Special Session Summary Consumer Behavior and Public Health

Anthony D. Cox, Indiana University
Dena Cox, Indiana University
[ to cite ]:
Anthony D. Cox and Dena Cox (1997) ,"Special Session Summary Consumer Behavior and Public Health", in NA - Advances in Consumer Research Volume 24, eds. Merrie Brucks and Deborah J. MacInnis, Provo, UT : Association for Consumer Research, Pages: 303-304.

Advances in Consumer Research Volume 24, 1997      Pages 303-304



Anthony D. Cox, Indiana University

Dena Cox, Indiana University


The health care system in the United States has profound problems. To begin with, it is enormously expensive, costing Americans about $1 trillion a year, or about $4,000 per capita, the highest rate in the world. These costs place an increasingly heavy financial burden on families, businesses and government. An uninsured family can rapidly be bankrupted by a serious medical problem (e.g. a coronary bypass operation can easily cost $50,000); the exploding costs of Medicaid (the federally-mandated health insurance for the poor, that is largely funded by the states) has thrown dozens of states in severe budget crises.

However, despite these enormous expenditures, the health of the American public lags behind that of many other countries. For example, Americans spend about 40% more per capita on health care than do Canadians, but Canadians live longer (U.S. Industrial Outlook 1994). Similarly, the infant mortality rate in the United States is higher than that of many other industrialized countries.

Why do such health problems persist despite these enormous health care expenditures? In many cases, the underlying cause is problematic consumer behavior. For example, the relatively high rate of infant mortality in the United States is largely traceable to counter-productive consumer behavior: Many new American mothers (particularly if they are young and poor) continue to consume alcohol and tobacco during and after pregnancy, feed both themselves and their children inadequate diets, and fail to get their young children immunized, even when immunizations are available for free. Similarly, the spread of AIDS occurs mainly through problematic consumer behaviors, such the failure to use condoms and the sharing of hypodermic needles among drug users.

Policy makers cannot effectively address these health problems unless they can change the underlying patterns of consumer behavior that contribute to them. This is where consumer researchers can make a crucial contribution. Each of the presentations in this special session explores ways in which consume research can provide guidance to policy makers trying to solve these important public health problems.




Alan R. Andreasen, Georgetown University

There is substantial evidence in the research literature that consumers do not undertake high involvement behavior changes in single steps. They go through a series of stages from indifference and ignorance through to action and commitment to the new behavior. Marketing scholars have referred to stage models in the past. However, their focus has been either on the "hierarchy of effects" of advertising and similar communications (e.g. Lavidge and Steiner 1961) or on the stages of adoption of new ideas (Rogers 1962, 1983).

In recent years, a number of researchers have developed generalized stage models to look at how people voluntarily change problematic behaviors such as smoking, using drugs, or overeating (e.g. Prochaska and DiClemente 1983). This work has established that (a) stages exist; (b) they can be identified by rather simple measurements, and (c) interventions tailored to particular stages will be more effective than interventions that do not make this distinction. Recently, Maibach (1995) and Andreasen (1995) have employed stage models as basic building blocks to their general approaches to social marketing.

The potential for using stage models to ground research in other areas of consumer behavior has been largely ignored. Yet, stage models can be extremely useful in understanding how consumers come to adopt new eating patterns, take up hobbies or other leisure pursuits, or settle into new patterns when they move to new communities.

This paper outlines the major characteristics of stage models. It summarizes some of the central findings in social marketing and then sets forth a generalized approach that can be used in a wide variety of consumer settings. A number of propositions for field and experimental research are set forth as means of testing these models in more conventional contexts. The paper concludes with recommendations for both researchers and consumer marketers.




Anthony D. Cox, Indiana University

Dena Cox, Indiana University

In recent years business and political leaders have searched for ways to improve public health while controlling health care costs. Almost every proposal has called for an increased emphasis in the health care system on the prevention and early detection of disease. This shift makes great sense, both economically and medically. Many of the major killers in an industrialized society (e.g. high blood pressure, diabetes, and some cancers) can be detected through relatively inexpensive medical tests, and can be treated much more effectively and cheaply if they are detected early. However the successful implementation of a prevention/detection healthcare strategy represents a major marketing challenge: Persuading consumers who are feeling fine to expend money, time and effort on medical services (e.g., Pap smears, prostate exams) which may appear to offer no immediate benefits.

A good illustration of this challenge is the low rate of adoption of annual screening mammograms. Breast cancer is one of the leading causes of death among women (Miller and Champion 1993), and research indicates that screening mammography can greatly reduce the mortality rate of this disease (Reynolds and Jackson 1991). Yet most women either do not have mammograms at all, or have them less often than recommended by the National Cancer Institute (Lehrman et al. 1990). Why is this so? One possible explanation may be consumers’ misperception of their own health risks: Women who shun screening mammograms may tend to underestimate their personal risk of contracting breast cancer (Stein et al. 1992; Lehrman et al. 1990;Vernon et al. 1990) and may tend to have a poor understanding of the risk factors for the disease. For example, there is evidence that as the age of women increases, their perceived susceptibility to breast cancer decreases, while in fact their actual risk increases dramatically (Vernon et al. 1993). This is consistent with psychological research indicating that consumers tend to have distorted (usually over-optimistic) perceptions of their own medical and other risks (Plous 1993, pp. 131-144).

