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Public Health BrandingApplying marketing for social change$

W. Douglas Evans and Gerard Hastings

Print publication date: 2008

Print ISBN-13: 9780199237135

Published to Oxford Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780199237135.001.0001

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Branding through cultural grounding: The keepin’ it REAL curriculum

Branding through cultural grounding: The keepin’ it REAL curriculum

(p.161) 9 Branding through cultural grounding: The keepin’ it REAL curriculum
Public Health Branding

Michael L. Hecht

Jeong Kyu Lee

Oxford University Press

Abstract and Keywords

Culture plays an important role in commercial as well as public health branding. A cultural grounding approach to branding appeals to the cultural/social elements of the target population and nurtures a relationship with audiences by calling up their own meanings, messages, and identities. The cultural grounding approach was used to develop the keepin' it REAL curriculum, an efficacious, multicultural, substance abuse middle school prevention program. The keepin' it REAL curriculum culturally grounded its branded health promotion messages through narratives and community-based participatory research. Cultural grounding to branding is a method for developing culturally grounded health brand and provides useful insights for health message design centered on social and cultural forces.

Keywords:   branding, culture, cultural grounding, keepin' it REAL curriculum, community-based participatory research


Health message design theory has long recognized the role of culture and the social marketing approach of branding seems particularly attuned to this viewpoint. This approach recognizes the need to build strong brands in the globalized market. However, brands are not easily transportable across cultures. For example, China’s new open-door policy has created an attractive new market for western companies. Yet, many western organizations rushed into China without considering cultural differences between the Chinese and domestic markets. As a result, many failed to build successful brands in the emerging Chinese market because they adopted marketing strategies that had proven successful in the western market and applied them to the Chinese market. Many companies now realize these approaches were problematic and are blending their brands with regional and cultural concerns (Melewar et al. 2004; Keller 2007).

This leads to the question, ‘What is culture?’ Although no single definition of culture is universally accepted in social science, there is generally agreement that culture is learned, (p.162) shared and transmitted from one generation to the next, and it can be seen in a group’s values, norms, practices, systems of meaning, ways of life, other social regularities and so on (Kreuter et al. 2003; Baldwin et al. 2006). Some specific examples illustrate how global brands have successfully capitalized on cultural elements in foreign markets. Coca-Cola adapted one of its brand names, ‘Diet Coke’ to ‘Coke Light’ or ‘Coca-Cola Light’ when it found that the word diet connoted the need for weight-reduction rather than minimizing weight gain in some countries (Dana and Oldfield 1999). In Indonesia, home to the world’s largest Muslim population, KFC used Ramadan-themed outdoor advertising to encourage consumers to come to the restaurants during that holiday season (Keegan and Green 2005). Lastly, McDonald’s advertising has been successful in Japan during the past several years. Their advertising has mainly focused on various aspects of fatherhood and relationship with family members. By doing so, McDonald’s has encouraged Japanese consumers to associate the restaurant with family members interacting in various situations (Ono 1997).

Elaborating on this basis premise, we define culture as code (a system of meanings or rules), conversation (a way of interacting) and community (a sense of membership) (Philipsen 1992). These dimensions provide the basis for developing tailored and targeted health promotion messages because they help us to describe the cultural experiences and voices of group members as well as identify cultural similarities and differences across groups. Based on this definition, designers of health messages need to consider how members of a group will interpret a message (code), the best medium or form for conveying the message (conversation) to them, and the most salient identities of the target audience (community). In this chapter we explicate these ideas, describing a cultural approach to branding that we call cultural grounding (Hecht and Krieger 2006).

Culturally grounded branding is an audience-driven approach to understanding the ‘culture’ of groups as a starting point for health message design rather than adding culture to messages. The culturally grounded approach is predicated on the essential role of codes, conversations and communities in health message processing. Instead of universal messages focusing on dominant cultural values or even the modification of universal messages to ‘other’ cultures, an approach we call cultural sensitivity, a culturally grounded intervention creates a brand that involves cultural/social elements of branding because it utilizes the symbolic representations, norms and values of each identity group and communicates in a form and style that reflects those found within the culture. Cultural grounding attempts to make these branding elements into a network of associations (Mooij 1998) through multi-delivery strategies such as videos, billboards, product ancillaries, etc. In turn, it creates positive imagery associated with a brand and builds up strong relations with audiences. These networks emerge from the cultural code and are transmitted through social interaction among members of a community. As a result, brands can be developed from the codes, conversations and communities in order to make them more accessible to the target audience and promote identification and loyalty. Cultural grounding nurtures a relationship with the audience by calling upon their own meanings, messages and identities.

