom I want to express my gratitude.
The first acknowledge goes to my supervisor, Professor Doutor Joo F. Proena. He
provided me an important learning process to conduct academic research. I want to
manifest my profound recognition for his professionalism, availability, rigour and
constant demanding, as well as for his friendship and motivational support. Professor,
thank you for believing in me.
I want to thank the people that, in different ways, gave specialised assist to the
research: professionals from institutions working on HIV/AIDS prevention that showed
their campaigns and allowed confidence on the data collection process; translators of
data from French, German and Italian to English; and the independent coders.
I also give my recognition to the academics that reviewed and discussed this topic
with me, giving criticisms, suggestions and showing paths to follow. Those
contributions happened both at FEP, during the discussion of the thesis proposal, and in
the international scientific meetings where I presented papers.
Finally, but not less important, I express my deep acknowledge to my family and my
friends. They supported me in several levels with love, friendship, care, comprehension
and motivation. My thankfulness is, at the same time, an apologising for my distance
and absence in all those moments that I knew I was expected. Thank you for your sense
and for always being with me.

iv

Abbreviations
AIDS Acquired Immunodeficiency Syndrome
API - AIDS Programme Effort Index
CDC Center for Disease Control and Prevention
ECDC European Center for Disease Control and Prevention
EPPM - Extended Parallel Processing Model
EU European Union
GDP - Gross Domestic Product
HIV Human Immunodeficiency Virus
IDU - Injection Drug Users
MBA Master in Business Administration
MSc. Master of Science
MSM Men who have sex with men
NCPI - National Composite Policy Index
NGO - Non-Governmental Organisation
OECD - Organisation for Economic Co-operation and Development
OPM - Ordered Protection Motivation
PEH - Public Expenditure on Health
PhD Doctor of Philosophy
PLWHIV - People Living with HIV
PMT - Protection Motivation Theory
PRL - Proportional Reduction in Loss
TV Television
UN United Nation Orgnisation
UNAIDS - Joint United Nations Program on HIV/AIDS
WHO World Health Organisation

Abstract
The objective of this thesis is to understand the use of positive and negative appeals
in the practice of health-related social marketing, since the theoretical knowledge about
the effectiveness of appeals is inconsistent in the literature. The research proposes to
analyse the prevalence of positive and negative appeals in social marketing in a
longitudinal overview, characterising their form and the context where they are used.
The thesis examines whether the use of positive and negative appeals fit with the
theoretical knowledge of the conditions that differentiate their effectiveness - the target
audiences and behavioural change messages, the type of institutional sources, the policy
and cultural context, as well as the epidemic dynamics.
The researchers analysed 375 social advertisements preventing HIV/AIDS in four
European countries developed by governmental or non-governmental organisations and
broadcasted on television since the beginning of infection in 1981 until the end of 2011.
The thesis contributes with a content analysis model to identify and characterise
positive and negative appeals in health-related social advertisements and to classify ads
according to the proportion of appeals verified in their different components. Results
indicate that positive appeals have expressive and higher proportional use all the period
under analysis. This is an unexpected result, suggesting that social marketing practices
do not follow the theoretical evidences and predominance in the literature regarding the
effectiveness of negative appeals. Public health advertisements are essentially targeted
to general people, with general messages, and commonly framed by public policies in a
reactive response to health dynamics. The research showed sensitiveness between the
use of positive and negative appeals and countries profiles and epidemic rates.

vi

Resumo
O objetivo da tese consiste em compreender o uso de apelos positivos e negativos
nas prticas de marketing social em sade, considerando que o conhecimento terico
sobre a eficcia desses apelos inconsistente na literatura. A investigao prope-se a
analisar a prevalncia dos apelos positivos e negativos no marketing social numa
perspetiva longitudinal, caracterizando a sua forma e o contexto em que so usados. A
tese verifica se o uso de apelos positivos e negativos est em conformidade com o
conhecimento terico das condies que diferenciam a sua eficcia o segmento alvo e
as mensagens de mudana comportamental, o tipo de fonte institucional, o contexto
poltico e cultural, bem como a dinmica epidemiolgica.
Os investigadores analisaram 375 anncios publicitrios de preveno do VIH/sida
em quatro pases europeus desenvolvidos por organizaes governamentais ou nogovernamentais e exibidos na televiso desde o incio da infeo em 1981 at ao final
de 2011.
A tese contribui com um modelo de anlise de contedo para identificar e
caracterizar os apelos positivos e negativos nos anncios publicitrios de promoo da
sade e para classificar os anncios de acordo com a proporo de apelos verificados
nas suas diferentes componentes. Os resultados indicam que os apelos positivos tm um
uso expressivo e proporcionalmente maior em todo o perodo de anlise. Trata-se de um
resultado inesperado, que sugere que as prticas de marketing social no seguem as
evidncias tericas nem a predominncia na literatura relativamente eficcia dos
apelos negativos. Os anncios de sade pblica so essencialmente dirigidos
populao geral, com mensagens generalistas, e so frequentemente enquadrados em
aes de polticas pblicas numa resposta reativa s dinmicas de sade. A investigao
mostra uma sensibilidade entre o uso de apelos positivos e negativos e os perfis dos
pases e situao epidemiolgica.

vii

Contents
Authors Biography ..................................................................................................... iii
Acknowledgments ....................................................................................................... iv
Abbreviations ............................................................................................................... v
Abstract ....................................................................................................................... vi
Resumo ...................................................................................................................... vii
Contents .................................................................................................................... viii
List of Tables ............................................................................................................... x
List of Figures ............................................................................................................. xi
CHAPTER 1 - INTRODUCTION.......................................................................................... 1
1.1.

Motivation for the Research Topic .................................................................. 2

1.2.

Introduction .................................................................................................... 2

1.3.

Research Purpose ........................................................................................... 6

1.4.

Structure of the Thesis by Papers .................................................................... 7

1.5.

Methodological Approach ............................................................................ 10

CHAPTER 2 - SOCIAL

MARKETING POLICIES FOR PUBLIC HEALTH AND EPIDEMIC

DYNAMICS: A STUDY BASED ON HIV/AIDS PREVENTION TELEVISION ADVERTISEMENTS IN

FOUR EUROPEAN COUNTRIES .......................................................................................

15

2.1. Introduction...................................................................................................... 17
2.2. Literature Review ............................................................................................. 18
2.2.1. Health-Related Social Marketing Interventions within Public Policies and
NGOs

.............................................................................................................. 18

2.2.2. Social Marketing Effectiveness.................................................................... 20

2.2.3. Challenges and Barriers for Effective Health Social Marketing Programmes 21
2.3. Research Methods ............................................................................................ 24
2.3.1. Data Collection............................................................................................ 25
2.3.2. The Database ............................................................................................... 25
2.3.3. Data Analysis .............................................................................................. 26
2.4. Discussion ........................................................................................................ 30
2.4.1. Social Marketing as a Public Policy Intervention ......................................... 30
2.4.2. Longitudinal Appropriateness of Health-Related Social Marketing to
Epidemic Profiles .................................................................................................. 31

viii

2.4.3. Appropriateness of Targeting Policies and Behaviour Change Messages ......34

2.4.4. Adequacy to the Environment ......................................................................37
2.4.5. Social Marketing and Policy Ambivalences ..................................................40
2.5. Conclusion and Research Implications ..............................................................42
2.6. Limitations and Further Research ......................................................................43
CHAPTER 3 - A CONTENT ANALYSIS MODEL

TO

CLASSIFY SOCIAL ADVERTISEMENTS

ACCORDING TO THEIR USE OF POSITIVE OR NEGATIVE APPEALS ...................................45

3.1. Positive and Negative Appeals in Social Marketing ...........................................47
3.2. A Content Analysis Model to Classify Social Advertisements ...........................50
3.3. Methodology.....................................................................................................51
3.3.1. The Model....................................................................................................51
3.3.2. The Empirical Research ...............................................................................52
3.3.2.1. The sample data .....................................................................................52
3.3.2.2. The analysis of categories ......................................................................53
3.3.2.3. The comparison of classifications ..........................................................54
3.4. Results ..............................................................................................................55
3.4.1. Categories ....................................................................................................55
3.4.2. Reliability ....................................................................................................59
3.5. Conclusion and Research Implications ..............................................................60
3.6. Limitations and Further Research ......................................................................61
CHAPTER 4 - THE USE

OF

POSITIVE APPEALS

IN

SOCIAL MARKETING:

FOCUSED ON TELEVISION ADVERTISING FOR PREVENTING

A RESEARCH

HIV/AIDS IN FOUR EUROPEAN

COUNTRIES. .................................................................................................................. 63

4.1. Introduction ......................................................................................................65

4.2. Literature Review..............................................................................................66
4.2.1. The Persuasiveness of Negative Appeals ......................................................66
4.2.2. Positive Appeals: an alternative to fear control .............................................68
4.2.3. Factors Influencing the Efficacy of Positive and Negative Appeals...............69
4.3. The Research Design .........................................................................................72
4.4. Methodology.....................................................................................................73
4.4.1. The Database ................................................................................................74
4.4.2. Data Analysis ...............................................................................................75

ix

4.5. Results and Discussion ..................................................................................... 77

4.5.1. What are the most prevalent appeals in social advertising? .......................... 77
4.5.2. When are positive and negative appeals used in social advertising? ............. 78
4.5.3. How are positive and negative appeals used in social advertising? ............... 79
4.6. Conclusion and Research Implications ............................................................. 90
4.7. Limitations and Future Research ...................................................................... 92
CHAPTER 5 - CONCLUSIONS ......................................................................................... 93
5.1. Conclusions...................................................................................................... 94
5.2. Theoretical and Managerial Implications .......................................................... 96
5.3. Limitations and Future Research ...................................................................... 97
References .................................................................................................................. 99

List of Tables
Table 1.1 ...................................................................................................................... 9
Table 1.2 .................................................................................................................... 12
Table 1.3 .................................................................................................................... 12
Table 2.1 .................................................................................................................... 27
Table 2.2 .................................................................................................................... 30
Table 2.3 .................................................................................................................... 32
Table 2.4 .................................................................................................................... 33
Table 2.5 .................................................................................................................... 34
Table 2.6 .................................................................................................................... 34
Table 2.7 .................................................................................................................... 39
Table 3.1 .................................................................................................................... 55
Table 3.2 .................................................................................................................... 56
Table 3.3 .................................................................................................................... 58
Table 3.4 .................................................................................................................... 60
Table 4.1 .................................................................................................................... 72
Table 4.2 .................................................................................................................... 77

Table 4.3 .....................................................................................................................78

Table 4.4 .....................................................................................................................80
Table 4.5 .....................................................................................................................81
Table 4.6 .....................................................................................................................86
Table 4.7 .....................................................................................................................87
Table 4.8 .....................................................................................................................88
Table 4.9 .....................................................................................................................89
Table 4.10 ...................................................................................................................90

List of Figures
Figure 2.1 ....................................................................................................................23
Figure 2.2 ....................................................................................................................29
Figure 2.3 ....................................................................................................................31
Figure 2.4 ....................................................................................................................36
Figure 2.5 ....................................................................................................................38
Figure 4.1 ....................................................................................................................73
Figure 4.2 ....................................................................................................................79
Figure 4.3 ....................................................................................................................82
Figure 4.4 ....................................................................................................................83
Figure 4.5 ....................................................................................................................84

xi

To my parents.

Chapter 1
1. Introduction

1.1.

Motivation for the Research Topic

Social Marketing is a topic with increasing implications in the economy and society
of the 21st century, considering its importance for the policy of social welfare, which is
crucial for the development of sustainable markets and resources (Andreasen, 2002;
Hastings, 2003; Hill and Martin, 2014; Shultz et al., 2012). That is why social
marketing is an actual and an important issue, which requires boundary research.
The motivation for this topic is connected with the fact of the doctoral candidate had
been social marketing manager at the Portuguese Ministry of Health during a period of
five years. That experience gave her a daily conscious of lacks of knowledge whose
research could contribute to support management decisions. One of those issues on
social marketing was researched by the candidate in her master thesis. She analysed the
inhibitions and implications of celebrity endorsements in social marketing interventions.
For this doctoral thesis, the ambivalences faced in practice as a social marketer when
designing the strategy of public health social advertising campaigns made the candidate
wonder about the use of positive and negative emotional appeals. Despite laboratory
research about the effectiveness of messages, the perception about managerial decisions
and their contextual scope is also important. It helps other practitioners to choose
strategic options in different situations and overtake trade-offs faced involving social
marketing management. Moreover, the knowledge about practice is an important
contribution to conceptualise theory (Bourdieu, 1990; Reckwitz, 2002).

1.2.

Introduction

Health promotion is an important topic for public policies, considering that

prevention is worthier and cheaper than treatments (Frieden, 2010; McGinnis et al.,
2002; Rothschild, 1999). There is evidence that policy interventions adopting social
marketing principles have been effective in changing behaviours, with expressive use
and effectiveness in public health (Andreasen, 2003; Crawshaw, 2013; Evans, 2006;
Evans and McCormack, 2008; Gordon et al., 2006; Grier and Bryant, 2005; Hastings
and Saren, 2003; Hastings et al., 1998; Helmig and Thaler, 2010; Morris and Clarkson,
2

2009; Stead et al., 2007; Truong, 2014; Walsh et al., 1993; Wong, 2002). Social
marketing consists on the adaptation of marketing techniques to the promotion of
behaviour change (Andreasen, 2002; Andreasen, 2003; Dann, 2010; Evans and
McCormack, 2008; Gordon et al., 2006; Keller and Lehmann, 2008; Kotler and
Zaltman, 1971; Quinn et al., 2010; Smith, 2000; Stead et al., 2007; Truong, 2014) with
the end goal of improving welfare and society (Andreasen, 2002; Andreasen, 2003;
Quinn et al., 2010). It is applied in non-profit organisations and the public sector
(Donovan, 2011).
Social marketers encourage individual compliance by using message appeals. The
direction of appeals can be positive or negative, and the tonality can be informational or
emotional (Brennan and Binney, 2010; Helmig and Thaler, 2010; McKay-Nesbitt et al.,
2011). Social marketing appeals may be expressed positively or negatively according to
the intention of guiding behaviours. Positive appeals aim to show the direct benefits and
gains of behaviour change as an incentive. Negative appeals describe losses and
unintended consequences of certain attitudes and behaviours, by creating psychic
discomfort (Brennan and Binney, 2010). This distinction follows the assumptions of
Prospect Theory (Kahneman and Tversky, 1979; Tversly and Kahneman, 1981), which
considers the existence of gain-framed and loss-framed messages that affect the riskseeking and the risk-averse attitudes (Kahneman and Tversky, 1979; Rothman et al.,
1993; Tversly and Kahneman, 1981).
In social marketing, the literature is not agreed on whether the most effective strategy
is the use of positive emotional appeals or negative ones (Block and Keller, 1995;
Brennan and Binney, 2010; Dillard and Anderson, 2004; Gardner and Wilheim, 1987;
Hastings et al., 2004; Helmig and Thaler, 2010; Lewis et al., 2007; Lewis et al., 2009;
Reeves et al., 1991; Rothman et al., 1993), since the effectiveness of informational
messages is devaluated (Brennan and Binney, 2010; Hastings et al., 2004; Helmig and
Thaler, 2010; Tanner et al., 1991). On the one hand, some experts consider positive
emotional appeals to be a more efficient strategy in long-term and an alternative to the
saturation and to the unintended effects of negatives (Cho and Salmon, 2007; Hastings
et al., 2004; Jones et al., 2003; Lewis et al., 2007; O'Keefe and Jensen, 2008; Slavin et
al., 2007); on the other hand negative emotional appeals, adopting threats (Cauberghe et
al., 2009; Lewis et al., 2007) and provoking viewer reactions such as fear, guilt and

shame have been more often identified than positive appeals in social marketing studies
(Basu and Wang, 2009; Cismaru et al., 2009; Dickinson-Delaporte and Holmes, 2011;
Hastings et al., 2004; Lewis et al., 2007; Vincent and Dubinsky, 2005). The recognition
of negative appeals in the literature follows the evidences of effectiveness suggested by
fear-drive models and health-protective behavioural theories (Cauberghe et al., 2009;
Dillard and Anderson, 2004; Witte, 1992), such as the Protection Motivation Theory
(PMT) (Prentice-Dunn and Rogers, 1986; Rogers, 1983) and the Extended Parallel
Processing Model (EPPM) (Witte, 1992; Witte and Allen, 2000). Research has shown
that higher levels of perceived threat, vulnerability and perceived self-efficacy have a
significant impact on protection motivation (Floyd et al., 2000; Rogers, 1983).
However, fear control or maladaptive coping responses are defensive reactions to fear
appeals, that result in unintended consequences such as the boomerang effect (Cho and
Salmon, 2007; Eppright et al., 2003; Floyd et al., 2000; Gallopel-Morvan et al., 2009;
Good and Abraham, 2007; Hastings et al., 2004; Ruiter et al., 2001). To prevent this
problem, some authors suggest combining negative appeals with positive appeals
(Gallopel-Morvan et al., 2009) following for instance the Ordered Protection
Motivation model (OPM) proposed by Eppright, Hunt and Tanner. OPM sustains that
an ordered combination of loss and gain framed messages may reduce maladaptive
responses and increase adaptive protection behaviours (Eppright et al., 2003; Tanner et
al., 1991). Even though, OPM is not a unanimous theory in the literature (Cox and Cox,
2001; Ho, 2000).
Social marketing effectiveness depends on the correct management of marketing
strategies, such as segmentation and targeting to vulnerable or most at risk populations
(Albrecht, 1996; Andreasen, 2002; Bloom and Novelli, 1981; Fine, 1980; Grier and
Bryant, 2005; Walsh et al., 1993). In his six benchmarks for identifying social
marketing, Andreasen (2002) highlights the importance of market research and
segmentation of target audiences as well as the creation of attractive and motivational
exchanges (Albrecht, 1996; CangelosiJr. et al., 2009; Deshpande and Rundle-Thiele,
2011; Fine, 1980; Forthofer and Bryant, 2000; Grier and Bryant, 2005; Grier and
Kumanyika, 2010; Kreps, 2008; Noar et al., 2009; Self and Findley, 2010; Walsh et al.,
2010). It is necessary to know the epidemic situation of the health issue, estimate future
trends, understand the social, economic, cultural and policy constraints, and decide the

priorities for the local situation with an adapted social marketing intervention (Grassly
et al., 2001; Hankins and Zalduondo, 2010; Likatavicius and VandeLaar, 2012; Silva
and Silva, 2012; Wymer, 2011).
Positive and negative emotional appeals may be tools for changing behaviours in
different situations (Henley and Donovan, 1999; Jones and Owen, 2006). Different
responses depend on an individuals motivation or self-regulation to change (Brennan
and Binney, 2010; Gygax et al., 2010; Hastings et al., 2004; Keller and Lehmann, 2008;
Self and Findley, 2010; Zhao and Pechmann, 2007), and on the level of message
response perceived efficacy (Block and Keller, 1995; Meyerowitz and Chaiken, 1987).
The effectiveness of positive or negative appeals is related to the perceived risk (Cooper
et al., 2014; Rothman et al., 1993; Sar and Anghelcev, 2013), which varies with the
conscious of the seriousness of consequences and the level of vulnerability to the
problem (Cooper et al., 2014; Rothman et al., 1993; Ruiter et al., 2004). The effects on
persuasion are connected to the Regulatory Focus Theory (Higgins, 1997; Higgins,
1998) and depend on the level of motivation of the target, which is segmented by
demographic factors, the level of efficacy of the recommended behaviour and the
perceived self-efficacy to do it (Cooper et al., 2014; Keller, 2006; Keller and Lehmann,
2008; Zhao and Pechmann, 2007).
Besides the appropriateness to the target audiences, the type of messages and the
seriousness of the disease, cultural context is also an important topic for consideration
in the design of marketing appeals, both in commercial and social marketing
(Airhihenbuwa and Obregon, 2000; Chan et al., 2007; Hastings et al., 2004; Laroche et
al., 2001; Orth et al., 2007; Vincent and Dubinsky, 2005). The context also influence
the effectiveness of positive and negative emotional appeals (Reardon et al., 2006;
Rothman et al., 1993). Strategies for the direction of message appeals may reflect
conservative or progressive political philosophies (Green and Witte, 2006; Hastings et
al., 2004), since social marketing by itself has a political role to achieve certain goals
(Cho and Salmon, 2007; Raftopoulou and Hogg, 2010). The acceptance of messages
influence the reputation and image of sponsored organisations (Hastings et al., 2004).
Negative appeals, exaggerating the danger consequences of a behaviour, reflect badly
on the reputation of a government, when sponsored by the public sector (Hastings et al.,
2004).

1.3.

Research Purpose

The analysis of message strategies that work better in public health is a research
challenge (Evans and McCormack, 2008) in order to find paths to reach social
marketing success. Despite the inconsistency in theory around the effectiveness of
positive and negative appeals in social marketing, there are few studies about their
application in practice. Those that have been done reflect the predominance of negative
appeals, but consist on meta-analysis of the presence in the literature and do not explain
when and how of that prevalence (Hastings et al., 2004; Slavin et al., 2007).
The purpose of this thesis is to research the use of positive and negative appeals in
social marketing practices in order to get advances on the knowledge about the topic.
Marketing has societal responsibilities (Hill and Martin, 2014). Theories and practices
should consider peoples heterogeneity and contextual particularities and it is important
to research what marketing does in public policy and how it is done (Hill and Martin,
2014). That reasons that the research proposes to analyse the practice of management
decisions through the evidence about what are the most prevalent appeals used,
according to the direction of messages, when they are used and how they take form and
are used in different situations. This allows the discussion about whether positive and
negative appeals fit the conditions that interfere in the effectiveness of appeals
according to literature review: the target audiences, messages, the type of institutional
sources, the cultural and political context, as well as the health situation in terms of the
seriousness of the epidemic dynamics.
The literature has failed to address the appropriateness of social marketing policies to
their specific context, highlighted by several authors as an important challenge
(Andreasen, 2002; Grassly et al., 2001; Grier and Kumanyika, 2010; Hankins and
Zalduondo, 2010; Likatavicius and VandeLaar, 2012; Vega and Roland, 2005). The
analysis of the fit between previous evidences of effectiveness in theory and the
application of those recommendations into practice by framing the most effective
direction of appeal to each situation may help to resolve the theoretical inconsistencies
and give an understanding about where changes in the management of this matter
should be firstly and more intensively implemented if it is the case. Filling in these

lacks of knowledge in the state of art is essential, considering that theory is based on the
analysis of practice (Bourdieu, 1977; Bourdieu, 1990; Reckwitz, 2002).
Following the reported effectiveness of fear appeals in the literature, both in research
that focused on effectiveness and in meta-analysis of literature (Block and Keller, 1995;
Brennan and Binney, 2010; Cauberghe et al., 2009; Charry and Demoulin, 2012;
Cismaru and Lavack, 2007; Cismaru et al., 2008; Cismaru et al., 2009; Dillard and
Anderson, 2004; Gallopel-Morvan et al., 2009; Hastings et al., 2004; McKinley, 2009;
Vincent and Dubinsky, 2005) we would expect a high prevalence of negative appeals in
social marketing, which might alternate or be combined with positive appeals to avoid
saturation and fear control, fitting the dynamics of epidemics severity (Cooper et al.,
2014; Grassly et al., 2001; Ruiter et al., 2004).
The purpose of this research is to analyse what is the prevalence of positive and
negative appeals, when and how they take form and are differently applied.

