The Impact of Influence: Technology and Strategy in Health and Wellbeing

By David Nutt

A Facebook post about a bad day, the placement of chocolate milk in the school cafeteria, taxes on sodas: Research on strategies for health and wellbeing is now encroaching on the turf of advertising, social media and behavioral economics. To understand influence—what nudges our minds and behaviors in seemingly small ways—CALS researchers are harnessing research in communication, psychology, economics and public policy to find new and inventive ways to give public health a big boost.

Natalie Bazarova
“Preliminary data show that people with depression are more concerned about how they present themselves on social media than ‘normal’ folks and they’re less satisfied with what they share, even when they get responses from others.”

Natalie Bazarova, assistant professor of communication
Photo: Rob Way

Assistant professor of communication Natalie Bazarova ’05, Ph.D. ’09, looks at how people communicate across social media and what effects this has on their lives, relationships and wellbeing. She’s particularly interested in the personal information people share—and sometimes overshare—through social media applications like Facebook, Twitter and Yik Yak, as well as their goals and motivations in sharing this material.

“The technology is always changing,” said Bazarova, who directs the Social Media Lab at Cornell. “We want to understand the principles of human communication and its relationship to health that extend beyond a specific app.”

To develop the necessary tools to explore these kinds of communication, Bazarova sought out interdisciplinary partners, including Dan Cosley, associate professor of information science, and Janis Whitlock, Ph.D. HumEc ’03, a research scientist in the Bronfenbrenner Center for Translational Research and director of the Cornell Research Program on Self-Injury and Recovery.

Recently the group undertook a National Science Foundation-funded study that examined mental health and how it relates to human experiences on the internet through the prism of social media. By asking subjects what they share online, how people respond to these posts, and how the sharers’ sense of wellbeing fluctuates in the presence or absence of social support, Bazarova and her collaborators are finding that while social media has the potential to boost wellbeing it can also have negative consequences when people overshare personal information.

“Yes, it can help us with wellbeing, but it can also open a can of worms, from cyberbullying to silence,” Bazarova said.

Another recent study looks at the way people use social media to send distress messages and how others make sense of those messages and evaluate whether they require help. A related project examines what happens when messages are not just distressing but damaging to others and whether such displays of cyberbullying motivate people to act.

“Are we promoting a culture of bystanders because it’s happening in social media?” Bazarova asked.

A study currently underway investigates people who have a history of mental health issues and how their experiences with social media differ from the rest of the population. The researchers are hoping to see if the way these people share information online could be an early indicator of distress.

“Preliminary data show that people with depression are more concerned about how they present themselves on social media than ‘normal’ folks and they’re less satisfied with what they share, even when they get responses from others,” Bazarova said.

The ultimate goal is to create a more caring community in this new digital environment, one in which participants can intervene and mitigate negative consequences.

Nutritional Nudges

David Just
“When there’s a perception of abundance people take a lot because it’s suggested they should. That perception of abundance helps sell it. So making it look like ‘Well, you can take these, but we don’t have a lot of them’ was enough to change people’s behavior.”

David Just, professor in the Charles H. Dyson School of Applied Economics and Management
Photo: Rob Way

For David Just, it is the little things that have the greatest impact. Just is a professor in the Charles H. Dyson School of Applied Economics and Management and co-director of the Cornell Center for Behavioral Economics in Child Nutrition Programs (BEN), and he combines psychology and economics to understand how consumers make decisions in “food choice environments,” like the lunch line at school or a grocery store checkout.

“For the most part people don’t think very carefully about food decisions, even when they’re making them,” Just said. “They are responding to their environments and what they think is normal and acceptable. It’s pretty easy to change that up.”

The challenge, according to Just, is that the majority of food policies that encourage people to eat healthier—labeling calories, for example, or banning unhealthy items—fail to take into account the way consumers actually behave, and these policies rarely reach the people who truly need their help.

The trick is to motivate people to eat healthier foods, like fruit and vegetables, and fewer sugary snacks without overburdening them in the process.

In a recent field experiment that sought to boost fruit and vegetable consumption among the Hispanic population in El Paso, Texas, Just and his team visited a grocery store and placed six-foot-by-three-foot arrows on the floor pointing toward the produce section. The arrows resulted in a 9.5-percent bump in produce sales.