This presentation discusses some survey findings regarding the determinants of older women’s perceived risk of getting breast cancer, and how these risk perceptions affect their intentions to obtain a mammogram. The data yield some surprising results. Most notably, preliminary analysis suggest that women who perceive themselves as likely to get breast cancer are no more likely to intend to get a screening mammogram. Several interpretations for this finding are discussed, including the possibility that early detection of cancer may be perceived as (at best) a mixed blessing by consumers who perceive themselves to be at high risk.




Ronald Paul Hill, University of Portland

Debra Lynn Stephens, University of Michigan

Following their defeat of the Democrats in the November 1994 elections, the House Republicans put forth 10 draft bills that make up their "Contract With America." One aspect of this proposed legislation, the Personal Responsibility Act (PRA), would reduce significantly the number of poor Americans on the welfare rolls as well as those currently receiving health insurance through the Medicaid program. However, research demonstrates that the relationship between welfare (Aid to Families with Dependent ChildrenCAFDC) payments and receipt of Medicaid is more complex than policy makers realize.

Schneider (1993) found that the association between these two programs was asymmetrical, meaning that Medicaid spending has an impact on AFDC payments rather than the reverse. Others (see Hill and Macan 1996) have interpreted these results to suggest that poor women who value medical insurance are likely to seek and attempt to maintain AFDC eligibility in order to ensure health coverage. Further, Moffitt and Wolfe (1992) found that an extension of health insurance coverage to the poor would lead to a 25 percent reduction in AFDC caseloads.

This presentation examines research involving welfare mothers and their consumer survival strategies within the current and proposed welfare systems. Further, we will examine this ongoing debate from a historical perspective and submit evidence that demonstrates the failure of proposed reform measures to eliminate/reduce poverty, solve health care dilemmas faced by the poor, or control government spending. The close will advance social marketing implications that may help resolve these failures. Specifically, we will advance the development of outreach programs that encourage the poor to apply for health insurance coverage while simultaneously allowing them to seek employment.


As the presentations in this session illustrate, consumer researchers can make significant contributions to understanding serious public health problems. However, consumer researchers wishing to investigate these issues may need to adopt some unaccustomed ways of thinking about consumers and consumer behavior. First, while much traditional consumer research focuses on selective demand (e.g. brand choice, store patronage) public health issues are more likely to relate to primary consumer demand; e.g., consumption of tobacco products, or alcohol, or firearms, or (on the positive side) use of mammograms or immunizations. Second, while traditional marketing strateies tend to focus on research attention on the most receptive consumers (i.e., "the best prospects" for one’s product), those in public health often must try to reach the most resistant consumers, e.g. the "hard core" 25% of the adult population that continues to smoke. Finally, while affluent consumers generally receive the most attention from marketing researchers (and indeed, some definitions of a "market" includes the ability to spend money to satisfy one’s needs), those in public health are often most interested in reaching consumers with the least income and education, among whom many high risk consumer behaviors are most prevalent. Thus while consumer researchers have many skills that can be useful in addressing public health problems, doing so will involve changing many of the perspectives traditional consumer research.


Andreasen, Alan (1995), Marketing Social Change: Changing Behavior to Promote Health, Social Development and the Environment, San Francisco: Jossey-Bass.

Hill, Ronald Paul and Sandi Macan (1996), "Consumer Survival on Welfare With an Emphasis on Medicaid and the Food Stamp Program," Journal of Public Policy & Marketing, 15 (Spring), forthcoming.

Lavidge, R. and G. Steiner (1961), "A Model for Predictive Measurements of Advertising Effectiveness," Journal of Marketing, 25 (Oct.), 59-62.

Lehrman, C., B. Reimer, B. Troch, A. Balshem, P. Engstrom (1990), "Factors Associated With Repeat Adherence to Breast Cancer Screening," Preventive Medicine, 19, 279-290.

Maibach, E. and R. Parrott (1995), Designing Health Messages: Approaches from Communication Theory and Public Health Practice, Thousand Oaks, CA: Sage Publications.

Miller, A. and V. Champion (1993), "Mammography in Women 50 Years of Age," Cancer Nursing, 16(4), 260-269.

Moffitt, Robert and Barbara L. Wolfe (1992), "The Effect of the Medicaid Program on Welfare Participation and Labor Supply," Review of Economics and Statistics, 74 (4), 615-626.

Plous, S., (1993), The Psychology of Judgment and Decision Making. Philadelphia, PA: Temple University Press.

Prochaska, J.O. and C.C. DiClemente (1983), "Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change," Journal of Consulting and Clinical Psychology, 51 (3), 390-5.

Reynolds, H. and V. Jackson (1991), "Self-Referred Mammography Patients: Analysis of Patients’ Characteristics," American Journal of Radiology, 157, 481-484.

Rogers, E. (1962, 1983), Diffusion of Innovations, New York: Free Press.

Schneider, Saundra K. (1993), "Examining the Relationship Between Public Policies: AFDC and Medicaid," Public Administration Review, 53 (July/August), 368-380.

Stein, J., S. Fox, P. Murata, D. Morisky (1992), "Mammography Usage and the Health Belief Model," Health Education Quarterly, 19(4), 447-462.

Vernon, S., E. LaVille, G. Jackson (1990), "Participation in Breast Cancer Screening Programs: A Review," Social Science and Medicine, 30(10), 1107-1118.