1.4.

Structure of the Thesis by Papers

The thesis is structured in three papers. The chapter 2 presents the first paper, chapter
3 contains the second paper and chapter 4 shows the third paper. The content and
sequence of the three papers follow the scope and working process of the research. We
conclude the thesis with a last chapter that summarises the findings and contributions of
the studies, and presents the global overview of the research, discussing the theoretical
and managerial implications. Limitations and future research are suggested.
Chapter 1 gives the reader an introduction to the research problem. Theoretical
background is later examined in the literature review of the papers with a specific focus
on the purpose of each study. The three papers are interconnected, since the database
and methodology of analysis have a common origin. For that reason, there are similar
contents especially in the explanation of methods. For readers commodity, the thesis
presents transversal information about the methodological approach in chapter 1. The
papers were slightly adapted in order to avoid repetitions and concentrate on the specific
aspects connected with the purpose of those studies.

The thesis is organised in a sequential form in terms of pagination, numeration of

topics, tables and figures (by chapters). With the purpose of simplifying the reading
process, the mention to contents, tables or figures that appeared before in the thesis are
orientated to the previous reference, though being autonomous papers. Bibliographic
references are compiled at the end.
The first paper reflects the first phase of work after the literature review and data
collection: the coding of advertisements according to the country, year of broadcast,
institutional source, targeting audience and behaviour changes message provided. This
coding allowed the characterisation of the database with a content and descriptive
analysis of advertisements. The study discusses social marketing policies and their fit
with the countries profiles, as well as with the epidemic data. This empirical research
provided the discussion of propositions developed after the literature review about
social marketing policies. To identify the use of positive and negative appeals, we
developed the second paper proposing a content analysis model to classify social
advertisements, considering the proportion of positive and negative appeals. Then, in
the third paper we classify those advertisements as positive, negative or as an equal
combination of both appeals. We analyse that classification throughout the time and the
way the direction of appeals take form in the ads, discussing that use with the
characteristics of ads identified in the first paper - the type of messages, target
audiences, type of sources and contextual environment, such as the political, cultural
and epidemic profiles.
The research question of the thesis, regarding the use of positive and negative
emotional appeals in social marketing is split in three studies with particular purposes.
Table 1.1 compares the three papers systematizing their purpose, the scope,
methodological approach, process for publication and identifies their contribution to the
global research question of the thesis.

Process of
publication

Database and
Methods

Scope

Purpose

Paper

Table 1.1
Comparison of the Papers
Paper 1 - Social Marketing Policies for
Public Health and Epidemic Dynamics:
a study based on HIV/AIDS prevention
television advertisements in four
European countries
Characterise interventions over time
(number, messages, targets and type of
sources) and evaluate the fit with
situational context, such as the political,
socio-economic or cultural environment
and epidemic dynamics.
Empirical research and discussion of 6
propositions about health-related social
marketing as a public policy intervention
and the fit to situational needs (vulnerable
populations, prevention methods,
contextual profiles, reactive to epidemic
dynamics).
Database: 375 national HIV/AIDS
prevention television advertisements from
France, Germany, Portugal and Italy. Data
analysis: content analysis with
independent coders and PRL reliability
approach; descriptive and correlation
analysis.
Paper 1 is the result of the discussion of a
preliminary paper published in the
proceedings of the 2013 AMA Marketing
and Public Policy Conference and some
insights received after a poster
presentation in the 1st European Social
Marketing Conference.

Paper 2 - A Content Analysis Model

to Classify Social Advertisements
According to their Use of Positive and
Negative Appeals

Paper 3 - The Use of Positive Appeals in Social

Marketing: a research focused on television
advertising for preventing HIV/AIDS in four
European countries

Design a model for content analysis to

classify health promotion TV social ads
as positive, negative or a combination of
both appeals through their proportional
use in advertising components.

Analyse the use of positive and negative appeals in

social marketing in a longitudinal overview in order to
discuss what are their prevalence over time, how they
take form and are used in different situations.

Empirical research of the designed model

with contributions from independent
coders: story review, narrative, slogan,
rhetoric, music/tonality of voice, colours,
signs and characters.

Empirical research about what, when and how positive

and negative appeals are used: their form and their
application according to target audiences, behaviour
change messages, type of institutional sources, policy
and cultural profile in terms of uncertainty avoidance and
correlation with epidemic incidence rates.

Database: sample of 20 ads aleatory

extracted from the database of 375
national HIV/AIDS prevention television
advertisements from France, Germany,
Portugal and Italy. Data analysis: content
analysis with independent coders and
PRL reliability approach.
Paper 2 is the result of the discussion of a
short paper published in the Proceedings
of the 2013 International Conference on
Research in Advertising (ICORIA). A
modified version is published as a book
chapter in Advances in Advertising
Research (Vol. V).

Database: 375 national HIV/AIDS prevention television

advertisements from France, Germany, Portugal and
Italy. Data analysis: content analysis with independent
coders and PRL reliability approach; descriptive and
correlation analysis.

Source: authors.

Paper 3 is the result of a preliminary paper published in

the Proceedings of the 39th Annual Macromarketing
Conference and a short version published in the 2014
International Conference on Research in Advertising
(ICORIA). A part of the study was presented in 11th
International Colloquium on Non-profit, Arts, Heritage,
and Social Marketing, winning the Best Paper Award
provided by Journal of Social Marketing.

Global Contribution
The characterisation of
social marketing policies
in Paper 1 showed the
preponderance of social
marketing in the public
sector, with frequently
generalized interventions
or reactive responses.
With the contribution of
the content analysis
model presented in Paper
2, we could identify and
classify positive and
negative emotional
appeals in health
prevention TV ads in the
following study.
We concluded in Paper 3
that there is a longitudinal
and generalised
preponderance of positive
appeals, in opposition
with the expectations
inferred from the
literature. It suggests
sensitiveness of that use
with country profiles and
epidemic dynamics.

1.5.

Methodological Approach

The purpose of the research consists on the study of the use of positive and negative
emotional appeals in social marketing. Communication has been a very important
component within social marketing programmes and social advertising on television
one of the most used communication tools in the field (Abroms and Maibach, 2008;
Block and Keller, 1995; Griffin and O'Cass, 2004; Hastings and Haywood, 1991;
Mattson and Basu, 2010). In order to identify and characterise positive and negative
appeals, the researchers conducted content analysis of the social ads, which also
allowed the characterisation of target audiences and messages. Then, it was proceeded a
descriptive and correlation analysis to examine the use of appeals in a longitudinal
overview and the fit with target audiences, messages, type of sources, contextual
profiles and epidemic rates of the countries.
HIV/AIDS is a good example for research the defined purpose and has already been
used in other studies about social marketing appeals (Ho, 2000; Witte, 1991). Our study
is focused on social advertising preventing HIV/AIDS as case study. It is a health
priority since it represents a global problem, for which a wide number of social
marketing interventions have been developed by both public services and nongovernmental organisations (NGOs). It is also a communicable disease with an
established epidemic surveillance system (ECDC/WHO, 2012) and different means of
transmission, which require different behaviour change messages in different
intervention settings (Merson et al., 2008; Rimal et al., 2009). The topic has contextual
implications, asking for policy, socioeconomic and cultural appropriateness (Rimal et
al., 2009). The stereotypes created at the beginning of infection, proclaiming that HIV is
a disease of promiscuity people, led to individuals may not experience fear of
transmission that might prompt preventive messages acceptance (Campbell and
Babrow, 2004). On the other hand, scaring the already scared may accentuate the
existing stigma and discrimination towards the most vulnerable populations, such as
men who have sex with men, sex workers, or drug users, as well as people leaving with
HIV (Muthusamy et al., 2009). This fact may create trade-offs for social marketers
when deciding the strategy of positive and negative emotional appeals in prevention
messages.

10

This thesis focuses on television advertisements preventing HIV/AIDS. TV has been

a popular medium in promoting social change with manifest use and support in
HIV/AIDS prevention (Abroms and Maibach, 2008; Griffin and O'Cass, 2004; Hastings
et al., 1998; Lefebvre, 2011). Extensive numbers of TV social advertisements focusing
on HIV prevention have been produced worldwide, generally considered effective
(Mattson and Basu, 2010; Noar et al., 2009).

Data Collection and Database

Data collection was done on the internet, given that institutions have increasingly
digitalised their audio-visual archives, even the oldest ones, and share them online on
official websites, in social networks and online video sharing websites (Paek et al.,
2010; Spigel, 2009). The researchers collected national HIV/AIDS prevention television
advertisements broadcast in European Union (EU) countries since the infection was first
diagnosed in 1981 to the end of 2011. The data collection process occurred from the 1st
of January to the 30th of June 2012, after which saturation was reached in the search
process with the repeated occurrence of redundant findings (Bowen, 2008). The ads had
to be developed by governments and/or NGOs, because the social marketing concept is
intrinsically linked to the action of those organisations (Donovan, 2011; Hastings and
Angus, 2011). Data found focusing only on sexually transmitted infections (STIs) or
contraception were not included, unless they also mentioned HIV. Data collection was
done browsing institutional websites and Facebook profiles of governmental institutions
coordinating HIV/AIDS prevention and NGO members of Aids Action Europe in
each EU country. The researchers also searched for data in the video-sharing websites
Youtube, Vimeo, Dailymotion and Google Video and in the websites www.ina.fr,
www.culturepub.fr and www.coloribus.com. Table 1.2 systematises the internet
databases where data was collected.

11

Table 1.2
Sources for Data Collection
Browsing institutional websites and
Facebook profiles

video-sharing websites

Searching

online media archive

www.ina.fr1

online media archive

www.culturepub.fr1
online media archive
www.coloribus.com
Source: authors.

Governmental institutions coordinating HIV/AIDS

prevention in each EU country
NGOs members of Aids Action Europe in each EU
country
Youtube
Vimeo
Dailymotion
Google Videos
the website from the National Audiovisual Institute in
France that saves all the institutional communications
broadcasted on television in France
the website from a french television programme which
shows advertisements from around the world
website with an advertising archive from around the
world

The search terms in video sharing websites were HIV AIDS Prevention
advertisement in English followed by the name of each EU country, also in English.
After saturation (Bowen, 2008), the researchers translated the expression to each of the
twenty-three official European languages as shown in Table 1.3.
Table 1.3
Expressions used to search the video-sharing websites
Expression

Name of the Country

Austria; Belgium; Bulgaria; Cyprus; Czech Republic; Denmark;
HIV AIDS
1)
Estonia; Finland; France; Germany; Greece; Hungary; Ireland; Italy;
Prevention
+
Latvia; Lithuania; Luxemburg; Malta; Netherlands; Poland; Portugal;
advertisement
Romania; Slovakia; Slovenia; Spain; Sweden; United Kingdom.
Expression Translated to EU Languages
(Bulgarian); HIV AIDS reklama (Czech, Polish and Slovak); hiv-aids
annoncen (Danish); HIV AIDSi ennetamise reklaam (Estonian); HIV AIDS ehkisy mainos
(Finnish); Publicit de prvention du VIH aides (Spotswood et al.); HIV-AIDS-Prvention Werbung
(German); HIV AIDS (Greek); HIV-AIDS megelzs reklm (Hungarian);
2)
VEID a chosc fgra iseanna (Irish); HIV AIDS pubblicit (Italian); HIV AIDS profilakse reklma
(Latvian); IV ir AIDS prevencijos reklama (Lithuanian); HIV-AIDS prevenzjoni reklam (Maltese);
HIV-AIDS-preventie advertentie (Dutch); Anncio de Preveno VIH SIDA (Portuguese); HIV
SIDA publicitate (Romanian); HIV aidsa oglas (Slovene); Publicidad prevencin VIH SIDA
(Spanish); hiv aids annons (Swedish); HIV AIDS Prevention advertisement (English).
Source: authors.

The websites www.ina.fr and www.culturepub.fr emerged from the online research of data and may
explain the high prevalence of french advertisements in our database, though these kind of online media
archives were not found in other countries research.

12

As the video-sharing websites provide suggestions for other videos connected to the
search terms and/or also were seen by people who viewed the ones shown, we also
followed those suggestions, resulting in a richer data collection.
The research focuses on the analysis of social ads preventing HIV/AIDS in four
European countries. Out of a database of 539 television social advertisements on
HIV/AIDS prevention collected from 21 EU countries developed by governments
or/and NGOs between 1986 and 2011, we selected all the ads from four countries that
represented 69.6% of the database. The research was conducted with 375 national HIV
prevention advertisements broadcasted on TV. 146 are from France (38.9%), 115 from
Germany (30.7%), 76 from Portugal (20.3%) and 38 from Italy (10.1%).

13

14

Chapter 2
2. Social marketing policies for public health
and epidemic dynamics: a study based on
HIV/AIDS prevention television
advertisements in four European countries 2

An extended abstract of this paper, with the title "The relationship between social marketing policies on
Public Health and Epidemiological Situations: an exploratory research based on television advertisements
preventing HIV/AIDS in France, Germany, Portugal and Italy", is published in the proceedings of the
2013 AMA Marketing and Public Policy Conference, ISBN 0-87757-353-0. A part of this study was
showed in the poster The ambivalence between social marketing segmentation and targeting and the
avoidance of illness stigma: a research about the practice of HIV prevention in the European Union and
discussed in the poster session of the 1st. European Social Marketing Conference.

15

This paper examines health-related social marketing in order to identify its use and
evaluate its appropriateness to situational needs, such as epidemic dynamics and the
context where it is implemented. The paper also discusses the barriers that policymakers face in creating these linkages.
375 national HIV/AIDS prevention television advertisements from France, Germany,
Portugal and Italy were viewed and analysed over time of production, exploring the
sources, the target audiences and the messages delivered. The research compares
management choices with HIV epidemics in each country and their contextual profiles.
The findings indicate that social advertising is commonly framed within public
policies and does not usually target the most vulnerable and affected populations.
Furthermore, social ads are reactive to epidemic dynamics.
The paper suggests the adoption of proactive public policies. The existence of tradeoffs between putting forward theoretical marketing recommendations and taking
account of contextual fracturing issues or increasing stigma and discrimination are also
considered.
The study is useful for public sector management due to the importance of evaluating
the investments done in order to improve future strategies. The discussion about
restrictions and concerns for policy-makers is important to improve management
decisions.

Keywords:
Social Marketing; HIV/AIDS Prevention; Social Advertising

16

2.1. Introduction

The well-being of society is partially a consequence of the development of public

policies and of advocacy by non-governmental organisations (NGOs) that work towards
the achievement of the social good (Shultz et al., 2012). As is widely acknowledged,
public health policy has a profound impact on health status (Brownson et al., 2009),
since many health conditions are determined by behavioural choices (Frieden, 2010;
McGinnis et al., 2002; OECD, 2013a).
Several empirical studies have shown the effectiveness of health-related social
marketing (Evans, 2006; Evans and McCormack, 2008; Gordon et al., 2006; Stead et
al., 2007; Truong, 2014), although they have revealed some problems in terms of
evaluation design (Evans et al., 2009; Noar et al., 2009; Wymer, 2011). It is important
to fit social marketing policies to the specific context (Andreasen, 2002; Grassly et al.,
2001; Grier and Kumanyika, 2010; Hankins and Zalduondo, 2010; Likatavicius and
VandeLaar, 2012; Vega and Roland, 2005). Marketing and public policy research
should explore the links between the number of campaigns and the evolution of
illnesses, the appropriateness to the targets and the messages, as well as examine
whether their contents are suitably adapted to the policy, socioeconomic and cultural
profiles (Hill and Martin, 2014).
Social marketing is commonly used in the public and non-profit sector to encourage
behavioural change (Buurma, 2001; Shultz et al., 2012). In order to understand where
changes in the management of this matter should be firstly and more intensively
implemented, we question whether health-related social marketing is more often used
within public policies or NGO interventions or even in partnerships of both. Another
important question, whose answer is essential to improve social marketing in the future,
is whether action is taken reactively or proactively. The purpose of this study is to
research the appropriateness of social marketing to the epidemic dynamics and to
discuss possible barriers to the desirable fit between policies and societal needs.
The literature review provides an integrated conceptual background. The research
questions are translated into propositions where the researchers speculate findings of a
case study on the basis of theoretical review (Rowley, 2002). The researchers formulate
propositions for analysis and discussion of questions and systematise that approach of

17

propositions at the end of the background section: health-related social marketing is

more often used within public policy interventions; the number of actions tend to fit the
contours of epidemic dynamics; there is appropriateness both in terms of target and
message; suitability to the context where they are implemented.
In order to discuss the propositions, the authors analyse national governmental and
non-governmental HIV/AIDS prevention television advertisements broadcast in four
European Union (EU) countries France, Germany, Portugal and Italy since the
infection was first diagnosed in 1981 to the end of 2011. The research identifies and
analyses the production of those TV ads in each country over time, the type of sources,
the target audiences and the main messages delivered. The paper discusses the
management choices followed in relation to the HIV epidemics in each country and
their contextual profiles.
The analysis of consistency between social marketing policies and societal needs has
implications on the theory, based on the insights it provides on its appropriateness when
put into practice. Even interventions developed by NGOs are usually connected with
public policy commitments or investments and have a substantial impact on public
health (Buurma, 2001; Donovan, 2011; Shultz et al., 2012). The study is useful for
public sector management due to the importance of evaluating the investments done in
order to improve future strategies. We discuss contextual factors linked to policy
practices or target barriers, which may represent restrictions and concerns for policymakers.

2.2. Literature Review

2.2.1. Health-Related Social Marketing Interventions within Public Policies and

NGOs
Public policy governs the main determinants of health (Frieden, 2010; McGinnis et
al., 2002; OECD, 2013a). It influences socioeconomic factors, such as education,
poverty, employment, sanitary conditions, environment, medical care or social
cohesion, for example, and public policy actions have a direct effect on the health of
society (Frieden, 2010; McGinnis et al., 2002; OECD, 2013a). Moreover, policy-

18

makers have power to influence behavioural patterns: they inform and motivate people,
encourage health decisions, facilitating access to health or minimizing the efforts aimed
at behaviour change, and implement the policy incentives to encourage change, through
for example tax regulation, advertising restrictions or economic incentives to encourage
healthy habits (Frieden, 2010; McGinnis et al., 2002; OECD, 2013a).
Behaviour change is a challenge for public policy because of its importance in longterm effective and efficient interventions (Crawshaw, 2013; Rothschild, 1999). Healthrelated social marketing, by influencing lifestyles, has been an important tool in
improving the health of populations (Andreasen, 1994; Gordon et al., 2006; Grier and
Bryant, 2005; Hastings and Haywood, 1991; Rothschild, 2010; Truong, 2014). It has
impact in decreasing costs linked to health care (Rothschild, 1999), an important and
expanding expenditure issue in public policy (OECD, 2013a). Social marketing has
grown in importance in the 21st century and it is being increasingly adopted worldwide
(Andreasen, 2002; Andreasen, 2003). Social marketing was defined by Kotler and
Zaltman (1971) as a tool to change social ideas and behaviours, based on previous
reflections on the boundaries of marketing to solve social problems (Kotler and Levy,
1969; Wiebe, 1951). Social marketing focuses on behaviour change through the use of
marketing principles with the end goal of improving welfare and society (Andreasen,
1994; Andreasen, 2002; Andreasen, 2003). It is applied in the public sector and NGOs
(Donovan, 2011) and its recognition is connected to the growth of the non-profit sector
(Kong, 2008; Milbourne, 2009; Saxton and Bonson, 2005) and the rising concerns of
governments towards sustainability and the assurance of social welfare (Buurma, 2001),
in order to achieve political goals (Gruskin et al., 2007; Kaplan and Haenlein, 2009;
Raftopoulou and Hogg, 2010).
Social marketing has been widely discussed by public policy scholars and in the
literature (Andreasen, 1994; Andreasen, 2002; Andreasen, 2012; Brenkert, 2002; Griffin
and O'Cass, 2004; Kemp and Eagle, 2008). The United Nations (UN) also proclaimed
the leading role of governments in the development of social marketing programmes
(UNO, 2001). Although there are valuable collaborations between public and non-profit
organisations (Surez, 2011), the third sector emerged late as a stakeholder in the policy
process (Kendall and Anheier, 1999). Public institutions have higher budgets for social
marketing activities whereas funding of the third sector usually depends on

19

governments and policy patterns (Froelich, 1999; Kendall and Anheier, 1999). This fact
may prevent NGOs from developing activities targeting behaviour change, especially
those which require more financial expenditure, such as TV advertising, for example.
The identification of the main sources of social marketing interventions is important
to characterise the activities in the topic and plan where the required changes should be
made firstly and more intensively.
Proposition 2.1 (P2.1) Health-related social marketing is predominantly developed
within public policy interventions rather than by non-governmental organisations.

