Delivering a jolt to spotlight a health crisis

In 2011, about 40% of Georgia's children were overweight or obese. Doctors at the state's largest children's hospital knew it was a recipe for big public health issues down the road, but doing something about it was a different matter.

Hospital officials had seen survey results showing half of Georgians didn't think obesity was a problem. More disconcerting, 3 out of 4 parents with an obese child didn't think anything was wrong.

“There was a major denial issue here,” recalled Linda Matzigkeit, chief administrative officer at Children's Healthcare of Atlanta. “We had the second-highest rate of childhood obesity in the country.”

They knew how to help parents help their kids—but how could they prod the parents to act? The answer they hit on was to antagonize them.

Around the same time, Atlanta was buzzing about shocking TV ads about another big problem, methamphetamine use. The ads were hard to watch and upset viewers—showing teens being dumped at emergency rooms, very young addicts engaging in prostitution and kids screaming in agony. But people were talking about them. Everybody had at least heard there was meth problem.

That's what Children's Healthcare of Atlanta wanted to do with child obesity—force a conversation.

Inspired in part by the meth campaign, the hospital jolted parents—and stirred up plenty of criticism— with TV ads and billboards featuring pictures of overweight children, many with messages that subtly criticized parents. One, for example, said, “Big bones didn't make me this way. Big meals did.”

It was an unusually risky ad campaign, but the kind of risk healthcare organizations and advertising experts say can pay off if done right. From local hospitals to major insurers, from major multifaceted health systems to pharmaceutical companies, few across the spectrum of healthcare seek to wade into controversy in their advertising. But sometimes, they start conversations that are important, and can be effective, even if they make some uneasy.

Matzigkeit said Children's Healthcare officials knew they would offend people after pretesting the obesity campaign in focus groups, and some said the ads made them uncomfortable. That was the idea.

“It was intended to wake everybody up,” Matzigkeit said.

And it did. Childhood obesity became a hot topic in Atlanta, and the two other Georgia cities where the TV spots ran, Macon and Columbus. There was widespread news coverage, there were letters to the editor, and just people in the community talking.

“Quite frankly, whether you liked it or didn't, everybody was talking about it,” Matzigkeit said. “It was intended to create awareness about a crisis.”

The ad campaign was unusual for healthcare providers, which generally don't want to make people angry, said University of Georgia professor Karen King, who studies public health advertising. She heard from many people saying they were put off by the ads. “The criticism was that this was fat-shaming,” she said. “How would this make kids feel?”

And it came with a risk that people might think their local children's hospital, which King said enjoys enormous local goodwill, was being judgmental, which is hardly welcoming.

It's very uncommon to see healthcare providers take many big risks in advertising, agreed Kathleen Lewton, principal of Lewton, Seekins & Trester, a public affairs and marketing firm that advises hospitals.

Most healthcare provider ads are positive, designed to enhance reputation, build brand image or encourage people to use services and physicians.

“It's hard for an organization that needs all sectors of a community to support it to risk taking a stand on a controversial issue and creating backlash that affects reputation, staff recruitment, marketing, fund-raising,” Lewton said.

But while the Children's Healthcare of Atlanta ads may have been attention-grabbing, the use of “anticipated regret,” or making people think about possible consequences of negative health choices, isn't really that rare.

“We hear all the time about the harms of smoking, of not getting a flu shot, of forgetting to take medicine as prescribed,” said Noel Brewer, a professor in the University of North Carolina Gillings School of Global Public Health who studies how people make medical decisions.

Most recently, Merck ran an ad this summer for Gardasil, its human papillomavirus vaccine, in which a boy reasons that his parents perhaps weren't aware he could end up with cancer from HPV.

“Maybe my parents just didn't know,” he reasons in the TV spot, which ran frequently during the Summer Olympics. “Right, Mom? Dad?”

There are ways to cautiously dip into difficult issues, said Christine Paige, Kaiser Permanente's senior vice president for marketing and digital strategy. She said antagonism isn't in the Kaiser advertising playbook. “We feel if you're in the business of helping people, you have to start from an affirmative.”

That's not to say Kaiser won't get provocative or deal with potentially sensitive issues. The Oakland, Calif.-based system recently ran an ad taking on the stigma of mental illness through the perspective of a young boy who recites rapper Kendrick Lamar's lyrics about battling depression.

“I went to war last night. I've been dealing with depression ever since an adolescent,” the boy says in the TV spot. “Duckin' every other blessin'. I can never see the message.”

The ad addresses a topic health experts say demands greater attention. It's also an issue that has driven controversy as Kaiser and other providers face criticism from regulators about not devoting more resources to treat mental illness.

The ad wasn't meant to address that criticism specifically, Paige said, but Kaiser wants to start a broad conversation about mental health and to get more people to seek treatment.

Kaiser also stepped subtly into another potentially controversial issue in a different ad.

Kaiser's 2015 ad “Grow Old With Me” is more typical of healthcare marketing—it's warm and tugs at the heartstrings with scenes of loving family interaction. But one scene briefly shows two men who have just married each other.

“You can contemplate whether somebody will be offended, but the approach we took is, we serve everyone,” Paige said. “And that's part of that broad tapestry of life. ... We were very clear our goal was to be fully inclusive.”

There was no major backlash to including the gay couple in the ad.

Another reason hospitals may stay away from touchy issues: Thanks to social media, local controversies can quickly spiral.

“You do something that inadvertently offends three people who tweet 'this is outrageous' and it gets picked up by a blogger and re-tweeted and suddenly it gets magnified, but like with the Hubble telescope,” Lewton said.

That's what happened with the Children's Healthcare of Atlanta childhood obesity ads, which drew international news coverage and pushback from advocacy groups around the country.

But Matzigkeit said they'd expected it, which prevented the reaction from feeling like a crisis. She said it's critical to have key stakeholders know what's coming. That's why they pretested the ad. And then, she said, “You've got to have your board say, 'No matter what, we'll stand behind it.' ”

Hospital officials not only didn't have second thoughts—they went back to the tactic for a second campaign as part of the Strong4Life initiative aimed at encouraging healthy behavior. The “Rewind the Future” video ran in movie theaters before the film, just when parents would be handing their kids extra-large sodas and giant candy bars.

It was a flashback of a heart attack victim, showing all the unhealthy things he did through childhood, most enabled by his parents. His dad orders an extra-large pizza, and his earliest memory is of his mom feeding him french fries to avoid a tantrum.

Matzigkeit noted the campaign went far beyond the ads. There was follow-up, including working with schools on meal planning and training doctors how to better talk with parents.

Child obesity has decreased slightly in Georgia since, although it's difficult to determine what role the campaign has played, if any. Officials do know the percentage of people who think obesity is a problem has grown.

“It was successful, because it got the dialogue going,” Matzigkeit said. “We definitely shifted the perception. People now see it's a problem.”

David Royse is a freelance writer based in Chicago.