Another experiment found that consumers will purchase bottled water instead of soda if the bottled water is in a more visible and accessible location. An experiment at a food pantry revealed that if given the choice between a pile of bagels or a pile of donut holes, one-third of participants would pick the calorie-dense donut holes. But when the display quantity of donut holes is limited to a single bag of six donut holes versus a stack of many bags of six bagels, only seven percent of participants chose the donut holes.

“When there’s a perception of abundance people take a lot because it’s suggested they should. That perception of abundance helps sell it,” Just said. “So making it look like ‘Well, you can take these, but we don’t have a lot of them’ was enough to change people’s behavior.”

Through his work with the BEN Center’s Smarter Lunchrooms Movement, Just has helped bring these types of simple, yet heathy, solutions into school cafeterias across the country. Recommended strategies include providing healthy food items in “grab-and-go” lines while keeping unhealthy items in longer lines that make students wait, and placing white milk first in lunchroom coolers, which resulted in an increase of up to 46 percent in white milk sales.

“These are simple interventions, but at the same time we’re doing it in a way that doesn’t overburden them. Food pantries don’t have many resources, and schools don’t have many resources. Grocery stores actually run pretty thin as well,” Just said. “So it has to be something that’s super simple, not particularly expensive, and that actually has a measureable benefit.”

Scaling Back

David Levitsky
"People are gaining weight, and when you ask them 'Why?' they don't know, because that weight gain, despite being five pounds over 12 weeks, is still too small for you to see. So the scale is a way of actively visualizing it."

David Levitsky, professor of nutritional science
Photo: Rob Way

For David Levitsky, a CALS professor in the Division of Nutritional Sciences, the solution is not in the food aisle but on the scale.

Levitsky has spent his professional career studying the control of food intake and regulation of body weight, and he believes the number one nutritional problem faced by the United States—and most countries, for that matter—is rising obesity rates, which have been increasing for the last 50 years.

To slow the growth of girth, Levitsky advocates for another simple technique: frequent self-weighing.

Levitsky’s research into self-weighing began about ten years ago when he started looking into the amount of weight Cornell freshmen typically gain in their first semester on campus.

“We discovered what the students knew anyway. The weight gain at Cornell is pretty hefty,” Levitsky said. “It’s about five pounds that first semester. And I became intrigued with this because that’s exactly what’s happening in the world outside of Cornell. People are gaining weight, and when you ask them ‘Why?’ they don’t know, because that weight gain, despite being five pounds over 12 weeks, is still too small for you to see. So the scale is a way of actively visualizing it.”

The basic act of stepping on a scale every morning serves as a “negative prime,” countering the stimuli that lead a person to eat. And those stimuli can be quite persuasive. Levitsky’s studies have shown that the mere act of discussing food, seeing a food ad on TV, or even looking at a bowl, can trigger a person to eat.

“There’s this environmental structure in the food system that makes becoming overweight very easy,” said Lua Wilkinson, a graduate student in the Division of Nutritional Sciences and advisee of Levitsky. “Making that system visible to the individual is very difficult, particularly when they’re just inundated with unhealthy practices, including high fat, fast food, convenience food, low exercise, ads on TV. Frequent weighing helps you make these invisible forces more visible so you’re able to see your weight change over time with the environment you’re in.”

Between the ages of 20 and 40, most people gain an average of one pound a year, Levitsky said, and it’s this incremental creep that can eventually lead to obesity.

The problem is even more pronounced for adolescents. In a recent pilot study in Huntsville, Ala., Levitsky focused on obese and overweight children between the ages of 8 and 11. While the amount of weight they gain is smaller, it adds up over time and becomes that much harder to shed after adolescence. Levitsky is hopeful that self-weighing each day will help the children avoid a lifetime of health issues.

“All the major pathologies, whether you’re talking about diabetes, heart disease, stroke or cancer, all increase as weight increases,” he said. “These are expensive diseases, and the fatter we get, the greater the expenses. It’s eventually going to hit us in the pocketbook, and the medical cost of insurance will skyrocket unless we can at least stop gaining weight.”

Pitch or Policy

Harry Kaiser
“When you use a fiscal type of policy like a tax or subsidy to try to change behavior, you’re already dealing with people who are not very price-sensitive anyway, so whether you increase the price or decrease the price you have to do it by quite a bit to have much of an impact.”