2.2.2. Social Marketing Effectiveness

Evaluation is an important step in policy planning, distinguishing worthy
interventions based on measures of the outcomes reached and the rates of policy effort
(King et al., 2007; Weiss, 1999). Like in policy programmes, evaluation is also essential
in social marketing as in any marketing plan (Grier and Bryant, 2005; Silva and Silva,
2012; Wymer, 2011). The World Health Organisation (WHO) and UNAIDS, for
example, created API (AIDS Programme Effort Index) to evaluate the existence of a
HIV/AIDS prevention policy, its characteristics and the contribution of efforts to the
programmes success in a variety of social and cultural settings (Merson et al., 2008;
USAID et al., 2003). API shows the importance of prevention efforts in epidemic
outcomes, revealing that HIV prevention efforts are related with epidemic rates (Merson
et al.). This index was conducted in 54 countries and highlights that the nations with the
highest HIV/AIDS prevalence rates have, on average, lower API scores than those with
relatively low prevalence rates (USAID et al., 2003).
Studies with systematic reviews evaluate social marketing as effective in public
health (Evans, 2006; Gordon et al., 2006; Stead et al., 2007). There is evidence that
health interventions adopting social marketing principles have been increasingly used
(Andreasen, 2003; Grier and Bryant, 2005; Helmig and Thaler, 2010; Walsh et al.,
1993) because of their potential to change behaviour (Lefebvre and Flora, 1988; Morris
and Clarkson, 2009). After the first description of a social marketing activity in 1960s
with a family planning campaign in India (Dholakia, 1984), it has been used in
reproductive health as a whole, with enthusiastic results in raising awareness of sexual
risks, knowledge of contraceptive methods and in the increasing use of oral

20

contraception or condoms for birth control (Meekers, 2000; Rossem and Meekers,
2000). Social marketing has been effective in HIV/AIDS prevention, with reports of
changes in HIV-related knowledge, attitudes and behaviours, although interventions are
few and far between (Bertrand et al., 2006; Kennedy et al., 2000; Merson et al., 2008;
Noar et al., 2009; Svenkerud and Singhal, 1998). Social marketing has also been
effective in reducing the transmission of infections, improving hand hygiene practices
in health-care providers (Mah et al., 2006) or in reducing the uptake of smoking by
young people (Devlin et al., 2007; Evans and McCormack, 2008; Gordon et al., 2006;
Stead et al., 2007). The literature also identifies effectiveness in lowering incidences of
alcohol or illicit drug consumption, in higher levels of healthy nutrition and sports
activity (Gordon et al., 2006; Stead et al., 2007), and in increasing early case detection
and treatment of leprosy (Wong, 2002).
Studies on social marketing effectiveness aim to evaluate if programmes achieve
their intended purpose, comparing data before and after the interventions. Data are
usually obtained from interviews and surveys, measuring the changes in knowledge,
attitudes and behaviours, and by examining the results in epidemic reports (Bertrand et
al., 2006; Gordon et al., 2006; Grier and Bryant, 2005; Stead et al., 2007). However,
social marketing programmes have weak evaluation designs and flaws in planning
(Gordon et al., 2006; Grier and Bryant, 2005; Noar et al., 2009). Most interventions that
are considered effective could potentially be more effective and efficient than they are
(Evans et al., 2009; Wymer, 2011).

2.2.3. Challenges and Barriers for Effective Health Social Marketing Programmes
To be effective, social marketing should follow the steps of a marketing plan:
purpose, situational analysis, target profile, positioning, marketing-mix and plan
evaluation (Noar et al., 2009; Silva and Silva, 2012). Social marketing should benefit
from segmentation strategies to target the priority populations appropriately as stated in
the theoretical bases of social marketing (Albrecht, 1996; Andreasen, 2002; Bloom and
Novelli, 1981; Fine, 1980; Grier and Bryant, 2005; Grier and Kumanyika, 2010; Walsh
et al., 1993). Reactions to the promotion of behaviour change vary across different
target groups (Forthofer and Bryant, 2000). As policy makers should consider peoples
heterogeneity (Hill and Martin, 2014), social marketers also should divide populations

21

on the basis of their characteristics (Grier and Bryant, 2005; Grier and Kumanyika,
2010). It is also important to look at the contextual factors of the audiences because
standard packages of prevention do not work universally (Andreasen, 2002; Hankins
and Zalduondo, 2010; Vega and Roland, 2005). This appropriateness determines the
measurable impact for epidemic outcomes (Grassly et al., 2001; Likatavicius and
VandeLaar, 2012).
Literature on HIV/AIDS prevention social marketing, for example, shows there is
increasing research on target audiences and tend to follow theoretical guidelines to
design effective social marketing programmes (Noar et al., 2009). A systematic review
of studies on mass media campaigns for HIV prevention between 1998 and 2007
reported that 94% had a specific target audience, while a previous study on campaigns
developed between 1986 and 1998 reported that 59% of those studies were targeted at
the general population (Noar et al., 2009). The literature lacks information on whether
the campaigns segmentation was adjusted to the epidemiological situations or the
context where they were applied.
Proposition 2.2 (P2.2) The number of health-related social marketing interventions
fits with epidemic rates evolution.
Proposition 2.3 (P2.3) The identified targets are appropriate for the affected
populations.
Proposition 2.4 (P2.4) The identified messages are appropriate for the health
prevention methods.
Proposition 2.5 (P2.5) Health-related social marketing fits the policy,
socioeconomic and cultural context.

A marketing strategy may respond to societal needs, but in a reactive manner.

Marketing theory states that managers may have a reactive or a proactive marketing
orientation (Jaworski and Kohli, 1993). In proactive marketing, instead of looking only
at current customers as is the case of reactive marketing, firms develop also an
exploratory learning of new market opportunities, observing actual behaviours to
discover future needs and making adjustments (Jaworski and Kohli, 1993). Social
marketers should develop a proactive marketing orientation, looking at the epidemic
trends and developing proactive prevention policies (Jones and Iverson, 2012;

22

Likatavicius and VandeLaar, 2012). Proactive social marketing interventions have been
crucial during the outbreaks of bird flu or swine flu, for example, promptly
communicating the preventive and medical recommendations to the population, which
may ultimately have adverted their potential of becoming a pandemic influenza (Jones
and Iverson, 2012).
The epidemic information on communicable diseases is provided by the UN, WHO,
Centre for Disease Control (CDC) and European Centre for Disease Control (ECDC).
These reports focus on public health surveillances and present only short discussions on
future trends and challenges. The fact that several social marketers and policy-makers
have only borderline knowledge of epidemic trends or audience research (Grier and
Bryant, 2005; Wymer, 2011) suggests the following research proposition. An
understanding of a reactive marketing orientation constitutes a step in designing
proactive strategies in the future.
Proposition 2.6 (P2.6) - Health-related social marketing is reactive to epidemic
dynamics.

Figure 2.1 systematises the research questions and this papers propositions.
Figure 2.1
Propositions of the study
Health-Related Social Marketing as a Public Policy Intervention
P 2.1 - Health-related social marketing is predominantly developed within public policy
interventions rather than by non-governmental organizations.
The Fit of Health-Related Social Marketing to Situational Needs
P 2.2 - Health-related social marketing responds to epidemic rates evolution
P 2.3 - The identified targets are appropriate for the affected populations.
P 2.4 - The identified messages are appropriate for the health prevention methods.
P 2.5 - Health-related social marketing fits the policy, socioeconomic and cultural context.
P 2.6 - Health-related social marketing is reactive to epidemic dynamics.
Source: authors.

23

2.3. Research Methods

The literature review explained above and the propositions formulated lead the
researchers to examine the appropriateness of health-related social marketing policies to
the epidemics and context of the targeting interventions. The study is focused on
HIV/AIDS, a health priority that represents a global problem in public policy
(UNAIDS, 2012b; UNO, 2001; UNO, 2011), for which a wide number of social
marketing interventions have been developed by both public services and NGOs, and
which also faces problems of stigma and discrimination in society (Castro et al., 2010;
Gruskin et al., 2007; Lefebvre, 2011; Merson et al., 2008; Uhrig et al., 2010).
HIV/AIDS prevention, besides being a good example for case study as already
explained, has also a big impact in public policy and represents high levels of
expenditure.
HIV infection was first diagnosed in 1981 in the United States of America (USA)
and AIDS has been a major cause of death due to a cure or vaccine has yet to be
discovered and because of problems with therapy adherence (Merson et al., 2008).
Initially a death sentence because it was marked by a starting period with a huge
number of deaths, AIDS became a chronic disease in 1996 with the discovery of antiretroviral treatments (Merson et al., 2008). People living with HIV suffer from stigma
and discrimination because behaviours associated with infection transmission are
related to sexual conduct or the use of injected drugs (Castro et al., 2010; Gruskin et al.,
2007; Merson et al., 2008; Uhrig et al., 2010). The first worldwide public-health
strategy to engage with human rights was motivated by the discrimination towards
people living with HIV (Gruskin et al., 2007). That stigma still persists nowadays
despite science realising that HIV infection is a global epidemic that can be transmitted
by basic unprotected behaviours of any human-beings (Merson et al., 2008).
Nevertheless, people has been away from prevention programmes because of the lack of
the conscious of self-vulnerability (Gruskin et al., 2007). Fighting HIV/AIDS infection,
including fighting against HIV discrimination, is a public policy challenge worldwide
and one of the UNs millennium goals (UNAIDS, 2012b; UNO, 2001). It is also a major
concern for social marketers, including campaigns against stigma and discrimination

24

(Lefebvre, 2011). A recent political resolution declared that efforts will be intensified to
eradicate the infection (UNO, 2011).

2.3.1. Data Collection

The researchers collected national HIV/AIDS prevention social ads broadcasted on
TV in Europe since the infection was first diagnosed, in 1981, to the end of 2011. Use
of mass media, as television, also implies examining segmentation needs and the
potential consequences of stigma and discrimination in consequence of the targeting
strategy (Grier and Brumbaugh, 1999; Newton et al., 2013).
Data collection was done on the internet. The internet was the most accessible and
convenient tool to collect data and we were highly successful in this task for France,
Germany, Portugal and Italy. We also found that institutions and countries have
different habits of sharing social marketing ads online. There was the risk that this
methodology could have yielded mainly recent data, but after contacting institutions in
the four countries, it became clear that the database could confidently be considered
reliable, showing that the internet is an appropriate tool to conduct a longitudinal
collection of television HIV/AIDS prevention advertisements.
We searched for data during six months in the sources referred in Table 1.2 (see
p.12). The search expressions employed on video sharing websites were HIV AIDS
Prevention advertisement in English followed by the name of each EU country, also in
English and then translated into each of the twenty-three European official languages, as
shown in Table 1.3 (see p.12). Suggestions provided by video-sharing websites were
also considered.

2.3.2. The Database

We collected 539 HIV prevention TV ads from EU countries, excepting Croatia
which was not a member at the time of the data collection. We selected all the ads
collected from four countries whose data was well distributed over the period of
analysis and represented 69.6% of the database. The other data showed low numbers of
advertisements by country. Seven countries had less than 25 ads, mostly concentrated in
a specific time period, and ten countries had less than ten ads, which would also not
provide a longitudinal perspective. We selected 375 national HIV prevention

25

advertisements from four European countries as case studies. 146 are from France
(38.9%), 115 from Germany (30.7%), 76 from Portugal (20.3%) and 38 from Italy
(10.1%).
This is not a cross-country study, but although the four countries selected are all from
the western part of Europe, and long-time members of the EU, they are politically,
socioeconomically and culturally diverse. This strengthened the scope of our study
because culture plays an important role in health communication both in message
effectiveness and in the expectations of message design (Airhihenbuwa and Obregon,
2000; Kreuter and McClure, 2004; Reardon et al., 2006). Despite the commitment of
member states to exchange information and strengthen cooperation within the European
Commission in order to develop homogeneous policies regarding health prevention
(EU, 2009), there are still inequalities in national AIDS leaderships and in HIV
epidemics in Europe (EU, 2009).

2.3.3. Data Analysis

Before the analysis, the narratives of the social advertisements were translated from
the original languages to English. This task was performed by native speakers in some
cases and, in other cases, by translation professionals with extensive knowledge of the
culture and environment of the countries, having had the experience of living there.
Besides the translations, they were asked to point out contextual aspects of the
advertisements, such as national celebrities, use of famous songs, national symbols or
metaphors.

Content Analysis

The narratives in English were transcribed into the NVIVO software. The content
analysis, performed by this papers first author, involved describing the characters,
music, colours, non-verbal symbols and the story review of each advertisement. These
notes were recorded in NVIVO and served as a basis for the coding process.
The coding categories were built based on the literature review pinpointing the most
frequent messages and target audiences in HIV prevention advertisements (Noar et al.,
2009), which are congruent with the knowledge of the most commonly-known means of
HIV transmission (Merson et al., 2008). The literature identifies as frequent criteria for

26

audience segmentation in HIV prevention campaigns gender, race, sexual orientation,

age, geographic region, sensation-seeking and impulsivity (Noar et al., 2009). The most
prevalent prevention messages are the promotion of HIV testing, condom use and
general slogans about AIDS awareness without direct references to behavioural change
(Noar et al., 2009). Data coding also led to the creation of categories that had not been
considered previously, in an effort to find new outcomes in the data. Each ad was coded
in the NVIVO software considering 7 categories for behaviour change messages and 9
categories for target audiences. To code the target audiences, the characters, narratives
and slogans were examined. Special symbols and music also resolved any coding
doubts, especially in the case of young people. As Table 2.1 shows, data were also
coded according to the country, year of broadcast and the source, information frequently
subtitled in the sourced websites or in the last pack shot of the ads. When not available,
especially the years, we looked for information on the official websites and reports from
the supporting institutions.

Behaviour Change Message

Condom use
Incentive to do the test

Target Audiences
Source
Country
General Population (GP)
Adolescents (Adolesc.)
Governmental
Men who have sex with men
Anti-discrimination
(MSM)
vs.
France
General awareness of HIV
Injection Drug Users (IDU)
Germany
Treatment adherence
Sex Workers (SW)
NGO
Portugal
Discourage needle sharing
Women (W)
Italy
vs.
Ask for information / helplines
Men (M)
Migrants (Mig.)
Partnership
People Living with HIV
(PLWHIV)
General Population (GP) = ads whose target is generalized and not included in the other specified
populations;
Adolescents (Adolesc.) = young people between 13-19 years old;
Women (W) = ads directly targeting female gender;
Men (M) = ads directly targeting male gender
Migrants (Mig.) = people from other countries, races or whose job requires regular migrations.
Source: authors.

Year of Broadcast

Table 2.1
Coding categories

After the first author completed the coding, three independent coders were asked to
validate the procedure, in order to avoid imprecise and subjective judgments
(Kassarjian, 1977; Perreault and Leigh, 1989). A consensus among the coders does not

27

guarantee correct judgment, but if they tend to agree there is more confidence and
reliability (Rust and Cooil, 1994). The independent coders did not have academic or
professional experience in HIV prevention in order to simulate the reception of
messages by the general population. Briefings were conducted with the independent
coders in individual meetings. After a verbal explanation of the task, the coders received
a text describing the concept of social marketing and the contours of the task. Initial
doubts were resolved and they were trained with some examples. Then, the independent
coders were asked to watch a random sample of 20 social advertisements and classify
the behaviour change message and target audience of those advertisements into the
categories described in Table 2.1 in order to validate the researchers coding. The
sample represented 5.3% of the 375 total ads. When disagreements were identified, the
sample was recoded and a similar coding error principle was applied to the remaining
data. The random sample of 20 advertisements was created on this basis: 1) for each of
the four countries the data was divided into five groups - 1987 to 1991, 1992 to 1996,
1997 to 2001, 2002 to 2006, and 2007 to 2011; 2) from each group and country the third
ad in the NVIVO software was selected, ordered alphabetically by code
(Country_Year_Source_N).
After collecting the independent coders opinions and comparing the results, most of
the (few) discrepancies found were resolved through individual discussion between the
coders and the researcher who performed the coding, which resulted in a better
definition of the coding rules. In a few cases, discrepancies were maintained after
profound discussions on recoding, where the predominant judgment prevailed.
The Proportional Reduction in Loss (PRL) approach was used to calculate intercoder
reliability of the behaviour change messages and target audiences, an appropriate
measure for qualitative judgment data (Rust and Cooil, 1994). With four judges three
independent coders and one of the researchers the number of pair agreements between
the six pairs of judges was calculated. Figure 2.2 briefly describes the process of data
analysis and shows the percentage of pair agreements for each coding category out of
the possible agreements.

28

Figure 2.2
Process of data analysis and PRL reliability for target and message coding

Data translation to English and Transcriptions to NVivo

First Author's Coding
(Country; Year; Source; Message and Target)
Selection of a sample of 20 ads
Independent Coders - Validation of the coding of message and target
in the sample with external judges by PRL reliability

Intercoder Agreements
Total Intercoder Agreements Possible
Proportion of Intercoder Agreement (A)
PRL Reliability for 5 categories and 4 judges (Rust and Cooil, 1994)

Target
101
120
0.84
0.99

Message
117
120
0.975
100

Resolution of disagreement principles

Recoding
Comparison of results by country with epidemiological and contextual descriptions
Source: authors.

The results assign a PRL reliability of 0.99 to target audience and 100 to behaviour
message. This indicates there is significant agreement among the coders, considering
the Nunnally rule that recommends a minimum 0.70 PRL level to sustain intercoder
reliability (Rust and Cooil, 1994). This means that we can be fairly confident in our
judges classifications as well as in the defined categories (Kassarjian, 1977).

Correlation Analysis

To complement the content analysis, we conducted a correlation analysis in order to

explore the fit between social marketing policies and epidemics collected in the official
epidemic reports (ECDC/WHO, 2010; ECDC/WHO, 2012). SPSS software was used to
calculate the correlations between the number of ads in each country over time by target
and message and HIV incidence rates and cases by means of transmission. We also
correlated the number of ads in each country with indicators that could represent the
socio-economic and public policy levels. We used Gross Domestic Product per capita
(GDP) and Public Expenditure on Health (PEH) - available in official statistic
documents (OECD, 2013b) as indicators to correlate. These correlations are limited to

29

the years with official data reported, and only the ads from those periods were selected
for this task.

2.4. Discussion

2.4.1. Social Marketing as a Public Policy Intervention

The practice of social marketing by NGOs has been considerable and consistent over
time (Andreasen, 2003; Donovan, 2011). However, the majority of advertisements
analysed in this study were developed by governmental institutions. Table 2.2 shows the
distribution of the advertisements under study according to the type of sponsor.

Table 2.2
Types of Announcers of HIV prevention TV ADS
Number
of
Ads (%)
146
France
(38.9%)
115
Germany
(30.7%)
76
Portugal
(20.3%)
38
Italy
(10.1%)
TOTAL
375
(100%)
Source: authors.
Country

Number of
Governmental
Ads (%)
102
(69.9%)
66
(57.4%)
56
(73.7%)
21
(55.3%)
245
(65.3%)

Number of
NGO Ads (%)
42
(28.8%)
42
(36.5%)
18
(23.7%)
17
(44.7%)
119
(31.7%)

Number of
GOV+NGO
Ads (%)
2
(1.4%)
7
(6.1%)
2
(2.6%)
0
(0.0%)
11
(2.9%)

Total
100%
100%
100%
100%
100%

The number of partnerships between public institutions and NGOs is residual and
response to the advertisements from civil society began later, remaining lower than the
public sector. Considering our database, the four countries governments produced the
first HIV prevention social ads in the 1987-1991 period, while the first HIV prevention
TV advertisement by a NGO dates from 2004 in Germany, 1997 in Italy, 1994 in
France, and 1992 in Portugal. These results follow the idea of P2.1 (Health-related
social marketing is predominantly developed within public policy interventions rather
than by non-governmental organisations), highlighting the importance of social
marketing in public policy and that a management change regarding this aspect should

30

be implemented in government interventions. We can link this result to the

proclamation by UNAIDS in 2003 of the Three Ones key principle, advising
countries to develop one policy leadership with a national AIDS coordinating authority;
one action plan; and one monitoring and evaluation system (UNAIDS, 2004).

2.4.2. Longitudinal Appropriateness of Health-Related Social Marketing to

Epidemic Profiles
Although the research focused on the three decades of HIV history, 50.1% of the 375
advertisements under analysis were broadcast in the last decade, much more than the
36.5% in the second decade and 13.3% in the first decade. There are no data for
HIV/AIDS prevention advertisements before 1987 in the four countries, when the first
cases were still being reported and the means of transmission were being studied.
Figure 2.3 shows the time distribution of HIV prevention advertisements broadcast in
France, Germany, Portugal and Italy by periods of five years.
Figure 2.3
Distribution of advertisements collected from France, Germany, Portugal and Italy by
periods of five years
70

64

Advertisements (n)

60
50
40
40
30

France

31

28

28

27

Germany

23
19 18

20

18 16

12

12
8

10

Portugal
Italy

0
1987-1991

13.3%

1992-1996

18.1%

1997-2001
Time Period
18.4%

Source: authors.

31

2002-2006

16.8%

2007-2011

33.3%

TOTAL=100%

Portugal has the highest rates of newly diagnosed HIV infection among the four
countries, although the rates are decreasing. In France, the epidemic remains stable with
a significant decrease in 2011, which requires careful analysis because of reporting
delay. Germany has the lowest HIV incidence rates, much lower than the EU average.
Table 2.3 shows the evolution of HIV incidence rates in France, Germany, Portugal and
Italy since 2000 - the first year with officially reported data - until 2011.

Table 2.3
Newly diagnosed HIV infections in France, Germany, Italy, Portugal and EU - rates per
100.000 population by year of diagnosis

Incidence Rate by Year of Diagnosis (rate per 100.000 population by country and year of
diagnosis - 2001-2010)
Country
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
France
8.2
9.2
9.5
9.0
8.9
9.0
8.4
8.5
6.3
Germany
2.1
1.8
2.1
2.4
2.7
3.0
3.2
3.4
3.5
3.5
3.6
3.5
Italy
8.7
7.7
7.5
6.3
5.5
4.8
6.3
5.8
Portugal
27.6 22.6 21.2 19.5
19
17.4 17.9 17.4 17.8 15.6 13.6
8.5
EU/EEA
4.7
5.5
5.8
6.6
6.5
6.5
6.4
6.5
6.6
6.1
6.3
5.7
EU/EEA = European Union / European Economic Area.
Source: authors, with data from HIV/AIDS surveillance in Europe 2011 (ECDC/WHO, 2012) and
HIV/AIDS surveillance in Europe 2009 (ECDC/WHO, 2010).