This chapter introduces the keepin’ it REAL curriculum as an example of a culturally grounded approach to branding health promotion messages. At the heart of this process (p.163) is the community-based participatory formative research used to derive the brand from the culture. Thus, the chapter describes the principle of cultural grounding as a method for developing a health brand and the ways that the curriculum was developed and implemented for multicultural, school-based substance use prevention.

The role of culture in branding

Grounding means starting with the basic elements of culture articulated in our definition. Various cultural groups differ in their systems of meanings (codes), ways of interacting (conversation), and sense of memberships/identity (community). In public health branding, culture plays an important role in branding because it provides a framework for targeting or tailoring messages for identity groups and their members as well as identifying the means of communicating messages that will appeal to local meanings and values. Thus the chapter discusses branding through the lens of code, conversation and community.


Effective brands have significance that goes beyond their physical properties, utilitarian character and commercial value (Aaker et al. 2001) that largely rests upon their symbolic representations and expressions of cultural meanings and values (Richins 1994; Aaker et al. 2001). Shavitt has asserted that culture-specific meaning typically resides in the abstract qualities of the brand that provide primarily symbolic or value-expressive functions to the consumers (Shavitt 1990), what is commonly known as ‘brand image’.

For instance, the National Pork Board launched the ‘El cerdo es bueno (Pork is Good)’ campaign for the Hispanic market. Due to the experiences brought from their home countries, where pork-related illnesses are pervasive, many Hispanics, particularly among those who are immigrants or first-generation Americans, have health-related concerns regarding pork. The campaign was effective because it addressed key barriers to pork consumption based on their cultural experiences with a simple and straightforward message – ‘Pork is Good’ – conveying the meaning that US pork is safe, delicious and healthy (Korzenny and Korzenny 2005).

The truth campaign is another example of how effective branding utilizes cultural codes and images. The campaign builds a positive and anti-smoke identity through hard-hitting advertisements that feature teens confronting the tobacco industry (Farrelly et al. 2002). A well-known truth advertisement, called ‘Body Bag’, features teens piling body bags in front of a tobacco company’s headquarters and, broadcasting loudly through a megaphone, explaining that these represent the 1200 people who die daily from smoking. This example demonstrates that the series of ads, including ‘Body Bag’, tells how risky smoking is using images such as the piling of body bags.


Effective branding also must consider the messages and the channels through which they are presented. Brands tell stories or narratives that must resonate with cultural identities (p.164) through culturally appropriate media. Cultures differ in their style of communicating (Hecht et al. 2003a) and this necessitates different branding messages. For example, Kishii (1988) identified several message characteristics that differ between Japanese and American culture. According to his findings, indirect rather than direct forms of expression are preferred in Japanese messages. This roundabout way of expression is pervasive in all kinds of communication in Japanese culture. Usually only brief dialogue or narration is used in television commercials in Japan; this is because in Japanese culture, the more a person talks, the less they are perceived as trustworthy (Keegan and Green 2005).

Cultural differences also exist in media use among cultural groups. The use of billboards is extremely effective in reaching African-American consumers in central cities. Large billboards deliver specific messages to an entire neighborhood, playing off the sense of community that is a high priority among African-Americans (Campanelli 1991). A recent innovation in outdoor advertising has been increasing the use of smaller posters in African-American urban communities. Compared with the large highway billboards, the main advantage of the small posters is that they can be placed low and close to the street, thus facilitating greater accessibility to passersby of all age groups (Williams and Tharp 2001).