Harry Kaiser, the Gellert Family Professor in the Charles H. Dyson School of Applied Economics and Management
Photo: Rob Way

While individuals may struggle to stave off the pounds, there are also a number of anti-obesity policies that have been proposed to help in the battle of the bulge. Harry Kaiser, the Gellert Family Professor in the Charles H. Dyson School of Applied Economics and Management, is a behavioral economist whose recent research has examined the effectiveness and impacts of such policies, like fat and sugar taxes, anti-obesity advertising, and healthy food subsidies—financial incentives such as discounts and reduced prices.

“Obesity has reached epidemic proportions in the United States, and there are a lot of theories on why that is the case,” Kaiser said. “What I’ve been looking at is the efficacy of some of the social and economic policies that either have been implemented or are being proposed. I’m not really using traditional, economic models but more in the behavioral and experimental areas instead.”

Through his experiments and a National Institutes of Health-funded field study, Kaiser found the least effective policy is the healthy food subsidy, which has a tendency to backfire on participants, who end up purchasing more unhealthy foods along with more fruits and vegetables. The benefits, then, are negligible.

Taxing unhealthy foods proves to be a slightly more successful tactic, although it may not be effective in the long run. In Kaiser’s experiments he implements a 20-percent tax, which causes his subjects to curtail their purchasing of unhealthy foods immediately. However, over time people will generally return to their previous pre-tax consumption habits.

According to Kaiser, this reversion is particularly true with Americans, who—due to the relative wealth of the United States—are less sensitive to price increases than other populations around the world. And although income level can affect price sensitivity, even lower income Americans tend to be fairly insensitive to price changes under 25 percent.

“When you use a fiscal type of policy like a tax or subsidy to try to change behavior, you’re already dealing with people who are not very price-sensitive anyway, so whether you increase the price or decrease the price you have to do it by quite a bit to have much of an impact,” he said.

While some regions have tried to ban unhealthy products, most notably New York City in its campaign against large sodas, those policies often trigger a backlash among consumers, who will actively seek out the banned product as a way to reaffirm their freedom of choice.

Kaiser’s studies show that the strongest policy for reducing obesity is healthy food and anti-obesity advertising, and his ideal solution would be a tag-team approach: implementing a food tax on unhealthy items, with the proceeds funding a robust anti-obesity advertising program.

“There’s a reason we have so much advertising,” Kaiser said. “Because it works.”

Mechanics of Messaging

Sahara Byrne
“If the labels are just the right amount of scary and they tell us how to solve the problem also, then we actually are more willing to let them in and think about how they apply to us.”

Sahara Byrne, associate professor of communication
Photo: Tiit Lukk

Given the ubiquity and sophistication of modern advertising, and how much media dominates contemporary life, Sahara Byrne, associate professor of communication, is working to help people make sense of all the health-related messaging that bombards them every day.

“They are being exposed to messages that are contrasting, that are helping, that are hurting, and so I’m trying to help supply some clarity and some effectiveness to that daily experience,” Byrne said.

Of particular interest to Byrne are the ways that messaging efforts intended to help people can sometimes go awry and have the opposite or unintended effect, or sometimes no effect at all.

For example, recently Byrne saw an ad in the subway that featured a drawing of an overweight man with a stomach full of visible items, including fast food, french fries, soda and donuts. An accompanying text explained how the unhealthy food had made the man fat. But for Byrne, rather than being dissuaded from buying junk food, the poster actually made her hungry. She also wondered how the poster would appear to children who could not read the explanatory text, or to women who felt the image only applied to men.

“These are all different kinds of mechanisms that might cause messaging to backfire or not work or have an unintended effect on audiences,” Byrne said.

For a recent grant from the National Institutes of Health, Byrne has teamed up with associate professor of communication Jeff Niederdeppe, dean of Human Ecology Alan Mathios and Cornell Law School professor Michael Dorf to examine the placement of graphic warning labels on cigarette packages. They are determining what such warning labels would look like, who they would be most effective for, and whether the graphic labels could backfire and instead scare people into covering them up and ignoring the message.