In Germany, where HIV incidence rates are relatively low but have nevertheless been
increasing since 2001, we find a relatively high number of HIV social ads. Table 2.4,
contains the correlation coefficients between the number of ads developed in each
country and the corresponding HIV incidence rates for the available time periods. It
shows that there is a moderate positive correlation in Germany. This indicates that
social marketers from this country responded to the increasing incidence of HIV with
the development of TV social advertisements, what is according to P2.2: Healthrelated social marketing responds to epidemic dynamics.

32

Table 2.4
Correlation Coefficients between the Number of Ads Developed by Country, Target
Audience and HIV Incidence Rates
No. Ads and
Incidence Rate

No. Ads Targeting

General Population and
Incidence Rates

-0.5
0.4
-0.7
-0.6

No. Ads Targeting

Adolescents and
Incidence Rate

0.3
0.7
-

Country
Period

France
2003-2011
0.1
Germany
2000-2011
0.5
Italy
2005-2011
-0.6
Portugal
2000-2011
-0.4
= Correlation Coefficient
Source: authors, with data from HIV/AIDS surveillance in Europe 2011 (ECDC/WHO, 2012) and
HIV/AIDS surveillance in Europe 2009 (ECDC/WHO, 2010).

This result refers to advertising on television, but it contradicts the API findings that
sustain there is a negative correlation between HIV prevention efforts and epidemics
(Merson et al., 2008; USAID et al., 2003). In Germany, the increasing incidence trend
has not changed yet with the high number of advertisements because 55.7% of the total
German HIV prevention ads collected were developed between 2007 and 2011,
suggesting a reactive prevention policy that is coincident with P2.6: Health-related
social marketing is reactive to epidemic dynamics. Portuguese and Italian data also
agrees with P2.2 and P2.6, but in a different way. In Portugal and Italy, we find
moderate negative correlations. The increased number of ads after 2006 in Portugal and
after 2009 in Italy may be a contribution to the decreasing incidence rates. It also
indicates a late response to the profile of these two countries that had the highest rates
of AIDS (the last phase of infection) in the European region at the beginning of the 21st
century and high HIV incidence rates, especially Portugal (ECDC/WHO, 2010;
ECDC/WHO, 2012). Over the entire longitudinal period under analysis, France has the
highest number of HIV prevention TV ads collected (146) but it is not the country with
highest incidence rates. It

should be noted that 79 advertisements (54.1%) were

produced before 2002, suggesting an appropriate prevention policy considering that

France ranked fourth in Europe in terms of reported AIDS cases until 2002
(ECDC/WHO, 2010), a fact that indicates the incidence rates were high in the 1990s. In
brief, the results are framed on P2.2 regarding the adequacy of the number of TV ads in
response to trends in epidemic incidence rates, but that adequacy tends to be reactive, in
accordance with P2.6.

33

2.4.3. Appropriateness of Targeting Policies and Behaviour Change Messages

Theory states that even television advertisements have to segment their messages,
because of the importance of adequacy to the markets, both in commercial and social
marketing (Fine, 1980). Table 2.5 shows that HIV/AIDS prevention advertisements on
TV collected from France, Germany, Portugal and Italy essentially target the general
population and adolescents.

Table 2.5
Targets of the HIV Prevention TV Ads by Country
Country
France
Germany
Portugal
Italy
TOTAL

No. Ads

GP

Adolesc.

MSM

IDU

SW

Mig.

146
(38.9%)
115
(30.7%)
76
(20.3%)
38
(10.1%)
375
(100%)

88
(60.3%)
85
(73.9%)
51
(67.1%)
28
(73.7%)
252
(67.2%)

34
(23.3%)
22
(19.1%)
14
(18.4%)
5
(13.2%)
75
(20.0%)

9
(6.2%)
5
(4.3%)
2
(2.6%)
2
(5.3%)
18
(4.8%)

0
(0.0%)
0
(0.0%)
1
(1.3%)
2
(5.3%)
3
(0.8%)

0
(0.0%)
0
(0.0%)
2
(2.6%)
0
(0.0%)
2
(0.5%)

10
(6.8%)
2
(1.7%)
5
(6.6%)
0
(0.0%)
17
(4.5%)

1
(0.7%)
0
(0.0%)
0
(0.0%)
0
(0.0%)
1
(0.3%)

2
(1.4%)
0
(0.0%)
1
(1.3%)
0
(0.0%)
3
(08%)

PLW
HIV
2
(1.4%)
1
(0.9%)
0
(0.0%)
1
(2.6%)
4
(1.1%)

Source: authors.

Table 2.6 shows the frequency of messages found by country.

Table 2.6
Messages of the HIV Prevention TV Ads by Country
Country

No. Ads

Condom
Use

Do the
Test

AntiDiscrimin.

France

146
(38.9%)
115
(30.7%)
76
(20.3%)
38
(10.1%)
375
(100%)

92
(63.0%)
83
(72.2%)
34
(44.7%)
12
(31.6)
221
(58.9%)

9
(6.2%)
1
(0.9%)
9
(11.8%)
3
(7.9%)
22
(5.9%)

24
(16.4%)
3
(2.6%)
19
(25.0%)
2
(5.3%)
48
(12.8%)

Germany
Portugal
Italy
TOTAL

Stop
/Avoid
AIDS
11
(7.5%)
27
(23.5%)
13
(17.1%)
16
(42.1%)
67
(17.9%)

Treatment
Adherence
1
(0.7%)
0
(0.0%)
0
(0.0%)
1
(2.6%)
2
(0.5%)

Discourage
needle
sharing
0
(0.0%)
0
(0.0%)
1
(1.3%)
2
(5.3%)
3
(0.8%)

Ask for
Information
/ Helpline
9
(6.2%)
1
(0.9%)
0
(0.0%)
2
(5.3%)
12
(3.2%)

Source: authors.

Social advertisements tend not to fit the epidemic needs in terms of target audience
(contrary to P2.3) but do use suitable messages (according with P2.4), except if they
potentially represent conflicts regarding the associated context or stigma.

34

Germany has recorded an increase in incidence rate between 2000 and 2011
(ECDC/WHO, 2010; ECDC/WHO, 2012; Likatavicius and VandeLaar, 2012) and
MSM transmission is responsible for that growth. Germany is the only country under
analysis where heterosexual intercourse is not the most prevalent means of HIV
transmission. When we compare these statistics proportionally with the countries total
population, we understand that the epidemics studied are concentrated in specific
groups of people with risky behaviours, as stated in the official reports (ECDC/WHO,
2012; Likatavicius and VandeLaar, 2012; UNAIDS, 2012b). MSM transmission has
also increased in Portugal, France and Italy since 2004, which highlights that the
prevention of HIV among MSM is the cornerstone of the infection response, because
interventions to control the HIV epidemic need to be adapted to the national
epidemiological situations (Rimal et al., 2009). Figure 2.4 illustrates the evolution of
newly diagnosed HIV infections by means of transmission.
The decreasing incidence rates and the expressive number of ads targeting the
general public have a moderate negative correlation in Portugal and France and a strong
negative correlation in Italy. In Germany, we find positive correlations between the
increasing incidence rates and ads targeting the general population and adolescents.
66.1% of the German ads were developed in the period 2002-2011 but they did not
result in an effective intervention to reverse the increasing trend of infection. HIV
transmission in this country is mainly between men in sexual relationships and MSMtargeted advertisements only represent 4.3% of the total German HIV/AIDS prevention
ads, all of them broadcast after 2007. This shows the inadequacy of the target audience
to the epidemic profile. We find similar results in other countries with increasing MSM
cases since 2004, such as Portugal and Italy, where HIV prevention TV ads targeting
MSMs only started in 2010. In contrast, French public HIV prevention ads on TV have
targeted MSMs since 1991.

35

Figure 2.4
HIV Infections Incidence Rates in France, Germany, Portugal and Italy by Means of
Transmission (2004-2011)

Number of Newly
Diagnosed HIV Infecctions

NEWLY DIAGNOSED HIV INFECTIONS IN FRANCE BY MEANS OF

TRANSMISSION AND YEAR OF DIAGNOSIS (2004-2011)
3000
2500
2000
1500
1000
500
0

Heterosexual
MSM

2004

2005

2006

2007

2008

2009

IDU
Mother-to-Child
2010
2011

NEWLY DIAGNOSED HIV INFECTIONS IN GERMANY BY MEANS OF

TRANSMISSION AND YEAR OF DIAGNOSIS (2004-2011)
Number of Newly
Diagnosed HIV Infections

2000
MSM

1500
1000

Heterossexual

500
0
2004

2005

2006

2007

2008

2009

IDU
Mother-to-child
2010
2011

Number of Newly
Diagnosed HIV Infections

NEWLY DIAGNOSED HIV INFECTIONS IN ITALY BY MEANS OF

TRANSMISSION AND YEAR OF DIAGNOSIS (2004-2011)
2000

Heterossexual

1500
MSM

1000
500

IDU
Mother-to-child

0
2004

2005

2006

2007

2008

2009

2010

2011

Number of Newly
Diagnosed HIV Infections

NEWLY DIAGNOSED HIV INFECTIONS IN PORTUGAL BY MEANS OF

TRANSMISSION AND YEAR OF DIAGNOSIS (2004-2011)
1500
1000
Heterossexual

500
0
2004

2005

2006

2007

2008

2009

MSM
IDU
Mother-to-child
2010
2011

Source: authors, with data from HIV/AIDS surveillance in Europe 2011 (ECDC/WHO, 2012).

36

We also note that P2.3 does not occur because Portugal neglected to target IDU
when this country was leading the number of HIV cases by this means of transmission
in Europe between 2004 and 2008 (ECDC/WHO, 2012; Likatavicius and VandeLaar,
2012). Furthermore, France and Portugal have developed several campaigns targeting
women while the infection is concentrated in men, and mother-to-child transmission is
residual (ECDC/WHO, 2012; Likatavicius and VandeLaar, 2012). The lack of ads
targeting players in the sex industry, a sector with a prevalence of high-risk behaviour
(Merson et al., 2008), is also curious.
Except for Italy, the use of condoms is the most prevalent message. This is because
sexual intercourse is the main means of transmission. In Italy, there are more
advertisements with general warnings about AIDS and appeals to stop/avoid infection,
without specifying an explicit behaviour that requires change. This is revealing of an
awareness policy rather than a behaviour change positioning. This fact is not
circumscribed to the first two decades of infection as recognised by the literature (Noar
et al., 2009) and may be related to possible concern with regard to mentioning
fracturing issues in the context of the countries. Portugal and France have a significant
number of ads with anti-discrimination messages. This may be a result of their having a
higher prevalence rate compared to Germany and Italy (UNAIDS, 2012b). These
findings may indicate that social marketers are concerned with HIV stigma and
discrimination.

2.4.4. Adequacy to the Environment

With the economic crisis in Europe, Mediterranean countries, such as Portugal and
Italy, are suffering from excessive public debt and face high disparity in relation to
countries from north and central Europe. In order to characterise social-economic
profiles of the countries, that could influence the production of social advertisements for
health prevention we analysed GDP per capita and PEH indicators. Figure 2.5 shows the
socioeconomic profile of the four countries analysed according with those chosen
indicators and evidences the gap between Portugal and Italy versus Germany and
France.

37

Figure 2.5
Gross Domestic Product Per Capita and Public Expenditure on Health in France,
Germany, Portugal and Italy
GROSS DOMESTIC PRODUCT (GDP) PER CAPITA OF FRANCE,
GERMANY, PORTUGAL AND ITALY 2004-2011
USD current - purchasing power
parity

45000
40000
35000
30000
25000
20000
15000
10000
5000
0

Germany
France
Italy
Portugal

2004

2005

2006

2007

2008

2009

2010

2011

PUBLIC EXPENDITURE ON HEALTH (2004-2010) IN GERMANY,

FRANCE, PORTUGAL AND ITALY (% OF GDP)
10

France
Germany
Italy
Portugal

% of GDP

8
6
4
2
0
2004

2005

2006

2007

2008

2009

2010

Source: authors, with data from OECD Factbook Statistics 2013 (OECD, 2013b).

The number of TV ads collected in each country varies and this policy of social
marketing communication seems to be related to both public expenditure on health and
the national economic situation as measured by GDP. Table 2.7 highlights that, apart
from the fact that the countries in this study with more advertisements are also the ones
with stronger economies, we also find moderate positive correlations between the
number of ads developed by Germany, Portugal and Italy and their respective GDPs
over time. Although an increasing PEH does not necessarily mean more budgets
dedicated to health promotion and TV social ads, there are strong positive correlations
between the number of ads developed by Germany and Italy and the respective PEH,

38

and a moderate correlation in the case of France. There is a fit between the number of
social advertisements and the economic context.

Table 2.7
Correlation Coefficients between the Number of Ads Developed by country with gross
domestic product per capita (GDP) and public expenditure on health (PEH)
No. Ads and GDP
No. Ads and PEH
Country
Period

Period

France
2004-2011
-0.2
2004-2010
0.3
Germany
2004-2011
0.4
2004-2009
0.7
Italy
2005-2011
-0.7
2005-2010
0.9
Portugal
2005-2011
-0.6
2005-2010
-0.3
= Correlation Coefficient
Source: authors, with data from OECD Factbook Statistics 2013 (OECD, 2013b)

Social advertisements are a product of several variables influencing the leaders of

governments and NGOs that undertake such campaigns and the people who expect
certain types of leadership according to the culture (Dorfman et al., 2012). Several
models have been developed to understand cultural differences, but the Hofstede Model
(Hofstede, 2001) and, more recently, the GLOBE project the Global Leadership and
Organisational Behaviour Effectiveness (House et al., 2004) have been the most used in
cross-cultural research, despite intensive debate on the methodological differences
between these models (Hofstede, 2010). The high prevalence of messages promoting
condom use may be connected with cultural issues. In Western Europe, this message is
not very controversial (and even less over time) for policy-level interventions (EU,
2009; Likatavicius and VandeLaar, 2012). The research on the national HIV prevention
policies shows that the four countries under analysis regularly deliver free condoms in
several settings and promote this prevention method in their strategic programmes. The
moral message regarding ABC prevention principles for HIV - Abstinence, Being
Faithful and, when appropriate, Condoms (DIvoire et al., 2004) - has been considered
by the scientific community as a way to oversimplify prevention (Coates et al., 2008),
because abstinence is not considered a realistic prevention method and being faithful is
not protective at all (Collins et al., 2008). The ABC prevention principle has been
especially encouraged by moral and conservative systems for ethical or religious
reasons (Coates et al., 2008). Italy has the lowest proportion of messages endorsing
condom use and this may be associated with it being regarded as a predominantly male

39

nation with strong religion beliefs (Hofstede, 2001), namely because of its proximity
with the Vatican. The high number of ads in Portugal encouraging the HIV testing and
dissuading discrimination towards the disease may be related to the fact that Portugal
has relatively high uncertainty avoidance, is feminine, of humanist orientation and
collectivist values (Hofstede, 2001; House et al., 2004).
The number of ads by country also reflects contextual strategic policies. France and
Germany show higher numbers of advertisements and rate their own prevention efforts
at higher levels than Portugal and Italy (UNAIDS, 2012a). The national authorities
explain the activities developed and rate their own prevention efforts in NCPI (National
Composite Policy Index), a survey powered by UNAIDS to evaluate national
commitments and policies regarding HIV (UNAIDS, 2012a). In the last NCPI survey,
countries had to rate in a self-evaluation their overall policy efforts in HIV prevention in
2011. Germany answered 9 (having answered 9 for 2009, 9 for 2007, and 8 for 2005);
France answered 9; Portugal answered 7 (6 for 2009), and Italy answered 6 (UNAIDS,
2012a). All of these countries NCPI reports mentioned the development of social
advertisements on TV within prevention and social marketing activities. This discussion
is in the same logic of P2.5: Health-related social marketing fits the policy,
socioeconomic and cultural context.

2.4.5. Social Marketing and Policy Ambivalences

Ethical considerations may inhibit the effectiveness and efficiency of social
marketing in public health (Grier and Bryant, 2005; Lefebvre and Flora, 1988). The use
of audience segmentation in social marketing is ethically justified (Newton et al., 2013)
and these programmes may even be used to reduce health disparities in society, as long
as they are culturally appropriate (Williams and Kumanyika, 2002). However, a nonsegmented mass media approach may unintentionally reinforce disparities in health
knowledge, increasing stereotypes and stigma towards some population segments (Grier
and Bryant, 2005; Grier and Brumbaugh, 1999; Newton et al., 2013). It is important to
anticipate any unintended effects because stigma and discrimination are connected with
certain illnesses (Valdisserri, 2002). Social marketing has been used to fight those
attitudes (Rimal and Creel, 2008) and an understanding of the potential barriers is
crucial to inform its development.

40

Besides the cultural trade-off discussed above between appropriateness to the

environment and not mentioning fracturing issues in social messages to avoid cultural
dissonance, our research also suggests that there is inadequacy between the targeting
strategies in social advertising and the prevalence of infection among populations. This
may indicate policy-makers have deliberately avoided escalating stigma and
discrimination in vulnerable populations connected to HIV transmission. This suggests
another trade-off: on the one hand, social marketers are asked to segment audiences and
design messages that are suited to the characteristics of specific targets, even in mass
media communications (Albrecht, 1996; Fine, 1980; Grier and Bryant, 2005; Rimal et
al., 2009); on the other hand, they are aware that they may worsen the exclusion that
people living with HIV report they feel (Grier and Brumbaugh, 1999; Newton et al.,
2013). Illness stigma and discrimination may inhibit policy-makers from targeting the
most vulnerable populations in social marketing activities when using mass media and
highlights a possible restriction to conducting coherent interventions regarding epidemic
needs.
The discussed trade-off is motivated by the focus of this study being the television
advertisements, a non-segmented mass media requiring at the same time marketing
segmentation and targeting (Albrecht, 1996; Fine, 1980; Grier and Bryant, 2005; Rimal
et al., 2009). The findings of this research sustain an absence of audience orientation in
TV ads, but we are aware that there may be activities targeting specific segments
through other communication tools or media or even other types of social marketing
interventions. The existence of this ethical trade-off that is being discussed and should
be tested in future research should not deter social marketers and policy-makers from
using TV for social advertisements because mass media coverage of health issues is
important. It provides an opportunity for the social inclusion of excluded population
groups and minimizes knowledge disparities about health prevention (Williams and
Kumanyika, 2002). Social marketing may make an important contribution to resolving
the suggested trade-offs between social marketing theory and ethical and cultural
conflicts, i.e., using behaviour changing tools to intensify anti-discrimination messages
and demystify wrong stereotypes or misunderstandings. The theoretical background to
the social marketing plan suggests actions for improvement (Grier and Bryant, 2005;
Silva and Silva, 2012). Carefully driven social marketing plans should be prepared with

41

in-depth research on audiences in order to avoid the presence of erroneous and

stereotyped scenes. The inclusion of members from the target audience in the planning
process may also be an important contribution to minimize errors.

2.5. Conclusion and Research Implications

This paper shows how social marketing is used in health public policy in four
European countries and its appropriateness to the environment in which it is applied
the epidemic dynamics and the policy, socioeconomic or cultural context. This research
evidenced that social marketing regarding HIV prevention advertisements on TV are
mainly provided by governments rather than by NGOs. We found that the number of
social marketing interventions is coherent with the infection incidence rates although in
a reactive manner. Social advertisements do not fit the epidemiological profiles
regarding the target audience, but the messages delivered tend to be appropriate, except
when they disrupt the context. This is because social ads tend to reflect the policy,
socioeconomic and cultural context of the country where they are implemented. The
data analysis and discussion follow the research propositions, with the exception of
P2.3. If cultural trade-off occurs, P2.4 is also deviated. The discussion about who
develops more social advertisements, their fit to societal needs and the barriers and
challenges to conducting more effective and efficient policies is useful for improving
public policies. This paper contributes to public policy and social marketing,
recommending proactive responses, fitting to epidemic trends and contextual
environments, and overcoming the ethical and cultural trade-offs that may occur.
To prevent reactive responses to epidemic trends, professionals must look at the data
over time in order to predict the diseases incidences trends in each segment and
conduct proactive and creative prevention policies that are suited to the epidemic
characteristics in terms of target and messages. Done frequently, this practice may result
in effective epidemic outcomes. Regarding HIV/AIDS prevention, policy-makers
should address to the increasing incidence trends among MSM and migrants
(ECDC/WHO, 2012; Likatavicius and VandeLaar, 2012; UNAIDS, 2012b).

42

The lack of coherence between policy design and the epidemic profiles suggest that
since policy-makers consider the adequacy of social marketing strategies to the
epidemic trends they may also consider possible negative externalities of their action,
such as the cultural dissonance of mentioning fracturing topics or increasing stigma and
discrimination towards the disease and people who suffer from it.

2.6. Limitations and Further Research

The contextual aspects of the cases analysed are a limitation of this research. The
English language used to analyse all the advertisements is also a limitation because of
the need to translate the ads, despite our careful recruitment and briefing with
translators.
Future research may consider a broader period of analysis with more epidemiological
data and may analyse social ads in other countries, especially developing countries with
generalized epidemics, including other media to compare results. Other health issues
could be also analysed in order make comparison of results. The conclusion on the
predominant use of social marketing by public policy institutions suggests that it could
be interesting to relate this studys results with an analysis of the political parties that
formed the governments in different time periods and by country, regarding their
conservative or progressive policy trends. The discussed trade-offs of social marketers
regarding the avoidance of mentioning fracturing issues or increasing stigma and
discrimination should be tested in further research.

43

44

Chapter 3
3. A Content Analysis Model to Classify Social
Advertisements According to Their Use of
Positive or Negative Appeals3

A short version of this paper with the title A Methodological Model to Classify Social
Advertisements According to the Direction of Appeals was published in the Proceedings of the 2013
International Conference on Research in Advertising (ICORIA). A modified version of the study with the
title A Model to Classify Television Social Advertisements According to Their Use of Positive Appeals
is published as a book chapter in Advances in Advertising Research (Vol. V) edited by Ivana Banks and
Shintaro Okazaki, Springer: Wiesbaden, 2014.