Another example is the radio soap opera, termed telenovela, which was a culturally appropriate way to broadcast AIDS prevention messages to the intended audience in Tanzania. In 1993, over half of Tanzanian households owned a radio and about 60 per cent of them regularly listened to radio when the campaign was launched. The radio telenovela was an especially effective way to reach truck drivers who were most at risk of AIDS infection because it was the primary communication source for the drivers on the road. With the culturally preferred medium, the entertainment-education radio soap opera was a successful AIDS prevention strategy in Tanzania (Vaughan and Rogers 2000).


Successful brands also create a sense of membership or loyalty that builds on identities in the community (Keller 2007). In the commercial domain, brand communities are organized and facilitated based on a structured set of relationships among admirers of a brand (Algesheimer et al. 2005). The truth campaign provides an excellent example of a health campaign that built a brand community. The campaign created a sense of membership in a rebellious youth culture around the code or image of ‘truth’. It branded nonsmoking adolescents with the appealing label of ‘truth teens’, establishing an idealized social image to which youth could then aspire (Evans et al. 2005). As youth were exposed to the truth messages, they were expected to have a sense of membership as ‘truth teens’ combined with positive social imagery of not smoking. This membership led community members to resist adult influence and decrease the progression to established smoking.

Another example is the Philip Morris ‘anti-smoking prevention’ campaign. This campaign created an image of the nonsmoker that at-risk kids would not want to hang out with so that the ‘models’ being presented in the campaign were negative examples (see Chapter 7 in this book). This message almost invites a boomerang effect by creating a community of nonsmokers that many adolescents would not want to join. This is a (p.165) kind of challenge to branding approaches, which build alternative identity for intervention. We will discuss this issue later.

Cultural grounding is a method for developing brands

Culture and the culturally sensitive approach

Culture is important for health-promotion interventions because the norms, attitudes and behavioral repertoires that adolescents use to make and enact decisions about risky behaviors are derived, at least in part, from their cultural backgrounds and identities. Effective health messages, like all communication, require adaptation to the intended audiences. It has long been recognized among communication scholars that the adaptation must reflect the situation, topic, context and other communicators (Street and Giles 1982). Despite this, many prevention messages are not suited to the groups for which they are intended. For example, a major criticism of the US ‘Just Say No’ campaign that began in the 1980s is that it promotes a singular resistance strategy at odds with the language practices of mainstream US youth culture (Hecht and Krieger 2006).

Cultural sensitivity is essential to the efficacy of interventions because it targets their cultural characteristics and broader sociocultural values of the intended target group (Kreuter et al. 2003). According to Resnicow et al. (1999), cultural sensitivity consists of two primary dimensions: surface structure and deep structure. Surface structure may include using certain colors, images, fonts or pictures of the group members (Kreuter et al. 2003). Resnicow et al. (1999) label these elements as ‘superficial’ characteristics of a proposed population and suggest that by matching materials to the superficial characteristics of the target group, the group’s receptivity and acceptance of messages can be enhanced. Deep structure of cultural sensitivity reflects the broader sociocultural aspects and it conveys salience to a priority group. Using this approach, the target group’s cultural values, beliefs and behaviors are recognized, reinforced and built upon to provide context and meaning to messages about a health problem or health behavior.

Castro and colleagues have suggested a three-part method for classifying accommodation strategies to achieve cultural sensitivity. The first is cognitive information processing characteristics, such as language and age or developmental level. The second is affective-motivational characteristics, such as gender, ethnic background and socioeconomic status. Finally, environmental characteristics should be considered, such as the ecological aspects of local community (Castro et al. 2004).

Kreuter et al. (2003) have proposed a more specific classification of the ways that prevention messages can be made culturally sensitive. First, peripheral strategies refer to ‘packaging’ the program to reflect the intended cultural group through the use of appropriate colors, images, fonts and pictures. Second, evidential strategies enhance the perceived relevance of a health issue for a group by presenting evidence about how it affects the group. Third, linguistic strategies make programs more accessible by providing them in the dominant or native tongue of the intended audience. Fourth, constituent-involving strategies draw on experiences of the group, such as involving lay community members in planning and decision making for the program. Fifth, sociocultural strategies (p.166) are similar to Resnicow et al.’s (1999) concept of deep structure, and refer to strategies that discuss health issues in broader context of social and cultural values and characteristics of the intended audience (Hecht and Krieger 2006).