“If the labels are just the right amount of scary and they tell us how to solve the problem also, then we actually are more willing to let them in and think about how they apply to us,” Byrne said.

Another study, which Byrne conducted with Geri Gay, communication and information science professor, examined the way that technology, and specifically iPhones, can deliver health messages custom-tailored to youths.

“That is going to be a huge area. Like marketing is very much tailored, so our health messaging will be,” Byrne said. “But it’s difficult to know what kind of processer a person is, if they are highly reactant or have lower cognitive ability. We are not quite there yet, but we’re getting really close.”

One constant challenge Byrne faces is that her research involves a great deal of field work, particularly with youths and underrepresented populations who are often difficult to reach. However, a recent NIH grant is funding a mobile lab equipped with experiment stations that will allow Byrne to travel to inner city neighborhoods and schools.

“That field work is about to get really interesting with this mobile lab. I’ve always had to bring all my equipment to malls, where I do a lot of research, or school grounds,” Byrne said. “Now I can bring it in its own little environment. Space is very scarce in schools and in cities. So I’ll be able to have the lab come to them.”

Strategic Storytelling

Jeff Niederdeppe
“You can have a message that says, ‘Look, this product kills 3,000 people a day,’ and ‘This company knows it and is promoting this product to you anyway.’ And that’s a really powerful combination.”

Jeff Niederdeppe, associate professor of communication
Photo: Rob Way

Sharing the grant for the mobile lab is fellow associate professor of communication Jeff Niederdeppe, whose own work measures the role of mediated communication in shaping human health behaviors and also the support such health-related policies receive.

Niederdeppe’s projects range from efforts that promote safer consumption of fish to those reducing smoking and obesity among youths to analyzing the marketing of prescription pain medication, all with an emphasis on prevention.

Recently Niederdeppe looked at the roles strategic communications play in shaping public support for policies that would create healthier environments, such as taxes on alcohol or sugar-sweetened beverages and restricting marketing to youths.

Specifically, Niederdeppe and colleagues wanted to see how various message strategies on the pro-policy side intersect with counter messages that come from industry and other opposition-minded groups. For instance, Niederdeppe compared the effectiveness of storytelling strategies that personalize issues, such as a mother with a daughter who is experimenting with cigarettes, versus an “inoculation” method that preemptively addresses the points that industry would make in opposition to policies to restrict their marketing and promotion. Niederdeppe found that while the storytelling approach is effective, if a policy faces strong resistance from an industry willing to spend great sums of money to undermine support, then the inoculation strategy is preferable.

Niederdeppe also collaborated with Rosemary Avery, professor in the College of Human Ecology’s Department of Policy Analysis and Management, to look at what types of anti-tobacco messages have most greatly reduced youth smoking rates over the last ten years.

Using a database that Avery assembled that catalogues and classifies tobacco ads from all 50 states over the last decade, the researchers were able to isolate two types of messages most often associated with lowered smoking rates: ads that emphasize long-term health consequences of smoking and ads that emphasize the tobacco industry’s role in promoting their products.

“Both of those have a synergistic effect,” Niederdeppe said. “You can have a message that says, ‘Look, this product kills 3,000 people a day,’ and ‘This company knows it and is promoting this product to you anyway.’ And that’s a really powerful combination.”

Another project undertaken with the Department of Policy Analysis and Management examined the impact that direct-to-consumer pharmaceutical ads have on the public. The researchers found that ads for statins, i.e., drugs that aim to reduce cholesterol, not only led to an increase in prescriptions, but the ads also had the biggest impact on people with comparatively lower levels of risk for diabetes or high-blood pressure. In short, the advertisements made the people who least needed the drugs request them more.

For Niederdeppe, this type of research may not change policy immediately but can slowly help shape it. The need is quite apparent. After all, healthier populations lead to more affordable insurance, a less strained healthcare system, and a stronger workforce. And one key to boosting collective health is to understand the messaging that supports—or sometimes undermines—it.

“Here in the United States we develop these campaigns to promote healthy behavior, and the level of exposure these campaigns receive are just drops in the bucket compared to the huge amount of health-related information we receive from big pharmaceutical companies, from fast food companies, from soda companies,” Niederdeppe said. “So we better understand what impact this other stuff is having, and if we want to compete with these messages we better understand what we’re competing with.”