45

Positive and negative appeals are a common research topic in social advertising,
considering the existence of contradictory theories about their psychological effects in
behaviour change. Researchers needed to identify appeals in social ads and propose a
model to classify social advertisements as positive, negative or a combination of both
appeals through qualitative content analysis. The model explores the evidences of
positive and negative appeals in the advertising components. It is based on theory and
empirical research conducted through a test with external judges using a sample of
twenty national HIV prevention television advertisements from four European countries
- France, Germany, Portugal and Italy. Researchers found reliability on the proposed
model throw the high ratio of agreements between the researchers classification and
external coders judgments. This model simplifies the identification and characterisation
of positive and negative appeals and can be useful to the categorization of social
advertisements according to the proportion use of appeals in the different components
of the ads.

Keywords:
Content Analysis, Discourse Analysis, Social Advertising, Social Marketing,
Communication Appeals.

46

3.1. Positive and Negative Appeals in Social Marketing

Social Marketing consists on the use of marketing principles and techniques to
influence behaviour change in order to improve social good (Andreasen, 1994;
Andreasen, 2003; Dann, 2010; Kotler and Zaltman, 1971; Smith, 2000). Interventions
adopting social marketing have been effective and it has been highly used in public
health (Evans, 2006; Evans and McCormack, 2008; Gordon et al., 2006; Grier and
Bryant, 2005; Helmig and Thaler, 2010; Morris and Clarkson, 2009; Stead et al., 2007;
Walsh et al., 1993). One of the most important and effective tools of social marketing in
public health has been social advertising, especially in television (Abroms and Maibach,
2008; Block and Keller, 1995; Della et al., 2008; Hastings et al., 1998). Advertising has
been recognised as an important communication component for successful marketing
exchanges depending on the attitudes and the associations towards the advertisements
by the way they are mentally processed (Ducoffe and Curlo, 2000; Heath, 2001).
Social marketing may be expressed with positive or negative appeals. Prospect
Theory (Kahneman and Tversky, 1979; Tversky and Kahneman, 1981) sustains that
people respond differently depending on how messages are framed exposing the
consequent gains or losses of behaviours. Positive appeals express the gains and the
direct benefits of behaviour change, as an incentive to adopt a specific behaviour with
coping information. Negative appeals describe the losses and unintended consequences
of certain attitudes and behaviours, by creating a disincentive to behave in a certain
way, for instance with threatening information (Brennan and Binney, 2010). This
classification interacts with a neurobiological system that varies across peoples
sensitivity to aversive stimuli: positive appeals are included in the behaviouralactivation system, while negative appeals are in the behavioural-inhibition system
(Dillard and Anderson, 2004). Prospect theory is studied around the topics that affect
the risk-seeking or risk-averse (Kahneman and Tversky, 1979; Rothman et al., 1993;
Tversky and Kahneman, 1981) and has been applied inclusively within social marketing
(Helmig and Thaler, 2010; Jones et al., 2003).
In order to inhibit people from continuing or adopting certain unhealthy behaviours,
social marketing explores viewer reactions such as fear, guilt and shame with negative
appeals of threats (Boudewyns et al., 2013; Cauberghe et al., 2009; LaTour and Rotfeld,

47

1997; Lewis et al., 2007; Ray and Wilkie, 1970). On the contrary, positive appeals are
based on humour, irony, hope, the exploration of benefits, and the use of celebrities or
social models, who activate the coping response of behaviours (Brennan and Binney,
2010; Hastings et al., 2004; Lewis et al., 2007).
Threat appeals are negative messages designed to scare people by describing the
terrible things that will happen to them if they do not do what the message recommends,
which is inhibiting of doing something (Witte, 1992). There are conceptual models
about how effective threat appeals are. Drive models suggest a curvilinear approach
where fear can persuade up to a certain level, beyond which it becomes
counterproductive (Janis, 1967). Health-protective behaviours theories, such as the
Health Belief Model (Rosenstock, 1974), Protection Motivation Theory (Rogers, 1983),
the Theory of Reasoned Action (Ajzen and Fishbein, 1980) and Subjective Expected
Utility Theory (Savage, 1954) are models that share the idea that perceived threat and
desire to avoid the negative outcomes or the consequences of illness motivate the
protection in the presence of risk (Floyd et al., 2000). The Parallel Response Model
(Leventhal, 1970) considers that in the presence of risk the receptors of messages
analyse danger and may develop a danger control or fear control. The Extended Parallel
Process Model combines Protection Motivation Theory and Parallel Response Model
and explains that when people evaluate the threat and the suggested coping responses,
assessing the response efficacy and the self-efficacy levels, there are some unintended
reactions towards threat appeals, such as the development of fear control and
maladaptive behaviours, especially when messages are perceived with low-efficacy and
the threat level is high (Cho and Salmon, 2007; Eppright et al., 2003; Floyd et al., 2000;
Gallopel-Morvan et al., 2009; Good and Abraham, 2007; Hastings et al., 2004; Ruiter et
al., 2001; Ruiter et al., 2004; Witte, 1992; Witte, 1994; Witte and Allen, 2000).
Despite the predominance of negative messages in social marketing studies (Brennan
and Binney, 2010; Charry and Demoulin, 2012; Dillard and Anderson, 2004; Soscia et
al., 2012), especially supported by the adopters of Protection Motivation Theory
(Cismaru and Lavack, 2007; Floyd et al., 2000; Witte, 1991), the literature is not agreed
on whether the most effective strategy is the use of positive appeals or negative ones
(Dillard and Anderson, 2004; Gardner and Wilheim, 1987; Helmig and Thaler, 2010;
Lewis et al., 2009; Reeves et al., 1991). On the one hand, not all the negative appeals

48

are created equally and their effectiveness vary (Cooper et al., 2014). On the other hand,
the fear control and maladaptive behaviours explored by the Extended Parallel Process
Model lead some authors to persuade to the advantages of positive appeals in social
marketing (Block and Keller, 1995; Cho and Salmon, 2007; Guttman and Ressler, 2001;
Hastings et al., 2004; Jones et al., 2003; Lewis et al., 2007; Maheswaran and MeyersLevy, 1990; O'Keefe and Jensen, 2008; Slavin et al., 2007). Positive appeals improve
the sustainability of health behaviours over longer periods of time, by increasing
perceptions about their benefits (Basu and Wang, 2009). On the contrary, research on
negative appeals does not reveal long-term effects (Hastings et al., 2004). After
prolonged exposure, fear-based ads become predictable, boring and may stop working
with repetition (Hastings et al., 2004). Positive appeals have the advantage of reducing
stigma and discrimination associated with illness or with high-risk populations by not
showing shocking images. The use of positive appeals in health-related social marketing
may reduce traumatic symptoms in people who have already suffered from the diseases
in cause (Lewis et al., 2007; Slavin et al., 2007).
A combination of negative and positive appeals in social advertisements is suggested
in the literature (Gallopel-Morvan et al., 2009) and sustained by the Ordered Protection
Motivation Theory (OPM), which defends that social marketing should process in the
same advertisement fear appeals first and then the copy response of desired behaviours
(Eppright et al., 2003; Tanner et al., 1991). We also see the combination use of humour
with threat appeals in order to decrease the defensive response to fear and increase its
effectiveness (Mukherjee and Dub, 2012; Yoon and Tinkham, 2013). OPM is not
unanimous s well (Cox and Cox, 2001; Ho, 2000).
A better understanding about the effectiveness of message appeals has long been a
research challenge (Block and Keller, 1995; Janis, 1967; Lewis et al., 2007; Lewis et
al., 2009) because the existing conclusions for the best direction positive or negative are not consistent (Block and Keller, 1995; Brennan and Binney, 2010; Dillard and
Anderson, 2004; Gardner and Wilheim, 1987; Hastings et al., 2004; Lewis et al., 2007;
Lwin et al., 2010; Reeves et al., 1991). This topic is also related to the self-efficacy
understood by the receptor and efficacy levels of the message response (Block and
Keller, 1995; Cooper et al., 2014; Manyiwa and Brennan, 2012), as well as the
motivation and involvement of the target, according to regulatory focus theory (Higgins,

49

1997; Higgins, 1998) and demographic factors that characterize it (Gygax et al., 2010;
Higgins, 1997; Jger and Eisend, 2013; Keller, 2006; Keller and Lehmann, 2008;
Krisjanous et al., 2013; Yoon and Tinkham, 2013).
The research about social advertising involves several studies which require the
analysis of the appeals used. It is crucial to analyse advertising appeals in order to
understand the feelings evoked next to the receptors (Aaker et al., 1988). A content
analysis model to classify social advertisements according to their proportion use of
positive and negative appeals might simplify the task and give a contribution to these
research challenges.

3.2. A Content Analysis Model to Classify Social Advertisements

It is common to combine both positive and negative appeals in social ads, as the
Ordered Protection Motivation Theory suggests (Eppright et al., 2003; Tanner et al.,
1991) or the new tendency of combining fear with humour (Mukherjee and Dub, 2012;
Yoon and Tinkham, 2013). The research on this topic requires the classification of
social advertisements, which is a complex task.
The literature uses to classify advertisements by the simple identification of
presence/no presence of such appeals, following their theoretical definitions (Cismaru et
al., 2009; Paek et al., 2010), without any model for qualitative analysis of
advertisements. Other method used is the implementation of a population inquiry with a
Likert scale from one to seven - one being totally negative, seven totally positive and
four a combination of both (Biener et al., 2004). We also note the use of qualitative
interviews or focus group in order to understand if people consider a social
advertisement as positive, negative or a combination of both appeals (Brennan and
Binney, 2010; Soscia et al., 2012).
Existing methods are difficult and expensive to develop, because they need
respondents for inquiries or interviews. The codification of ads by identifying the
presence of each appeal is influenced by diverse forms of communication (Anderson et
al., 2006; DeRosia, 2008; Mick, 1986), since positive and negative appeals may be used
in advertisements in verbal or non-verbal forms (Barthes, 1964). That is why it is

50

important to make a classification based on the proportion use of positive and negative
appeals in the same advertisement, considering both verbal and non-verbal
communication.
This paper proposes a model for content analysis of social advertisements in order to
classify them according to their use of positive or negative appeals. Content analysis is a
qualitative research approach (Cheek, 2004) which consists on the interpretation of
meaning from the content of data through the classification of coding categories and the
identification of themes and patterns with attention to the context (Hsieh and Shannon,
2005).

3.3. Methodology

The building process of the proposed model follows the techniques suggested in
theory to qualitative content analysis (Hsieh and Shannon, 2005): the authors searched
for the definitions of positive and negative appeals in the literature as guidance for
initial coding categories; allowed the perception of new coding categories evidenced
from the data; and proposed the use of the model with the count, comparison of
contents, and interpretation of the meanings according to the context. The authors
created a first version of the model with the theoretical background of positive and
negative appeals organised by the components of advertising creation and evaluation.
Then, they conducted an exploratory research and used external judges to validate the
analysis. The model was improved and strengthened with the identification of appeals
by a set of external judges in a sample range of social advertisements. The reliability of
the final model was tested with the comparison of agreement results between its use by
the researchers and the results of independent coders without using the model, as
recommended in the literature (Lombard et al., 2002).

3.3.1. The Model

The model for content analysis, whose purpose is the study of messages in social
advertisements, was organised in three areas of advertisement creation, since all of them
are important to communication, both in denotative and connotative meaning (Barthes,

51

1964; Oyedele and Minor, 2012) 1) the story concept (Starks and Trinidad, 2007); 2)
verbal and 3) non-verbal languages (Anderson et al., 2006; DeRosia, 2008; Harris and
Attour, 2003; McQuarrie and Mick, 1999; Vakratsas and Ambler, 1999; Vaughn, 1980).
The story concept is the creative guide and purpose of the advertisement in its main
message (Oyedele and Minor, 2012; Zhou and Belk, 2008). The authors used discourse
analysis of the spoken and written text of each ad framed in the appropriate context, as
recommended in the literature (Fairclough, 1992; VanDijk, 1993; VanDijk, 2006). The
research considered as important categories to analyse in verbal communication the
narrative structures, with the words used (Escalas, 2004) and the slogan, which gives
recognition and recall (Kohli et al., 2007). As categories of non-verbal communication
which also may affect the meaning of messages, the authors highlighted the type of
music, jingle or tonality of voice (Craton and Lantos, 2011), the colours (Aslam, 2006;
Kress and Leeuwen, 2002) and symbols from the scenes that are used to communicate
according to cultures and require contextual interpretation (Anderson et al., 2006;
Barthes, 1964; DeRosia, 2008; Harris and Attour, 2003; Jeong, 2008; McQuarrie and
Mick, 1999; Mick, 1986; Puntoni et al., 2010; Vakratsas and Ambler, 1999; Vaughn,
1980). Because content analysis should include a discourse and a semiotics research
approach to verbal and non-verbal communication forms (Anderson et al., 2006;
DeRosia, 2008), the model integrated the ideas in the concept of the story, the discourse
elements and non-verbal signs that could be positive or negative according to the
context (VanDijk, 2006). The authors searched for the definitions of positive and
negative appeals in social marketing literature focused on threat appeals, fear appeals,
protection motivation theory, drive models, health belief models and social advertising
as a whole.

3.3.2. The Empirical Research

3.3.2.1. The sample data
As social advertising is especially implemented in health prevention programmes
(Evans, 2006; Evans and McCormack, 2008; Gordon et al., 2006; Grier and Bryant,
2005; Helmig and Thaler, 2010; Morris and Clarkson, 2009; Stead et al., 2007; Walsh
et al., 1993), the study focuses on a health topic which had several social advertisements
developed with both positive and negative appeals. HIV prevention social

52

advertisements also reveal contradictory results about the effectiveness of positive and
negative appeals (Campbell and Babrow, 2004; Eppright et al., 2003; Green and Witte,
2006; Johnson and LaTour, 1991; Lwin et al., 2010; Muthusamy et al., 2009; Sampson
et al., 2001; Slavin et al., 2007; Smerecnik and Ruiter, 2010; Terblanche-Smit and
Terblanche, 2010) and has been a case study in the literature regarding the inconsistence
of literature about the issue (Ho, 2000; Witte, 1991). HIV/AIDS infection is a global
concerning disease, whose prevention consists on a priority for public policies (Merson
et al., 2008). Policy makers have being implemented several social marketing activities
around the world to fight HIV/AIDS infection, including social advertisements on
television (Myhre and Flora, 2000; Noar et al., 2009). Television has been the most
employed and effective media in AIDS prevention (Block and Keller, 1995; Mattson
and Basu, 2010) and health-related social marketing in general (Fuhrel-Forbis et al.,
2009; Self and Findley, 2010). It is a media with audio and visual components that
provides data for a richer analysis than other media.
The sample is based on twenty television social advertisements preventing
HIV/AIDS, aleatory chosen from the database of 375 HIV prevention television
advertisements from four countries previously characterised in Figure 2.3 (see p.31).
The sample included five ads from each of the four mentioned countries. We divided
data from each of the four countries into five chronological groups: 1987-1991; 19921996; 1997-2001; 2002-2006 and 2007-2011. As aleatory criteria to the sample of
twenty ads, we selected the third ad of each group appearing in the NVIVO software for
each of the four countries, in alphabetical order of code. The verbal forms of the data
were translated into English and totally transcribed to NVIVO software with a
description of the story and identifying all the nonverbal communication of each
advertisement. The translations were done by natives from the original languages or
people with a long period living in those countries, allowing translations with contextual
appropriateness and the required attention to cultural symbols (Oyedele and Minor,
2012; Zhou and Belk, 2008).

3.3.2.2. The analysis of categories

The consensus of several judges might be more accurate than the judgment of any
individual one (Perreault and Leigh, 1989). The authors asked three external judges

53

with wide academic experience in marketing and communication to view the twenty
television social ads. One has an MBA, one a MSc in Marketing and one is PhD in
Communication Sciences. After an individual briefing about the definition of positive
and negative appeals in social marketing and a quick training about the tasks, the
researchers asked the judges to complete an inquiry with an open question to identify in
the sample ads the positive and negative appeals.
The answers of the judges about where they identified positive and negative appeals
were coded in the initial defined categories extracted from theory. We used the NVIVO
software to code the answers. The assessment of the judges considerations also allowed
the inclusion of new coding categories to the model suggested from the analysed data,
as recommended by the literature about content analysis (Hsieh and Shannon, 2005).
After this process the researchers rebuilt the model, creating a final proposal.

3.3.2.3. The comparison of classifications

The external judges were also asked to grade the direction of each social
advertisement from one to seven - one being a totally negative direction and seven
totally positive, with four an equal combination of both appeals. This followed the
Likert Scale method that has already been used in the literature to research the presence
of positive and negative appeals in social marketing (Biener et al., 2004).
In order to compare the results of the judges with the final proposed model, including
new insights on the organisation of categories that arose from the exploratory analysis,
the researchers did a discourse analysis and a semiotic analysis of the data, conducting
the coding process into the categories of the final model. The context of signs and
connotative associations with HIV/AIDS infection were also considered in the analysis,
because the context is an important factor in qualitative and semiotic analysis (Mick,
1986; Zhou and Belk, 2008). Finally, each social advertisement was classified as
positive or negative focused, depending on the proportion of references of each
direction in all categories. Advertisements were classified as a combination of appeals
when there was a draw between positive and negative appeals in each category or
advertisement.
The content analysis method should include intercoder reliability of agreements in
order to understand if independent judges make the same coding decisions in evaluating

54

messages (Lombard et al., 2002). The study used the Proportional Reduction in Loss
(PRL) approach to calculate reliability, an appropriate measure for qualitative judgment
data (Rust and Cooil, 1994) that has been largely adopted and recognised in qualitative
research literature of several research areas including marketing and advertising. In the
case of 4 judges - 3 external judges and 1 of the researchers the agreements between
the 6 pair of judgments were calculated.
The brief design of the described process of empirical test of the proposed model can
be analysed in Table 3.1.

Table 3.1
Design of the Process to the Empirical Test of the Model
External Judges
Step 1.
Classification of
the
advertisements
according to the
direction of
appeals
(1-7)

Step 2.
Description of
the positive and
negative appeals
in each
advertisement

Researchers
Step 3.
Content analysis
of description to
find coding
categories to the
model (confirm
theory and add
new categories)

Step 4.
Re-conception
of the model

Step 5.
Data
Content
Analysis

Step 6.
Comparison of
results by PRL
reliability:
a) using the
model with b)
the results of
external judges
(1-7)

Source: authors.

3.4. Results
3.4.1. Categories
The researchers analysed all the answers of judges identifying positive and negative
appeals in the twenty sample ads. Examples of answers that identify positive appeals are
the following: the interlocutor has a smoothing, confident tone; balanced and
comfortable atmosphere; the participant is a public figure (Interviewee 1); The funny
way of the spot and the message appealing to the viewers protective behaviour through
the use of condoms. The actor says that with a condom he is going to have an excellent
night. The slogan informs to be prevented (Interviewee 2); The spot aims at
conveying a positive message: how good it is to have healthy offspring. There are
music, peoples and childrens smiles, images of people who are reassured because they

55

got tested (Interviewee 3). We also present examples of answers identifying negative
appeals: The spots colour scheme; a rising line; the line colour in red alludes to
blood/tragedy. (Interviewee 1); The message conveys that, even though we think Aids
has disappeared, it can be transmitted and it does happen. The peoples gaze is
suspicious and the sound is heavy. (Interviewee 2); The ad has a gloomy atmosphere
with a dark background. The young man shows a serious problem in his face but does
not have the courage to speak with his family (interviewee 3). With these examples we
find the importance of tonality of voice, the environment of the scene, the characters,
the humour rhetoric, the slogan, and story review, the music and facial sings, colours
and symbols as coding categories.
All the answers were coded in two hundred and twenty-five references. Table 3.2
presents the eleven categories identified from a qualitative analysis of the judges
answers. Those categories were re-organised into eight categories, as structured in Table
3.2 by tabs, because public figures or testimonials mentioned by the judges are in fact
characters of the advertisement and it can be only one category. Symbols are part of the
environment and scenes and can also be joined in one category.

Table 3.2
Number of references from external judges by categories identified in descriptions of
positive and negative appeals in the sample data - content analysis with NVIVO
No.
References
Colour
23
Character
15
Public Figure or Testimonial 8
Environment
21
Symbols
36
Humour
10
Music
19
Category

Voice

Narrative
Slogan
Story

24
11
56

Total: 11
Total: 225
Source: authors. NVIVO output.

56

The results confirm the previous categories created in the model based on the
background review and show that the characters and verbal rhetoric figures of the
discourse, for example the humorous tone as explained by the judges, were important
categories to add. These new categories were later confirmed in the literature (Barthes,
1964; Chang and Yen, 2013; Delbaere et al., 2011; Harris and Attour, 2003; McQuarrie
and Mick, 1999).
Table 3.3 shows the final proposed model to classifying social advertisements based
on positive or negative direction appeals. The model was created after identifying the
discourse and signs related to these two new categories, to distinguish positive and
negative appeals in a social advertisement. The model consists of eight categories with
literature support, divided into positive and negative appeals. One category concerns the
story concept (Starks and Trinidad, 2007), three narrative, slogan and rhetoric address verbal communication and four voice/music, colours, signs and characters consist of non-verbal communication (Anderson et al., 2006; DeRosia, 2008; Harris and
Attour, 2003; McQuarrie and Mick, 1999; Vakratsas and Ambler, 1999; Vaughn, 1980).