Defining cultural grounded approach

Typically, cultural sensitivity is concerned with how to transport an existing prevention program to a new culture through the introduction of superficial characteristics of the target group. Other times it involves infusing culture into a predetermined, transcultural health message. Cultural grounding incorporates the processes discussed in the cultural sensitivity approaches but it diverts philosophically through the assumption that prevention interventions are developed from within the culture, with cultural group members as active participants in message design and production.

This theoretical move is a ‘difference of kind’ or degree because those adopting the related sensitivity and adaptation approaches also enlist cultural members and incorporate their insights (Hecht and Krieger 2006). The principle of cultural grounding goes beyond modifying existing messages to a culture by assuming that the code, conversation and communities of the culture are the starting points for message design rather than an a priori often mainstream US or western message (Hecht and Krieger 2006). From this perspective, prevention interventions invoke symbolic representations and preferred communication modes across and within the variability in identities inherent within each culture by building on their narratives, cultural values and norms.

Cultural grounding as a method for developing a brand

In the traditional marketing perspective, brand is defined as the association of favorable imagery created by messages. A brand image is created that reflects what people think, feel and visualize when they see the brand’s symbol or name. Effective brands evoke richer, stronger and more consistent favorable meanings and associations (Batra et al. 1996). In this chapter, we suggest that in order to develop strong brand, brand images must be interpretable within the symbolic system of the culture, communicated in a form that is consistent with cultural practices, and invoked within the nexus of identities that characterize group memberships. The cultural grounding approach develops brands that are grounded in the salient identities by reflecting the symbolic representations, norms and values of each identity group and communicating in a form and style that reflect those found within the culture.


Narratives are an essential part of the grounding process. Narrative theory conceptualizes human thoughts and behaviors based upon narratives or stories. Narrative is both a way of coding or storing information (Howard 1991) as well as a method for expressing or communicating a meaning (Hecht and Miller-Day, in press). Narratives serve as the primary means for making sense of experiences and provide models for adolescent behavior (Bandura 1986). Several studies indicate that people see narrative messages as (p.167) more realistic than statistical evidence (Greene and Brinn 2003) and that messages that combine narrative and statistical evidence are more persuasive than those presenting either type of evidence alone (Allen et al. 2000). They have proven effective in health promotion (Green 2006).

The cultural grounding approach utilizes the narratives/stories of the group members as reflections of the values, beliefs and implicit assumptions of their culture (Gosin et al. 2003). These narratives provide good reasons, which justify actions based upon the dominant stories within the group (Fisher 1987). Effective narratives have fidelity, or ‘ring true’ to cultural group members, and are coherent, or hold together as a narrative or story (Fisher 1987; Hecht and Miller-Day, in press). Different cultures are characterized by different narratives, both as a way of thinking as well as a style of expression. For example, Native American narrative is typically organized nonlinearly, like the spokes of a wheel, reflecting a central organizing element (the hub) and various storylines (the spokes) rather than a chronological progression (Lake 1997). In contrast to western linearity expressed in deductive or inductive organization, this nonlinear narrative starts with a basic premise and then can go off in multiple directions, all held together by their common premise. Branded messages targeting this culture should reflect this narrative style.

The Joe Camel campaign provides an excellent example of narrativity. Joe is not just a ‘cool-looking’ hippodrome who smokes, but a story about what it means to be a cool guy – hanging out in bars, with lots of girlfriends, dressing stylishly and so forth. Cultural grounding allows a brand to draw upon culturally shared symbol systems that express membership while making stories meaningful to the intended audience.


Identity is a second aspect of grounding. Identity reflects a sense of membership in a group, be it national, religious, ethnic or other basis in origin. For example, racial/ethnic identity includes several elements such as ethnic pride, affinity for in-group culture (e.g. food, media and language), involvement with in-group and out-group members and so on (Resnicow et al. 1999). These identities provide a powerful basis for communication. Recent theorizing argues that messages and relationships, themselves, are often manifestations of identity (Hecht 1993; Hecht et al. 2004).