57

Table 3.3
Model to classify social advertisements in positive and negative appeals
Story Concept
Positive
Benefits of intended behaviours

Negative
Dangerous consequences of unintended behaviours

(Brennan and Binney, 2010; Cauberghe et al., 2009;

Hastings et al., 2004; Lewis et al., 2007; Lewis et al.,
2009)

(Biener et al., 2004; Brennan and Binney, 2010; Cauberghe

et al., 2009; Hastings et al., 2004; Lewis et al., 2007; Lewis
et al., 2009)

Verbal Communication (oral/written)

Words/Expressions used in the
narrative
Positive
Negative
Death,
disease,
Life, health,
illness,
danger,
smile, love,
fatality, fear,
respect, protect,
guilt, shame, risk,
prevent, treat,
losses, bad,
good,
consequences,
responsibility,
threat, effects,
copy, save, gains,
unintended
intended, efficacy
(Dillard and
Anderson, 2004;
Hastings et al.,
2004; Lewis et al.,
2007; Lewis et al.,
2009)

Slogan
Positive

(Brennan and
Binney, 2010;
Cauberghe et al.,
2009; Dillard and
Anderson, 2004;
Hastings et al.,
2004)

Verbal Rhetoric Figures

Negative

Positive

Incentive

Disincentive

(Dillard and
Anderson,
2004)

(Dillard and
Anderson,
2004)

Humour, irony,
metaphors
empathy,
motivation,
advising, copy
response
promotion
(Dillard and
Anderson, 2004;
Hastings et al.,
2004; Lewis et
al., 2007; Lewis
et al., 2009)

Negative

Shame,
Frightening,
Suspense with
fear
(Brennan and
Binney, 2010;
Cauberghe et al.,
2009; Dillard and
Anderson, 2004;
Hastings et al.,
2004)

Non-Verbal Communication
Tonality of Voice / Music
Positive
Negative
Motivating, Frightening
exciting,
, sad,
empathic
noisy,
(Dillard and
threatening
Anderson,
2004; Hastings
et al., 2004;
Lewis et al.,
2007; Lewis et
al., 2009)

(Brennan
and Binney,
2010;
Cauberghe
et al., 2009;
Dillard and
Anderson,
2004;
Hastings et
al., 2004)

Colours
Positive Negative
Varied
grey
palette,
scale,
blues,
red
(Aslam,
green,
2006;
white
(Aslam,
2006;
Kress and
Leeuwen,
2002;
Mick,
1986)

Kress and
Leeuwen,
2002;
Mick,
1986)

Signs in the Environment

Positive
Negative
Health,
Death, fear,
happiness, guilt, shame,
smiles,
desperation
hedonism, (Brennan and
(Dillard and
Anderson,
2004;
Hastings et
al., 2004;
Lewis et
al., 2007;
Lewis et
al., 2009)

Source: authors.

58

Binney, 2010;
Cauberghe et
al., 2009;
Dillard and
Anderson,
2004;
Hastings et
al., 2004)

Characters
Positive
Negative
Motivating
Worried
/Confident
people,
people,
Sad
social
people,
models,
hurt or
testimonial wounded
, public
people
(Brennan
figures
(Delbaere et
al., 2011;
Dillard and
Anderson,
2004;
Hastings et
al., 2004;
Lewis et al.,
2007; Lewis
et al., 2009)

and
Binney,
2010;
Cauberghe
et al.,
2009;
Dillard and
Anderson,
2004;
Hastings et
al., 2004)

For each advertisement, the researcher should code the transcriptions or notes
corresponding to positive or negative appeals in each of the 8 categories. The model
assumed that the negative form of discourse has to be considered in the syntax domain
to avoid incorrect results (Hsieh and Shannon, 2005). Considering the number of
references coded in each category for each appeal, we classify those categories as
positive or negative or even a combination of both. It is possible to classify a category
as Not Applicable. It happens in advertisements without data on that category an
advertisement without narrative, or without characters or slogan, for example -, and if
that absence has not a semiotics meaning. The final classification of the advertisement
may be positive, negative or a combination, depending on the proportion of
classifications in the eight categories. A social ad is only classified as a combination of
appeals if there are an equal number of categories classified as positive, negative and/or
combination of both. When there were several categories classified as a combination of
appeals, the number of categories classified only as positive or negative usually resolve
the draw. As social advertisements may include both negative and positive appeals
(Eppright et al., 2003; Gallopel-Morvan et al., 2009), the final classification of social
advertisements as positive, negative or a combination of both reflect the proportion of
codifications as positive and negative in the different categories of the model,
considering that each category has the same importance to the classification of social
ads.

3.4.2. Reliability
After the classifications of the external and independent coders, who did not have
access to the model, the researchers found that there is reliability in the use of the model
to classify positive and negative appeals in social advertisements. Table 3.4 shows the
number of intercoding agreements and PRL reliability of judgements of positive and
negative appeals from external judges who classified the ads on a Likert Scale and from
one of the researchers who used of the proposed model.

59

Table 3.4
Interjudge Reliability of the Data
Interjudge Agreements
Total Interjudge Agreements Possible
Proportion of Interjudge Agreement (A)
PRL Reliability for 3 categories and 4 judges
Source: authors.

95
120
0.791
0.97

We proposed three possible classifications to code data positive, negative or an

equal combination of both appeals - and found 79.1% intercoding agreement in the
classification of social advertisements of the sample. We measured the reliability of the
model with the Proportional Reduction in Loss (PRL) approach proposed by Roland
Rust and Bruce Cooil (1994). This result corresponds to a PRL reliability of 0.97
concerning the 4 judges. As the PRL is comparable to Cronbachs Alpha (Rust and
Cooil, 1994), the obtained PRL value is higher than the minimum reliability coefficient
and indicate interjudge reliability, which means that we can be fairly confident in the
classifications made in this exploratory analysis, as well as in the proposed model
(Kassarjian, 1977; Rust and Cooil, 1994). The existing disagreements between the
judges are not too accented because they respect to the differences of classification near
the combination point of the Likert Scale (point 4). The model proposes the
classification of an advertisement as combination when it shows an equal number of
positive and negative appeals. This specific result would be hard to fit always with the
simple classification of the external judges, who did not have the model to help their
analysis.

3.5. Conclusion and Research Implications

This paper proposed a content analysis model to classify social advertisements

according to their use of positive, negative and equal combination of both appeals. The
model is based on the definitions of positive and negative appeals in theory and is
confirmed by an exploratory research with data through the comparison of appeal
classifications of one of the researchers and three external judges. The results of this

60

study allow confidence in reliability of the model The model classifies social
advertisements as positive or negative appealed, considering the identification of
positive and negative appeals in the story review, verbal and non-verbal communication
of TV social advertisements. This paper gives a contribution with a method that may
simplify research concerning positive and negative appeals in social marketing, with
particular relevance in health prevention.

3.6. Limitations and Further Research

The model was tested with audiovisual advertisements, since they include more
dimensions and considering one health issue. In the future the model can be also tested
with other media and other subjects besides health. Future research may also discuss the
effectiveness of positive and negative appeals, comparing their use in the different
advertisement categories so that it can be possible to understand the communication
elements where appeals work better.

61

62

Chapter 4
4. The Use of Positive Appeals in Social
Marketing: a research focused on television
advertising for preventing HIV/AIDS in four
European countries. 4

A previous version of this paper was published in the Proceedings of the 39th Annual Macromarketing
Conference, ISSN 2168-1481, with the title The Gap between Theory and Practice in Social Marketing:
A Research about the use of Positive and Negative Appeals in European Television Advertising
Preventing HIV/AIDS. A short and adapted version titled Are threat appeals more popular than
positives in social advertising? was published in proceedings of the 2014 International Conference on
Research in Advertising (ICORIA). This paper includes the study Celebrity Endorsements in Social
Marketing: an exploratory research based on European Advertisements preventing HIV/AIDS published
in the book of abstracts from the 11th International Colloquium on Nonprofit, Arts, Heritage, and Social
Marketing, which won the Best Paper Award provided by Journal of Social Marketing, Emerald Group.

63

The paper analyses the use of positive and negative appeals in social marketing in a
longitudinal overview in order to discuss social marketers choices regarding this topic.
The researchers examined 375 television social advertisements on preventing HIV
from four European countries and found that, contrary to several theories, positive
appeals have a preponderant use although varying in frequency over time.
Advertisements are created with a combination of positive and negative appeals,
although not in equivalent proportions. This study describes those appeals and how they
are used and combined. Negative appeals are associated with conservative political
context and culture with uncertainty avoidance, as well as with the severity of epidemic
incidence rates.
A better understanding of social marketing practices may contribute to the theoretical
debate about the effectiveness of social marketing appeals and to lessening the gap
between theory and practice.

Keywords:
Positive Appeals, Negative Appeals, Social advertising, Social Marketing

64

4.1. Introduction
Prospect Theory states that people respond differently to risks depending on how
messages are framed - in positive or negative directions (Kahneman and Tversky, 1979;
Tversky and Kahneman, 1981). Messages can also have an informational or emotional
tonality (Brennan and Binney, 2010; Helmig and Thaler, 2010; McKay-Nesbitt et al.,
2011). As in commercial marketing (Bagozzi et al., 1999; McKay-Nesbitt et al., 2011),
the majority of social marketing messages have an emotional tonality (Basu and Wang,
2009; Block and Keller, 1995; Brennan and Binney, 2010; Keller, 2002; Keller and
Lehmann, 2008; Lang and Yegiyan, 2008) because of its effectiveness (Flora and
Maibach, 1990; Hastings et al., 2004; Helmig and Thaler, 2010; Lewis et al., 2007;
Vincent and Dubinsky, 2005). The literature is not agreed on whether the most effective
strategy is the use of positive emotional appeals or negative ones in social marketing
(Block and Keller, 1995; Brennan and Binney, 2010; Dillard and Anderson, 2004;
Gardner and Wilheim, 1987; Hastings et al., 2004; Lewis et al., 2007; Lewis et al.,
2009; Reeves et al., 1991). Several authors resort to negative appeals, according to the
effectiveness of Protection Motivation Theory (PMT) (Rogers, 1983) and other theories
that also highlight the advantages of fear and threat messages (Block and Keller, 1995;
Brennan and Binney, 2010; Cauberghe et al., 2009; Charry and Demoulin, 2012;
Cismaru and Lavack, 2007; Cismaru et al., 2008; Cismaru et al., 2009; Dillard and
Anderson, 2004; Gallopel-Morvan et al., 2009; Hastings et al., 2004; McKinley, 2009;
Vincent and Dubinsky, 2005). Negative appeals may be ineffective when they are
overused, and some authors consider positive appeals to be an efficient alternative with
several advantages (Brennan and Binney, 2010; Lewis et al., 2007; O'Keefe and Jensen,
2008), especially in the case of public health (Lewis et al., 2007; Slavin et al., 2007).
The existing findings are inconsistent and contradictory as a result of laboratory
research that only looked for the most effective appeals in different situations (Hastings
et al., 2004). Instead of discussing effectiveness, the present research aims at analysing
their use from a longitudinal overview. There are few studies on the prevalence of the
use of positive or negative social marketing appeals (Hastings et al., 2004; Slavin et al.,
2007). Those that have been done are based on a meta-analysis of the literature and do
not explain the how or when each appeal was used (Hastings et al., 2004; Slavin et al.,

65

2007). Prior knowledge about factors that influence the effectiveness of appeals may
influence their use in different circumstances. A better understanding of practice may be
an important contribution to social marketing theory (Quinn et al., 2010; Silva and
Silva, 2012). From the perspective of the theory of practice (Reckwitz, 2002), this study
allows an understanding of the contextual logic of routines in the case of social
marketing.

4.2. Literature Review

4.2.1. The Persuasiveness of Negative Appeals
Social marketing may be expressed with positive or negative appeals, according to
the intention of guiding behaviours (Brennan and Binney, 2010). In order to inhibit
people from continuing or adopting certain unhealthy behaviours social marketers use
negative messages with threats, to create viewer reactions such as fear, guilt and shame
as well as psychological discomfort that leads to a disincentive to behave in a certain
way (Boudewyns et al., 2013; Cauberghe et al., 2009; LaTour and Rotfeld, 1997; Lewis
et al., 2007; Ray and Wilkie, 1970). On the contrary, positive appeals aim to show the
direct benefits of behaviour change, as an incentive to adopt a specific behaviour
(Brennan and Binney, 2010; Hastings et al., 2004; Lewis et al., 2007; O'Keefe and
Jensen, 2008). This dichotomy of message frames affects the response to the perceived
risk (Rothman et al., 1993) in accordance to Prospect Theory (Kahneman and Tversky,
1979; Tversky and Kahneman, 1981) which is adopted in several topics of management
and decision process, including social marketing (Helmig and Thaler, 2010; Jones et al.,
2003).
Threat appeals are messages designed to frighten people by showing the consequent
losses if they do not heed message advices (Witte, 1992). Different models have
described the effectiveness of these negative appeals in social marketing, with a special
focus on research in health behaviour. Fear-drive models assert that the main factor in
the effectiveness of social marketing is the use of the correct level of fear, suggesting a
curvilinear approach where fear can persuade up to a certain level, beyond which it
becomes counterproductive (Janis, 1967). This means moderate fear is needed to

66

motivate people, but high levels of fear can boomerang. Drive models were later
rejected (Cauberghe et al., 2009; Dillard and Anderson, 2004; Witte, 1992) because of
the acceptance of health-protective behavioural theories such as the Health Belief
Model (Rosenstock, 1974), Protection Motivation Theory (PMT) (Rogers, 1983), the
Theory of Reasoned Action (Ajzen and Fishbein, 1980) and Subjective Expected Utility
Theory (Savage, 1954), which share the idea that healthy behaviours are based on the
desire to avoid negative health consequences or illness in general as well as on the
perceived threat to the risk (Floyd et al., 2000). Protection Motivation Theory (PMT)
(Rogers, 1983) has been widely studied as a disease prevention model, suggesting that
the level of fear is an indirect cause of persuasiveness. The direct cause is our ability to
perceive the severity of a threat, our perception of vulnerability and our perceived selfefficacy to change behaviours with low cost (Prentice-Dunn and Rogers, 1986; Rogers,
1983). Research has shown that higher levels of perceived threat, vulnerability and
perceived self-efficacy to change have a significant impact on protection motivation
(Floyd et al., 2000; Rogers, 1983). The Extended Parallel Processing Model (EPPM)
later included the explanation that the perceived efficacy of the message determines the
response. This theory combines PMT and Parallel Response Model (Leventhal, 1970)
sustaining that receptors towards threat may develop danger control and process an
adaptive behaviour, or fear control, developing a maladaptive behaviour. Fear control or
maladaptive coping responses are defensive reactions to fear appeals that result in
unintended consequences, such as the boomerang effect (Cho and Salmon, 2007;
Eppright et al., 2003; Floyd et al., 2000; Gallopel-Morvan et al., 2009; Good and
Abraham, 2007; Hastings et al., 2004; Ruiter et al., 2001; Witte and Allen, 2000). Lowefficacy perceived messages may lead to rejection by fear control (Witte, 1992; Witte
and Allen, 2000). To prevent this problem, PMT and EPPM suggest combining negative
appeals with positive appeals. This means the message is oriented to self-efficacy for
the recommended response and its benefits, combined with a warning about the dangers
of maintaining the current behaviour (Gallopel-Morvan et al., 2009). This idea is also
supported by the Ordered Protection Motivation Theory (OPM), which provides
adapted coping responses after threat appraisals in the sequence of advertising (Eppright
et al., 2003; Tanner et al., 1991). This means that a combination of negative and
positive appeals reduces maladaptive responses and increases adaptive protection

67

behaviours (Eppright et al., 2003). We also find the combined use of humour with threat
appeals in order to decrease the defensive response to fear and increase its effectiveness
(Mukherjee and Dub, 2012; Yoon and Tinkham, 2013). Some authors reject OPM
(Cox and Cox, 2001; Ho, 2000)
Consistent with PMT and EPPM, the literature suggests a relationship between fear
arousals and persuasion which means the more fear, the more persuasion (Witte and
Allen, 2000). This correlation does not assume the counterproductive overly high fear
levels as proposed by drive models, because of the lack of evidence (Green and Witte,
2006; LaTour, 2006; Witte and Allen, 2000). Using fear and threat, PMT and EPPM
have been widely used to help create social marketing actions and several researchers
demonstrate their effectiveness for creating persuasiveness in a variety of health
contexts (Biener et al., 2004; Block and Keller, 1995; Brennan and Binney, 2010;
Cauberghe et al., 2009; Charry and Demoulin, 2012; Cismaru and Lavack, 2007;
Cismaru et al., 2008; Cismaru et al., 2009; Dickinson-Delaporte and Holmes, 2011;
Dillard and Anderson, 2004; Eppright et al., 2003; Floyd et al., 2000; Gallopel-Morvan
et al., 2009; Gore and Bracken, 2005; Hastings et al., 2004; Keller and Lehmann, 2008;
McKinley, 2009; Vincent and Dubinsky, 2005; Witte and Allen, 2000). Other authors
claim that fear control does not necessarily undermine the effectiveness of a threat
appeal, but can also lead to its acceptance by moderating fear levels (Cauberghe et al.,
2009). Negative appeals have been more reported than positive appeals in social
marketing literature (Basu and Wang, 2009; Cismaru et al., 2009; Hastings et al., 2004;
Lewis et al., 2007; Vincent and Dubinsky, 2005) as well as in political marketing
(Brader, 2006; Mayer, 1996; Sides et al., 2010). We infer a preponderance of threat
appeals in practice.

4.2.2. Positive Appeals: an alternative to fear control

The literature presents positive appeals as an alternative to the overuse and saturation
of negative appeals. In 1990, findings from the Harvard School of Public Health linked
positive appeals with motivation to change and social marketing effectiveness (Block
and Keller, 1995; Maheswaran and Meyers-Levy, 1990). Positive emotional appeals are
based on humour, irony, hope, portraying benefits and using celebrities or social models
who activate the coping response (Brennan and Binney, 2010; Hastings et al., 2004;

68

Lewis et al., 2007). Positive emotional appeals are defended by some experts, despite
common criticisms about their inefficacy for the lack of shock messages (Hastings et
al., 2004). Although contrary to other findings (Dillard and Anderson, 2004; Floyd et
al., 2000; Witte and Allen, 2000), more fear may not always be better because people
reach a point of saturation, after which there is a decreased likelihood of negative appeal
effectiveness because of its indiscriminate overuse over the years (Brennan and Binney,
2010). Positive appeals improve the sustainability of health behaviours over longer
periods of time, by increasing perceptions about their benefits (Basu and Wang, 2009;
O'Keefe and Jensen, 2008). Research on negative appeals does not find long-term
effects (Hastings et al., 2004). After prolonged exposure, fear-based ads become
predictable and boring, and may stop working with repetition (Hastings et al., 2004).
Positive appeals have the advantage of reducing stigma and discrimination associated
with an illness or high-risk populations by not showing shocking images. The use of
positive appeals in health-related social marketing may reduce traumatic symptoms in
people who have already suffered from the diseases in question (Lewis et al., 2007;
Slavin et al., 2007).

4.2.3. Factors Influencing the Efficacy of Positive and Negative Appeals

A better understanding about the effectiveness of message appeals designed by social
marketers to influence people has long been a research challenge (Block and Keller,
1995; Janis, 1967; Lewis et al., 2007; Lewis et al., 2009), because conclusions for
whether positive or negative directions are best for message appeals to persuasion
remain contradictory, (Block and Keller, 1995; Brennan and Binney, 2010; Dillard and
Anderson, 2004; Gardner and Wilheim, 1987; Hastings et al., 2004; Lewis et al., 2007;
Lwin et al., 2010; Reeves et al., 1991) even when the cause is the same (Hastings et al.,
2004; Zhao and Pechmann, 2007). Some authors suggest differentiating their use
(Henley and Donovan, 1999; Jones and Owen, 2006) according to situations where one
direction is the most appropriate (Brennan and Binney, 2010; Keller and Lehmann,
2008; Self and Findley, 2010).

69

Regulatory Focus Theory

The effectiveness of positive or negative appeals is related to regulatory focus theory

(Higgins, 1997; Higgins, 1998). This approach considers differences in the targets
information process and decision making, influencing the effects of persuasion.
Promotion focus people are more sensitive to the gains while prevention focused people
are more sensitive to the losses and to messages of safety framed on personal
responsibilities. Regulatory focus theory has been studied in several topics about the
management of persuasion and a regulatory fit to the target audiences.
The literature sustains that the effectiveness of positive or negative appeals depends
on the level of motivation of the targets, which is segmented by demographic factors,
the level of efficacy of the recommended behaviour and the perceived self-efficacy to
do it (Cooper et al., 2014; Keller, 2006; Keller and Lehmann, 2008; Zhao and
Pechmann, 2007). Negative appeals are only effective with low efficacy conditions
(Block and Keller, 1995) and when subjects are motivated to process the message, as
prevention-focused people do (Gygax et al., 2010; Hastings et al., 2004; Keller, 2006;
Keller and Lehmann, 2008; Maheswaran and Meyers-Levy, 1990; Self and Findley,
2010; Zhao and Pechmann, 2007). The older female group is the most motivated and
impacted by health care information (CangelosiJr. et al., 2009; Keller and Lehmann,
2008). However, a recent research (Peters et al., 2013) contradicts that assumption and
shares the idea that negative appeals are only effective under high efficacy conditions
and that efficacy, of both recommended behaviours and self-efficacy to do that, only
happens with threat. This statement is inconsistent with the previous understanding that
with high-efficacy conditions, positive and negative frames are equally persuasive
(Block and Keller, 1995). Positive appeals are especially effective when subjects are not
motivated to process the message and it is probable that a recommended behaviour will
result in the desired outcome (Block and Keller, 1995; Maheswaran and Meyers-Levy,
1990). Those in greatest need of changing behaviours may be the most likely to exhibit
fear control and be least motivated to respond with behavioural changes when exposed
to health messages using negative appeals. That is why positive appeals are advised
when targeting promotion-focused people those who are likely to engage in unhealthy
risk behaviours. These sensation seekers are usually young males who are likely to
engage in suicide attempts, drug use, alcohol use, cigarette use and sexual promiscuity

70

(Gygax et al., 2010; Hastings et al., 2004; Higgins, 1997; Keller, 2006; Keller and
Lehmann, 2008; Lewis et al., 2007; Self and Findley, 2010).

Sensitivity to Context

Social marketing appeal direction should also fit with the culture of the targeted
country. This is in line with findings of cross-cultural research that has concluded that
the effectiveness of marketing appeals depends on sensitivity to culture, although the
effect of globalization can supersede cultural norms (Airhihenbuwa and Obregon, 2000;
Chan et al., 2007; Hastings et al., 2004; Kreuter and McClure, 2004; Orth et al., 2007;
Vincent and Dubinsky, 2005). For example, adolescents from cultures with high
uncertainty avoidance (Hofstede, 2001), respond more favourably to negative than
positive appeals in antismoking messages (Reardon et al., 2006). Public policies
developed in each country may also interfere in social marketing because it is important
for governments to seek certain political goals (Raftopoulou and Hogg, 2010). As
culture and politics influence current likes or dislikes, these factors also may impact on
the decision making process (Ralston et al., 2008). Negative messages are closer to
conservative or authoritarian models of society, while positive messages which do not
make judgments about unhealthy behaviours, are closer to progressive policies (Green
and Witte, 2006; Hastings et al., 2004). Fox (2009) analysed health-related posters
between 1920 and 1990 from Russia and the Soviet Union in terms of their themes and
appeals and found the narrative of the challenges faced by the country during the
twentieth century, identifying appeals to authority, fighting external enemies to health
and shame appeals (Fox, 2009). Both public and non-governmental organisations
(NGOs) reputations are affected by the attraction or aversion of an audience to the
appeals used in sponsored ads (Hastings et al., 2004). Negative appeals in health-related
social marketing sponsored by the public sector tend to reflect badly on the reputation
of a government, and exaggerated negative consequences have been shown to result in
discrediting sources (Hastings et al., 2004). Table 4.1 summarizes the factors
influencing the efficacy of positive and negative appeals in health-related social
marketing.

71

Table 4.1
Factors Influencing the Efficacy of Positive and Negative Appeals in Social Marketing
and Findings about the Most Effective Appeals
Factors
Motivation

Level of
efficacy

Most Effective Appeal

Preventive-Focused
People
Promotion-Focused
People

High motivation to
change
Low motivation to
change, risk seekers

Efficacy of the
recommended behaviour
or self efficacy perceived

High

Negative
Positive
Positive (or Negative)

Low
(Negative) or Combination
Culture
High Uncertainty Avoidance
Negative
Negative
Openness to Conservative
Change
Progressive
Positive
Sponsor
Negative appeals reflect badly on reputation, especially of Public Sector
Institution
Sources: authors, based on the literature review.

The literature also proposes the adaptation of social marketing policies to the context
of the related causes, as suits the epidemic dynamics and respective intervention (Casais
and Proenca, 2013; Grassly et al., 2001). In the case of positive and negative appeals,
the literature establishes a relationship between the effectiveness of fear with the
severity of the disease in the danger control process (Cooper et al., 2014; Ruiter et al.,
2004). This means that if negative appeals are the more shocking messages and positive
appeals the less discriminating, it is expected an alternate cycling should fit with
epidemic dynamics, besides other situational contexts.

4.3. The Research Design

The aim of this study is to find answers to the following questions:

Question 4.1 (Q4.1): What is the prevalence of positive and negative appeals in
social advertising? The answer may be compared with findings in the literature analysis
and also may give an indication about the gap between theory and practice (Quinn et al.,
2010; Silva and Silva, 2012). This question also allows an understanding of whether
appeals are used in combination as proposed in the literature (Cho and Salmon, 2007;
Gallopel-Morvan et al., 2009; Witte, 1992; Witte and Allen, 2000).

72

Question 4.2 (Q4.2): When have positive and negative appeals been used in social
advertising over time? This question allows understanding whether positive and
negative appeals are used in alternate cycles because of overuse in both directions and
their weakness or ineffectiveness caused by saturation (Brennan and Binney, 2010;
Hastings et al., 2004; Slavin et al., 2007).
Question 4.3 (Q4.3): How have positive and negative appeals been used in social
advertising? With this question the researchers seek to show evidence on how those
appeals take form in social advertising in order to contribute to their future
identification and discuss whether the context where they are applied fit with the
context where the literature shows that each appeal is more effective.
Figure 4.1 systematises the questions that structure the present study about the use of
positive and negative appeals in social advertising.

Figure 4.1
Research Questions
What?

When?

How?

Source: authors.

4.4. Methodology
This research concentrates on the use of positive and negative appeals in the case of
health-related social advertising because of the relevance of this communication tool in
social marketing for public health (Evans and McCormack, 2008; Gordon et al., 2006;
Griffin and O'Cass, 2004; Hastings and Haywood, 1991; Keller and Lehmann, 2008;
Stead et al., 2007). A longitudinal study on the use of positive and negative emotional
appeals in health-related social marketing may identify different realities, such as
different events in the history of diseases, different clinical developments, physical or
social impacts and costs of change which influence perceived self-efficacy (Keller and
Lehmann, 2008). That is why choosing a single case study is needed, even though the
results will be confined to that context. The case study should allow the use of a highlevel of threat, showing an outcome of death for example (Witte, 1992). At the same

73

time it should agree to the observation of unintended effects of that threat, such as
illness-related stigma (Lewis et al., 2007; Slavin et al., 2007). This allows for analysis
of resorts to positive alternative messages.
This paper presents research on the use of positive and negative appeals in social
advertising in a marketing context for a serious and discriminated disease, HIV/AIDS
infection, targeted at different segments with different messages (Noar et al., 2009;
UNAIDS, 2012b), allowing research comparisons according to the efficacy condition
and motivation to change (Keller and Lehmann, 2008). HIV also reveals contradictory
results about the effectiveness of direction appeals (Campbell and Babrow, 2004;
Eppright et al., 2003; Green and Witte, 2006; Johnson and LaTour, 1991; Lwin et al.,
2010; Muthusamy et al., 2009; Sampson et al., 2001; Slavin et al., 2007; Smerecnik and
Ruiter, 2010; Terblanche-Smit and Terblanche, 2010) and has been already used to
research this topic (Ho, 2000; Witte, 1991). We focused our research on television
advertisements for preventing HIV/AIDS in Europe, as it is a region with similarities in
disease prevalence and health assessment. This allows the researchers to control
comparisons of the perceived self-efficacy and motivation of the target (Keller and
Lehmann, 2008). Europe contains a diversity of cultures and public policies at the same
time (Green and Witte, 2006; Hastings et al., 2004; Hofstede, 2001; House et al., 2004;
Raftopoulou and Hogg, 2010).

4.4.1. The Database

Data collection was done in the internet in six months and followed the steps already
mentioned in the previous chapters and described in Table 1.2 and Table 1.3 (see p.12).
Within a database of 539 television social advertisements on HIV/AIDS prevention
developed by governments and/or NGOs between 1986 and 2011 from 21 EU countries,
we selected all the ads collected from four countries whose data was well distributed
over the period of analysis, representing 69.6% of the database. We analysed 375
national HIV prevention advertisements broadcast on TV whose distribution by
countries is shown in Figure 2.3 (see p.31) and the growing proportion of social ads
over time is evidenced related to the reactive prevention policies to the increasing
incidence of HIV epidemic (Casais and Proenca, 2013).

74

4.4.2. Data Analysis

The narratives of the social advertisements were translated from the original
languages to English. This task was performed by native speakers in some cases and in
other cases by translation professionals with extensive knowledge of the culture and
environment of the countries, having had the experience of living there. Besides the
translations they were asked to point out contextual aspects of the advertisements such
as the use of famous songs, national symbols or metaphors. We noted the
advertisements which were endorsed by celebrities. Most had the names of the
celebrities subtitled. Others referred to the names in the description written in the web
pages where the data were collected. When we did not recognise the celebrity we
searched for the name on the internet and verified that the person was well-known from
show business or sports. The narratives in English were transcribed into the NVIVO
software in order to perform content analysis. We described the characters, music,
colours, non-verbal symbols and the story review and type of rhetoric of each
advertisement. These notes were recorded in NVIVO and served as a basis for the
coding process.
As described in Figure 2.2 (see p.29), researchers classified, coded data and used the
Proportional Reduction in Loss (PRL) approach to calculate reliability of that coding, an
appropriate measure for qualitative judgment data (Rust and Cooil, 1994). With 4
judges - three external experts in marketing and communication and one of the
researchers we calculated the agreements between the 6 pairs of judges for coding a
sample of twenty advertisements composed of five ads from each country. We also
coded the positive and negative appeals of the advertisements following the content
analysis model showed in Table 3.3 (Casais and Proenca, 2014) (see p.58), which is
focused on the story concept of the ads and the verbal and non-verbal signs. The PRL
reliability of that model was calculated and is showed in Table 3.4 (see p.60).
Following the recommendations for the use of the model (Casais and Proenca, 2014),
the researchers coded the transcriptions or notes corresponding to positive or negative
appeals in each of the 8 categories concerning its contextual interpretation. The model
assumed that the negative form of discourse had to be considered in the syntax domain
to avoid incorrect results. Considering the number of references coded in each category
for each appeal, the researchers classified those categories as positive or negative or

75

even a combination of both. Categories without data were classified as Not

Applicable if that absence had no semiotics content. The final classification of the
advertisement might be positive, negative or a combination, depending on the
proportion of classifications in the eight categories. A social ad was only classified as a
combination of appeals if there were an equal number of categories classified as
positive, negative and/or combination of both. When there were several categories
classified as a combination of appeals, the number of categories classified only as
positive or negative usually resolved the draw. Since social advertisements might
include both negative and positive appeals (Eppright et al., 2003; Gallopel-Morvan et
al., 2009), the final classification of social advertisements as positive, negative or a
combination of both reflect the proportion of positive and negative codifications in the
different categories of the model, considering that each category has the same
importance to the classification of social ads (Casais and Proenca, 2014).
A descriptive analysis is done comparing the use of positive and negative appeals by
year of broadcast and country. In order to understand how positive and negative appeals
have been used (Henley and Donovan, 1999; Jones and Owen, 2006), we describe the
content analysis by word clouds with the most frequent words of the narratives and
analyse the presence of appeals in the categories of the advertisements as well as their
contribution to the final classification of the ads. We compared the classification of
appeals with the efficacy levels of the message response (Block and Keller, 1995) and
the motivation of the target, according to regulatory focus theory (Higgins, 1997;
Higgins, 1998) and demographic factors that characterise it (Gygax et al., 2010;
Higgins, 1997; Keller, 2006; Keller and Lehmann, 2008). Table 4.2 shows the criteria to
classify messages and target audience if it is not for the general population.

76

Table 4.2
Analysis of Classification of Social Ads Regarding Direction Appeals by Motivation to
Change and Perceived Self-Efficacy of the Target and Message Response Perceived
Efficacy.
Motivation to Change of the Target
(Gygax et al., 2010; Higgins, 1997; Keller, 2006; Keller and Lehmann,
2008)
Prevention-focused people
Female

Old
people

Risk
preventing

Promotion-focused people
Male

Young
people

Risk seeking
or
vulnerable

Message Response Perceived

Efficacy
(Block and Keller, 1995)
High-level

Low-level

Certain that
desirable
goal will be
reached

Not certain that

the desirable goal
will be reached

Source: authors, based on the literature review.

A longitudinal comparison of results is also done by type of source organisation, as

suggested by Hastings (2004), and country because of the influence of culture
(Airhihenbuwa and Obregon, 2000; Chan et al., 2007; Hastings et al., 2004; Laroche et
al., 2001; Orth et al., 2007; Vincent and Dubinsky, 2005) and public policies in appeal
direction effectiveness (Cho and Salmon, 2007; Raftopoulou and Hogg, 2010). Results
of each country are analysed by uncertainty avoidance/openness to change position
(Hofstede, 2001; House et al., 2004; Schwartz and Sagie, 2000), because of the
influence of these dimensions on the effectiveness of positive and negative appeals in
health-related social marketing (Reardon et al., 2006) as a strategy to promote change
(Dann, 2010; Kotler and Zaltman, 1971). This descriptive analysis was processed with
filters and dynamics tables of Microsoft Excel and with SPSS software. We also did a
correlation analysis between the use of appeals and epidemic incidence rates.

4.5. Results and Discussion

4.5.1. What are the most prevalent appeals in social advertising?
Positive appeals have an expressive use in social advertising for preventing
HIV/AIDS in France, Germany, Portugal and Italy. Table 4.3 shows the frequency of
advertisements classified as positive, negative and combination of appeals. The high
prevalence of positive appeals is evidenced in all the researched countries. Portugal has
more negative advertisements, although representing only 36.8% of the HIV/AIDS
prevention social advertisements in that country. Results contradict the state of the art

77

based on meta-analysis of the literature that recognises the advantages of negative

appeals in social marketing. Social ads were classified as a combination of appeals only
when the proportional use of positive and negative appeals was equal. Otherwise, the
researchers classified them with the more frequent appeal direction. The equal
combination of positive and negative appeals is residual.

Table 4.3
Frequency of Social Ads Classified as Negative, Positive and Combination of Appeals
Countries
France
Germany
Italy
Portugal
Total
Source: authors.

Combination
N
%
18
12.3
6
5.2
4
10.5
6
7.9
34
9.1

Negative
N
%
25
17.1
22
19.1
7
18.4
28
36.8
82
21.9

Positive
N
%
103
70.5
87
75.7
27
71.1
42
55.3
259
69.1

Total
N
146
115
38
76
375

%
100.0
100.0
100.0
100.0
100.0

4.5.2. When are positive and negative appeals used in social advertising?
We observe in Figure 4.2 that positive appeals have had higher prevalence over the
time span with the exception of 1992 and 1993 when negative appeals were more used,
and 2001 with more combinations of appeals in social ads. This may be related with
increasing numbers of infection. We do not see a cycling alternation between positive
and negative appeals, but a cycling increase and decrease of negative appeals, which
may be related with the appeal direction weaknesses discussed in the literature (Brennan
and Binney, 2010; Hastings et al., 2004; Slavin et al., 2007). Figure 4.2 shows the use
of positive and negative appeals over the time period in the four countries analysed,
which have a similar situation in terms of their use.

78

Figure 4.2
Classification of Appeals in Social Advertisements by Year (%)

1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Positive

Negative

Combination

Source: authors.

4.5.3. How are positive and negative appeals used in social advertising?
The fact that the combination of positive and negative appeals in the same proportion
is not highly evidenced does not mean the OPM theory is not used. Positive and
negative appeals may be combined, but not in the same proportion.
Table 4.4 shows the distribution of category classifications in the final coding of ads
according to the direction of appeals. The environment and story concepts categories
have the most equally combined appeals. The ads with combined non-verbal signs in
the scenes are classified as positive appeals (82.6%), while the ads with combined story
concept reflect a positive classification in 45.5% of cases and a negative classification
in 43.1%. We can see the evidence of positive coded categories that justify the
prevalence of positive appeal ads. Positive verbal rhetoric and music/tonality of voice
have high agreement with the final positive code of the ads. The categories with higher
contributions to negative appeal ads are the music/tonality of voice and the
environmental scenes, because of the importance of non-verbal signs for
communicating shocking messages (Craton and Lantos, 2011; DeRosia, 2008;
McQuarrie and Mick, 1999).

79

Table 4.4
Classification of advertising categories as positive, negative or combination of appeals by final classification of ads

Final
Classification
of Ads
Negative
Positive
Combination
Negative
Positive
Combination
Negative
Positive
Combination
Negative
Positive
Combination

Category
Classifications

Positive

Negative

Combination

Not Applicable

Total
Source: authors.

Characters
N
%
17
221
22
38
22
5
3
4
5
24
12
2
375

4.5
58.9
5.9
10.1
5.9
1.3
0.8
1.1
1.3
6.4
3.2
0.5
100.0

Colours
N
%
20
200
22
50
45
11
12
14
1
0
0
0
375

5.3
53.3
5.9
13.3
12.0
2.9
3.2
3.7
0.3
0.0
0.0
0.0
100.0

Environment
N
%
6
175
4
66
46
26
4
38
4
6
0
0
375

1.6
46.7
1.1
17.6
12.3
6.9
1.1
10.1
1.1
1.6
0.0
0.0
100.0

Categories
Verbal
Narrative
Rhetoric
N
%
N
%
13
3.5
15
4.0
155
41.3
242
64.5
8
2.1
12
3.2
58
15.5
48
12.8
55
14.7
3
0.8
14
3.7
7
1.9
6
1.6
19
5.1
11
2.9
14
3.7
10
2.7
15
4.0
5
1.3
0
0.0
38
10.1
0
0.0
2
0.5
0
0.0
375 100.0 375 100.0

80

Story
Concept
N
%
16
4.3
221
58.9
11
2.9
47
12.5
18
4.8
18
4.8
19
5.1
20
5.3
5
1.3
0
0.0
0
0.0
0
0.0
375
100.0

Slogan
N %
48
221
16
12
23
6
12
12
12
10
3
0
375

12.8
58.9
4.3
3.2
6.1
1.6
3.2
3.2
3.2
2.7
0.8
0.0
100.0

Voice Music
N %
9
223
7
67
27
15
6
8
11
0
1
1
375

2.4
59.5
1.9
17.9
7.2
4.0
1.6
2.1
2.9
0.0
0.3
0.3
100.0

Total Ads by
Final
Classification
N
%

Positive
259 69.1
Negative
82 21.9
Combination
34 9.1

375

100.0

The social advertisements classified as positive appeals are supported by a high

proportion of positive categories. 69.9% of positive ads have a 75% or greater
proportion of positive categories (six positive categories or more). Table 4.5 allows
identification of the level of positive appeals in positive social ads, according to the
classification of the eight categories. When the categories were classified as a
combination of positive and negative appeals those categories were annulled in the
counting of positive and negative appeals. Final classification as Combination reflected
an equal counting of positive and negative appeals or all the categories as a
combination. This explains the fact of positive advertising with only 3 or 4 categories
classified as positive. However, only 10.8% of positive social advertisements were
classified as positive in 3 or 4 categories, which is 50% or less.

Table 4.5
Proportion of Positive Categories in Positive Social Advertisements
Number of
Categories
Frequency
Classified as
(N)
Positive Appeals

Percent
(%)

Cumulative
Percent (%)

2.3

2.3

22

8.5

10.8

50

19.3

30.1

47

18.1

48.3

52

20.1

68.3

82

31.7

100.0

Total

259

100.0

Source: SPSS Output with authors data.

The country with the highest proportion of totally positive social advertisements is
German, with 44.8% of the positive social ads reflecting 100% of positive categories.
The narrative category does not have a high influence in final classification of ads,
but we note its importance in negative appeals. 11.9% of advertisements do not show
any narrative but when the final classification of the ads was positive, 21.2% of those
ads had a negative narrative as language about the disease (14.7% of total data), and
25.5% negative non-verbal signs in the scene environment as symbols or visual
metaphors (12.3% of total data). 33.9% of all data were classified with a negative

81

narrative and 36.8% with a negative environment, as the categories with more negative
appeals.
A word cloud is a visual representation of words frequency that appears in a text.
The words frequency is related with the font size and the more commonly each word
appears within a text, the larger the word is shown in the word cloud generated
(McNaught and Lam, 2010). The composition of word clouds allows a graphical
overview of the main topics of a text, since grammatical words and non-frequent words
are hidden (McNaught and Lam, 2010). Figure 4.3 shows a word cloud with the most
prevalent words in the narrative of the analysed advertisements that were coded as
positive or negative appeals. The word AIDS is used 176 times, representing 9% of
all the words coded in the narratives of data. HIV represents 3.61% and Love
3.46% of all words coded. Condom and Condoms have an appearance of 3.25%
and 2.53% respectively, reflecting the high frequency of ads with messages for condom
use (Noar et al., 2009).
Figure 4.3
Word Cloud of the Narrative of Analysed Ads

advice afraid

aids

attention avoid beautiful benefit best better blood care

careful carries chance children Chlamydia concern

condom condoms

conscience cool crazy cure cuts danger dangerous difficult disease easy efficient fear fight fighting

hiv
love

friend friends fun future get give go gold good happy help

infected infection kill kiss life live look

hiv-positive holidays

loved make nice night

protect
protected protection protects ready respect right risk risks safe seropositive
occasional people pleasure positive positives prevent prevention problem

sex sharing silence solidarity spreading sti sweet syringe syringes take test together transmissions
transmitted treatment treatments trust use

virus well without wonderful

Source: NVIVO Output with authors data.

The coding process was contextually sensitive, both in terms of cultural semantics
and syntax as recommended in the literature (Casais and Proenca, 2014; Fairclough,
82

1992; McNaught and Lam, 2010; VanDijk, 1993; VanDijk, 2006). For instance, the
word drugs was sometimes coded as negative, when the contextual meaning was
connoted with a higher risk of HIV transmission by its use, and sometimes it was coded
as positive when concerning AIDS treatment therapies. Another example is the word
positive, which can mean having a positive life or being HIV positive, depending on
the context. There are other cases of words coded as positive and also as negative
appeals, in different context. Figure 4.4 and Figure 4.5 show the word clouds of
negative and positive codes, respectively. Negative words are highly related with names
of diseases and disease risks, while positive words are related with protection practices.
These results reinforce the content analysis model used to classify the positive and
negative appeals in social advertisements (Casais and Proenca, 2014).

Figure 4.4
Word cloud of Negative Words in the Narrative of Analysed Ads

afraid

aids

atacked away bad blood carries cases chlamydia concern concerned

condoms consequence contagion crazy cure cuts danger dangerous death die difficult disease
diseases drug easy enemy epidemic epidemy fall falls fatal fear fight fighting fool gonorrhea hard hate

hepatitis herpes

hiv

hiv positive

infected infection infectious kill kills lacking less

loose moment needles night occasional patients people positive positives prevention problem
protect protection reduce risk risks risky seroposite

seropositive

seropositiveness

seropositives sexual sharing sick silence spread spreading sti stupidity suffering syphilis syringe
syringes take time transmission transmissions transmitted transmitted unfortunately unknown use
victims
Source: NVIVO Output with authors data.

virus world worry

83

Figure 4.5
Word Cloud of Positive Words in the Narrative of Analysed Ads
action adventure advice advices alright ambassador answer attention avoid beautiful benefit best

better birth care careful chance change children

condoms

condom

conscience cool courage crazy delighted desire dialogue

easy efficient elect enjoy families fantasy feel fight fighting fine friend friends fun future

get give go gold

life

like

good happy help holidays hug human informed kiss kissing

live look

love

loved mother mothers new nice

people play pleasure possible prevent prevention problem

protect

protected protection protects ready respect right safe sex simple solidarity
survive sweet take test tested together treatment treatments trust use well wonderful
work
Source: NVIVO Output with authors data.

Besides the high prevalence of positive appeals we also see evidence of positive
characters in social advertisements (69.3% of all data). Positive appeals may be based
on copy response messages, sometimes with testimonials from well-known people since
there is evidence that celebrity recognition, credibility and attractiveness can activate
positive attitudes among a target audience if attitudes toward the endorser are positive
(Amos et al., 2008; Erdogan et al., 2001; Mowen and Brown, 1981; Salmones et al.,
2013; Seno and Lukas, 2007; Silvera and Austad, 2004; Spry and Cornwell, 2011).
Famous people are examples of social lifestyles (Basil and Brown, 1997; Biskup and
Pfister, 1999; White and O'Brien, 1999; Wicks et al., 2007) in the case of HIV
prevention (Kalichman and Hunter, 1992) and marketing managers frequently use them,
despite the risk of negative images or scandals which are sometimes involved (Agrawal

84

and Kamakura, 1995; Till and Shimp, 1998). They can portray examples of a good
lifestyle (Erdogan et al., 2001) or misfortune, as in the case of Magic Johnson, who
became a successful resource for promoting sexually safe behaviours (Basil and Brown,
1997; Brown and Basil, 1995; Casey et al., 2003; Kalichman and Hunter, 1992).
Celebrities consider their motivation to endorse HIV prevention social marketing is
related to the serious nature of the infection, to the need to fight stigma and the close
relationship that some of them have with HIV/AIDS through friends or family (Casais
and Proenca, 2012). Celebrities believe their public image improves after promoting
social change, they assume that it does not have negative consequences for their public
image and they report a positive bias toward endorsing a cause for HIV/AIDS
prevention (Casais and Proenca, 2012). They also say that their reluctance to be the face
of an HIV prevention campaign is mostly due to their unavailability and not any fear of
a direct connotation with the disease (Casais and Proenca, 2012). However, this study
shows that social marketing has made little recruitment of public figures to endorse the
cause. Table 4.6 shows the frequency of social ads with celebrity endorsements by
country over time. 18.1% of the 375 social ads had public figures as characters, and
only 17% were coded as positive characters (94.1% of celebrity endorsements). In fact,
4 ads with public figures were coded as negative characters or combination because
they were showing illness, sadness, worries, or they were famous people with a bad
reputation, Hitler as a mass murderer for example. 57.3% of the 68 ads with celebrity
endorsements were produced in last five years of the database. Despite the sample size
being larger in the last five years, representing 33.3% of the total data, celebrity
endorsement has been growing: 31,2% of the data produced in the researched countries
between 2007 and 2011 had famous people, compared to 23.8% in the period 20022006, 0% from 1997-2001, 17.6% from 1992-1996 and 4% between 1987-1991.We
found that although celebrities say that they are especially motivated to endorse HIV
prevention social marketing activities and do not have prejudice against the disease
(Casais and Proenca, 2012), in practice the proportion of social ads endorsed by famous
people is small, although it has been increasing.

85

Table 4.6
Celebrity Endorsements of Social Ads by country and Year
Year
1987
1993
1994
1995
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Total
N (%)
Celebrity Endorsements
in the database % (N)
Source: authors.

12 (17.6)

33 (48.5)

2
12 (17.6)

11 (16.2)

Total N (%)
2 (2.9)
3 (4.4)
3 (4.4)
6 (8.8)
2 (2.9)
1 (1.5)
3 (4.4)
3 (4.4)
6 (8.8)
3 (4.4)
10 (14.7)
9 (13.2)
15 (22.1)
2 (2.9)
68 (100)

8.2 (146)

28.7 (115)

31.6 (38)

14.5 (76)

18.1 (375)

France (N)

Germany (N)
2

Italy (N)

Portugal (N)
1
3

6
2
2
2
4
1
1

1
1
1
2
1
7
7
11

1
2
2
4

We can consider that the increasing trend of endorsements may be related with the
growing importance of social responsibility by brands, including personal brands
(Salmones et al., 2013), and reactive-prevention policies towards the incidence rates of
the infection, which only started to decrease in the European Union in 2009
(ECDC/WHO, 2012) that might lead social marketers to invite more celebrities to these
campaigns. Although famous people declared a positive bias for HIV/AIDS (Casais and
Proenca, 2012) the results may reflect the fact of HIV being a stigmatised disease
(Castro et al., 2010).
Animation films are also a technique used in social advertising. 15.2% of social ads
analysed use this technique. Table 4.7 shows its distribution by country and evidences
that animation films tend to be classified as positive (77.2% of cases).
In fact, animation films may communicate a stigmatised disease easier without
shocking scenes and allow broadcasting the advertisement without timetable
restrictions. In negative advertisements this technique may serve as a mediation of
threat. The discussion above provides an extensive answer to Q4.3 and sustains the
content analysis model used as method of research (Casais and Proenca, 2014).

86

Table 4.7
Social advertisements with animations by country and classification of appeals
Direction of Appeals
Combination
Negative
Positive
Total Ads with
Animation
Total Ads and % of
Animation Movies
Source: authors.

France
N
%
0
0.0
5
8.8
18 31.6

Germany
N
%
0
0.0
4
7.0
12 21.1

Italy
N
%
2
3.5
1
1.8
3
5.3

Portugal
N
%
1
1.8
0
0.0
11 19.3

Total
N

Total
%

3
10
44

5.3
17.5
77.2

23

40.4

16

28.1

10.5

12

21.1

57

100.0

143

16.1

115

13.9

38

15.8

76

15.8

375

15.2

The prevalence of positive appeals in social ads should be discussed according to

their use in different situations. Regarding regulatory focus theory (Higgins, 1997;
Higgins, 1998), we considered women as prevention-focused people for whom negative
appeals would be more efficient (Gygax et al., 2010; Hastings et al., 2004; Keller, 2006;
Keller and Lehmann, 2008; Maheswaran and Meyers-Levy, 1990; Self and Findley,
2010; Zhao and Pechmann, 2007). However, out of only 17 social ads targeted at
women, 82.4% were classified as positive appeals. We considered promotion-focused
people in this study to be men, drug users, men who have sex with other men, sex
workers and young people because of their vulnerability and high risk. In this case,
results follow the efficacy of positive appeals for this type of target presented in the
literature (Block and Keller, 1995; Maheswaran and Meyers-Levy, 1990). 81.4% of the
102 social ads directed to the referred targets were classified as positive. Negative
appeals are suggested by the literature to be more appropriate for low levels of message
response efficacy perceived or self efficacy perceived. In those types of messages for
this study we included anti-discrimination social ads, general ads to stop or avoid AIDS
and the promotion of adherence to treatment because of the secondary effects of
therapy. Out of the 117 social ads with those messages we found that only 36.8% were
negative appeals and 48.7% were negative or combined appeals. If we add the messages
promoting condom use which might be also considered as having low levels of
perceived efficacy for the risk of ripping, we decrease the proportion of negative ads to
21.9% out of the 338 social advertisements and to 31% if considering the combined
advertisements also. These results show that social marketers have a strong preference
for positive appeals, even in situations where the literature advises the use of negative
appeals to increase effectiveness.

87

When comparing the results by source type, as suggested by Hastings (2004), we

find that 69.8% of social advertisements developed by governmental institutions were
classified as positive appealed. Considering the social ads developed by governments in
partnership with non-governmental organisations (NGOs), the percentage increases to
70.7%. Table 4.8 indicates the distribution of data by classification of appeals and
source institution and shows that NGOs also tend to use positive appeal advertisements,
perhaps in order not to stigmatize and discriminate against people living with the
disease.
Table 4.8
Classification of Social Ads by Appeal Direction and Source Institution

Appeals
Combination
Negative
Positive
Total
Source: authors.

GOV.+NGO
N
%
0
0.0
1
0.3
10
2.7
11
2.9

Source Institution
Governmental Non-Governmental
N
%
N
%
18
4.8
16
4.3
56
14.9
25
6.7
171
45.6
78
20.8
245
65.3
119
31.7

Total
N
34
82
259
375

%
9.1
21.9
69.1
100.0

Culture influences the effectiveness of appeals in advertising (Airhihenbuwa and

Obregon, 2000; Chan et al., 2007; Hastings et al., 2004; Laroche et al., 2001; Orth et
al., 2007; Vincent and Dubinsky, 2005) and may also influence decision-making in
social marketing (Fox, 2009; Ralston et al., 2008). The uncertainty avoidance
dimension measures the degree to which the members of a society feel uncomfortable
and threatened by ambiguity (Hofstede, 2001). This dimension is relevant as a factor of
appeal direction effectiveness in social marketing (Reardon et al., 2006), which is a
strategy to promote change (Dann, 2010; Kotler and Zaltman, 1971).
Within the countries under research, Portugal has the highest proportion of
negatively classified data - 36.8% as previously shown in Table 4.3. This country also
has relatively high uncertainty avoidance according to the Hofstedes index (2001),
which means it is a more conservative country following the Schwartz theory of cultural
values (2000) and less open to change. In the GLOBE scale (House et al., 2004), which
is more recent and reflects the weaken of cultural boundaries with the globalisation
phenomena, this dimension is no longer relevant for Portugal compared with the other

88

countries under analysis (House et al., 2004). However, 82.1% of the referred
Portuguese negative advertisements were developed before 2001, representing 44.2% of
all the analysed Portuguese data developed until that year.
The period before 2001 represents the higher prevalence of patients with AIDS in
Portugal (ECDC/WHO, 2010), suggesting a connection between the seriousness of
epidemics and the use of negative appeals 5. In Germany, which is the analysed country
with lower incidence rates but where rates have been increasing since 2001, as
previously shown in Table 2.3 (see p.32), 81.8% of all the German negative ads
analysed were produced after that year. Negative advertisements represent 22.5% of the
all German social ads preventing HIV/AIDS that were produced from then until the end
of 2011. Table 4.9 shows that there is a moderate positive correlation (0.4) between
increasing rates of HIV and the number of negative advertisements produced. This
means that increasing HIV incidence rates are associated with an increasing trend of
negative prevention advertisements, although still having a low proportion compared to
the use of positive appeals.

Table 4.9
Correlation Coefficient between the Number of German Negative Advertisements and
German HIV Incidence Rates in the Period 2001-2011
Year
2001
2004
2005
2007
2008
2009
2011
N=7

German Negative Ads (N)

German HIV Incidence Rates
1
1.8
1
2.7
3
3.0
2
3.4
8
3.5
2
3.5
1
3.5
Number of Ads = 18
Rates per 100.000 population by year of diagnosis
= correlation coefficient
0.40
Sources: authors, with data from HIV/AIDS surveillance in Europe 2011 (ECDC/WHO,
2012) and HIV/AIDS surveillance in Europe 2009 (ECDC/WHO, 2010).

On the other hand, the decreasing rates of HIV incidence in France, Portugal and
Italy in the 21st century since when official data began being reported - are negatively

The cumulative prevalence of AIDS is mentioned because there are not reported incidence rates by year
of diagnosis for the period before 2001, not allowing a correlation analysis ECDC/WHO (2010),
HIV/AIDS surveillance in Europe 2009. Stockholm: European Centre for Disease Prevention and
Control..

89

correlated with increasing use of positive HIV prevention advertisements. Italy has a
moderate negative correlation ( -0.6) that deserves attention, as Table 4.10 shows. In
fact, the appropriateness of social marketing with epidemics and contextual factors is an
important research topic (Casais and Proenca, 2013; Grassly et al., 2001; Silva and
Silva, 2012; Wymer, 2011).
Table 4.10
Correlation Coefficients between the Number of French, Portuguese and Italy Positive
Advertisements and respectively HIV Incidence Rates
Country
Period
Years (N)
Positive Ads (N)

(2003-11)
9
46
-0.18
France
(2001; 2004-11)
9
19
-0.19
Portugal
(2005-11)
7
16
-0.63
Italy
Sources: authors, with data from HIV/AIDS surveillance in Europe 2011 (ECDC/WHO, 2012)
and HIV/AIDS surveillance in Europe 2009 (ECDC/WHO, 2010).

The prevalence of positive appeals is not limited to the circumstances where

Regulatory Focus Theory is reported to be more efficient (Cooper et al., 2014; Keller,
2006; Keller and Lehmann, 2008; Zhao and Pechmann, 2007). Either, positive appeals
are not restricted to governmental institutions, as could be inferred by the literature
(Hastings et al., 2004). However, we observe that negative appeals may have a
relationship with cultural concerns, as in the case of higher uncertainty avoidance and
less openness to change in Portugal before the millennium. This fact may also be related
to the concern of an epidemic situation in Portugal at that time. The severity of
epidemics also might have influenced the increasing use of negative appeals in
Germany after 2001 and when the incidence rates decrease, the study shows that social
marketers increase the use of positive ads.

4.6. Conclusion and Research Implications

In opposition to the theoretical recommendations of threat messages for behaviour
change described in the literature, this paper shows the expressive use of positive
appeals in the practice of social advertising. In a longitudinal overview the expressive
use of positive appeals occurs all the period under analysis and follows a wavy

90

evolution, increasing and decreasing over time, which may be related with the
saturation of appeals and their vulnerabilities described in the theory.
The study shows that social advertisements have both positive and negative appeals
in their different components, although not with the same proportions. The prevalence
of advertisements classified as a combination of appeals is residual. Motivating verbal
rhetoric advising behaviour change, as well as positive music or an advisory voice
tonality are the advertising appeals with the higher contribution to positive classification
of social ads. Positive appeals have a significant proportion of positive categories
justifying that classification in 69.9% of positive advertisements the proportion of
positive categories is 75% or more.
With a content analysis of social ads the research describes how positive and
negative appeals take form, such as the positive words related to prevention and
protection, reinforcing the magnitude of life and love. Negative words are connected to
risks and disease. The narratives and signs from the scenes are the categories with more
negative appeals because of their power to shock. Some positive appeals take the form
of animation films. We found that contrary to the theory that sustains the importance of
coping response messages as positive appeals as well as the motivation of public figures
to endorse social causes, celebrity endorsements are few, although increasing in recent
years.
The results indicate that the use of positive appeals is not connected with the
diversity of target audience or the type of source organisation, since positive appeals are
generalised in social advertising. We found that there is sensitivity in social marketers
choices for positive and negative appeals to country profiles and epidemic contexts, in
the case of uncertainty avoidance cultural dimension and the policy openness to change,
as well as regarding the severity of disease rates. The increasing of incidence rates is
correlated with the use of negative ads and the decreasing with positive advertisements,
especially in Italy.

91

4.7. Limitations and Future Research

The conclusions of the paper should consider the specificities of the case researched,
as the particular stigma and discrimination that people living with HIV/AIDS still face
in society. The call for positive appeals may be stronger in order not to accentuate social
discrimination. That question based on research results should be tested in the future.
Future research might also analyse other themes of health-related social marketing, in
order to understand if positive appeals are a specificity of social marketing in the
prevention of HIV/AIDS. A wider number of countries may be analysed in order to
deep the conclusions about the sensitiveness of the use of positive and negative appeals
with context and epidemics. The research about the use of positive and negative appeals
could consider other tools of social marketing besides social advertising on television.

92

Chapter 5
5. Conclusions

93

This chapter contains the main conclusions of the thesis, organised by the three
presented papers. We also discuss the theoretical and managerial contributions to the
field, limitations and give some suggestions for future research.

5.1. Conclusions
We examined the use of positive and negative emotional appeals in social marketing,
and their adequacy to theoretical background and situational needs. The purpose of the
thesis was to understand over time the direction of appeals more frequently used
positive or negative appeals , and how they appear in social marketing, comparing with
factors reported in the literature as influencing their effectiveness: the target audiences
and behavioural change messages, type of sources, policy and cultural profiles and
epidemic trends. We studied television social advertisements preventing HIV/AIDS
infection in four European countries due to its seriousness and the high number of
interventions preventing the disease through social marketing use, particularly
television social advertising.
In the paper 1 we found that television advertisements preventing HIV/AIDS are
generally part of a public policy strategy but do not focus on the needs demonstrated by
the analysis of epidemic dynamics and the needs of the most at risk population. When
there is a relationship between marketers choices and epidemics, advertisements are
generally part of a reactive prevention policy. Television advertisements especially
target the general public and young people, suggesting some avoidance on targeting the
most HIV-vulnerable populations. Although condom use is the most prevalent message,
because sexual transmission is the most important way of getting the infection, general
messages on avoiding or stopping AIDS and fighting discrimination are also very
common in the data analysed. This study highlights that social marketing practices do
not fit the contextual needs, are reactive and leads to the discussion about cultural
particularities as well as illness stigma and discrimination may implying trade-offs to
social marketers management practices.
Paper 2 contributes with a content analysis model for the identification and
classification of television social advertising according to their proportion of positive

94

and negative emotional appeals. The model consists on the analysis of appeals within
categories based on the literature review and tested with independent coders: the story
review, the narrative, the slogans and rhetoric, the music or tonality of voice, colours,
signs and characters. The model presents positive and negative forms for those
categories. The classification of advertisements should be done based on the proportion
use of positive and negative appeals identified in the categories.
Paper 3 analysed the use of positive and negative emotional appeals in social
advertising. The analysis consist on the observation of their frequency over time, how
those appeals take form in the different components of television ads and their fit with
the contextual environment in a longitudinal overview sensitiveness to the target
audience, behaviour change message, type of institutional sources, cultural profiles,
namely the uncertainty avoidance and conservative levels of policy, as well as the
epidemic dynamics. Results show an expressive predominance of positive social
advertisements throughout the time. Positive appeals are more frequent in motivational
rhetoric and in active music or advisory voice tonality. Some positive appeals take form
of animation films and include celebrity endorsers few but increasing over time.
Social advertisements have also negative appeals in their components although in lower
proportion, especially in the narrative and signs of the scenes. We found an undulated
cycle with an increasing and decreasing use of positive and negative appeals, but
without affecting the preference of social marketers for positive messages. We did not
find sensitiveness to factors previously reported in the literature that differentiate the
effectiveness of appeals, as the target groups according to regulatory focus theory,
neither the level of efficacy of the behaviour change messages or the type of source. In
accordance with the previous literature there is a connection between the use of positive
and negative appeals and the country profiles and seriousness of epidemics. Negative
appeals are more frequent in Portugal until the end of the twentieth century, a country
with higher relative uncertainty avoidance and conservative society in that period. There
is a correlation between the increasing use of negative appeals in Germany in the
twenty-first century and the increasing incidence rates of infection in the same period.
The similar sensitiveness happens in the other analysed countries, in this same period,
especially in Italy. The increasing of positive appeals is correlated with the decreasing
in incidence rates of infection.

95

This thesis concludes that in opposition to the highly reported effectiveness of

negative appeals in the background theory, positive social ads are predominant and have
a much more expressive use all the time. We show that social ads also have negative
appeals in lower proportion, mainly in the narrative and signs of the scenes and that the
positive appeal to copy response by celebrity endorsements can be higher explored. As
social marketing practices do not show accordance with the conditions explored in the
literature influencing and differentiating the effectiveness of positive and negative
appeals in social ads, the researchers wonder about possible barriers and trade-offs
faced by public policy makers, since interventions are especially concentrated in the
public sector. We wonder if the fact of HIV prevention ads involving the discussion of
fracturing issues, as well as stigma and discrimination linked to the disease and reported
in the literature review, may concern social marketers and public policy makers, leading
them to avoid targeting strong threat messages to the most at-risk populations and
preferring incentives and not stigmatising positive appeals. The production of
generalised messages targeting generalised audiences and provided essentially by
governmental organisations may also be connected with that possible trade-off and
justify the lack of differentiation in the use of message appeals to the different targets,
messages and sources. The sensitiveness in the use of positive and negative emotional
appeals to cultural aspects and the epidemic dynamics reflect the background ideas that
identify positive appeals as progressive and negative appeals as conservative but
stronger and more effective messages used when incidence rates generate a more
concerning epidemic situation.

5.2. Theoretical and Managerial Implications

This thesis gives contributions for both academics and policy makers. As the focus of
the research consists on the analysis of practices, the recognition of practical
specificities may be a contribution to enrich social marketing theory, based on the
philosophy that theory is created with the insights of social practice. Given the
theoretical incongruence of studies about the effectiveness of positive and negative
appeals in social marketing, the knowledge about the expressive use of positive appeals

96

and how they take form in television social ads may reinforce their theoretical
definition, characteristics and advantages as a motivating insight. The sensitiveness to
culture and epidemic profiles also reinforce the theoretical evidences about the
differences on the effectiveness of appeals in different contexts. The content analysis
model proposed support academics to identify positive and negative appeals in a
theoretical vision and create social ads with them for laboratory research.
The lack of adequacy of theoretical knowledge to practice may reveal the concerning
with stigma and discrimination associated with the disease. It may represent a pressure
to the use of positive appeals, motivating people to change without showing shocking
images that might hurt people living with the infection or increase feelings of stigma in
society. That fact may influence the design of messages by social marketing
practitioners. This understanding has managerial implications because it may be an
important step to overtake fears in practice and better design oriented interventions
targeting vulnerable populations with the most effective appeals. The discussion of this
trade-off may be useful also for the theory and practice of public policy, concerning the
importance of evaluating the potential of their effectiveness with efficiency of the
financial investments. Since society is a mirror of public policies health-related social
marketing has consequences in epidemic control and can be an important vehicle
fighting illness stigma and discrimination.

5.3. Limitations and Future Research

The conclusions of this research should consider the specificities of the case, as the
particular stigma and discrimination that people living with HIV/AIDS still face in
society. The longitudinal amplitude of the research considered the first thirty years of
infection diagnosis. However, the reactive response to infection and their different
dimensions in the analysed countries inhibits the researchers of conducting deeper
longitudinal and geographical or cultural comparisons. Official epidemic data has been
available since 2000. The correlation analysis conducted between social marketing
policies and epidemic incidence rates could be deeper with more data available, to be
done in the future.

97

Further research might be conducted with a larger scope of countries and world
regions. That will allow the focus on other type of epidemic context and more
intercultural comparison. Future research asks for deeper studies about the
appropriateness of social marketing with cultural and epidemic profiles. As television
advertising is only one kind of media among others in communication, the results of this
thesis also might be enriched considering other types of media besides television and
other types of communication besides advertising. The research may also be compared
with other health issues, including illness stigmatised and not stigmatised diseases in
order to allow comparisons of results and wider the scope of conclusions. The results in
this thesis suggest that public policy makers should think about not hurting people
living with the disease, but at the same time should have in mind the fact that vulnerable
populations need to receive adapted messages targeting to them with most effective
appeals. Otherwise it may have consequences in the low outcome of behaviours
changes connected to social marketing interventions. Future research may explore the
existence of that trade-off and the specificities of communicating a stigmatised disease
that can require special attention is social marketing.

98

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