Culturally grounded branding emphasizes group membership in a number of different ways. Brands can call upon existing identities, linking to those ways of being to establish a positive image or bond people to the message or product by developing new identities that connect people together around produce usage. In the first approach, the images and narratives created by culturally grounded approach are derived from within the community, enhancing community involvement and engagement (Algesheimer et al. 2005). If cultural group members recognize their identities and accept their association with the product or idea, a strong brand loyalty toward their community will be created. For example, Hallmark Cards launched its Afrocentric brand, Mahogany, to meet the needs of African-American ethnic consumers. In 1987, Mahogany started with only 16 cards but it offers about 1000 cards by 2002 (Kotler 2002).

(p.168) On the other hand, brands also can create an identity group. This is very similar to brand community, which shares common values, norms and rituals among the brand community members. Brand community leads to greater community engagement and brand loyalty (Algesheimer et al. 2005). Harley-Davison’s Harley Owners Group is a prototypical example of a brand community. As previously discussed, the truth campaign established an ideal social imagery to which teens aspire, leading them to membership of the ‘truth teens’, an identity group that resists the social influence of smoking (Evans et al. 2005).

Developing effective brands through the active participation of group members

We also argue that cultural grounding requires the active participation of the group members in health message design and production. Active participation increases the chances that culturally grounded brands will be consistent with the values and norms of the culture and reflect their members’ cultural identities, meanings and values. These voices can be incorporated in many ways. Many use a ‘community-based participatory approach’ (Gosin et al. 2003) to gain the perspective of group members during formative research. In cultural grounding, the messages themselves emerge from this process with group members participating fully in message production so that accommodation of the prevention message occurs through the process of message development (Hecht and Krieger 2006).

Our approach utilizes community-based participatory research (Hecht and Miller-Day 2007). We believe that the fidelity and coherence of the narratives are enhanced when group members participate in designing and producing the materials and messages themselves. To us this means engaging the community as partners in the process, not just ‘informants’ or message evaluators. Partnership involves active participation in message creation, a process that often starts with narrative interviews to capture the stories of the target group members. Other methods include descriptions of existing narratives in the oral, written and mediated traditions of the group.

Evidence for a cultural grounding approach to branding

In some senses, cultural grounding parallels cultural sensitivity in that it is essential to general communication effectiveness (Hammer 1989) as well as interventions (Koss and Vargas 1992). Communication which adjusts to and accommodates culture is more effective (Hecht et al. 1993). Effective messages must be based on the underlying world views that develop through enculturation, and this is particularly true of interventions that seek to promote change (Koss and Vargas 1992). Schinke and his associates have argued that interventions targeting minority youth should emphasize ethnic pride and cultural identity (Schinke et al. 1990).

Some researchers assert that the targeted media are most effective when the symbols, characters and values depicted in the media are drawn from the intended audience’s cultural background (McGuire 1984; Appiah 2001). Culturally-specific ads allow the audience to better identify with the message and the source of the message (Appiah 2001). (p.169) Furthermore, people who are more likely to identify with media characters and perceive themselves to be similar to media characters, are more influenced by media content in which those characters are portrayed (Huesman et al. 1983). For example, black viewers are more likely to identify with, and evaluate more favorably, ads depicting black characters than ads featuring white characters (Whittler 1991). This tendency is also observed in other ethnic groups such as Hispanics who seek out representations of their own culture (Stevenson and McIntyre 1995).

In recent years, new technology has enhanced the efficacy of culturally matched messages. Appiah investigated the effect of culturally targeted messages on the internet. The results showed that black audiences with strong ethnic identities respond more favorably to black-targeted online media and less favorably to white-targeted media, whereas black audiences with weak identities responded no differently to the online media based on the ethnic target of the internet site (Appiah 2004). Prior empirical studies have demonstrated that cultural grounding often produces better outcomes than mismatched or half-matched culturally grounded programs because people are more likely to accept targeted messages reflecting their cultural narratives, values and norms (Hecht et al. 1993; Hecht et al. 2003).

The Drug Resistance Strategies Project: a case study in the culturally grounded branding approach

The Drug Resistance Strategies (DRS) Project is the name of a venture that involved research into the social properties of adolescent substance use and the development of a school-based substance use curriculum. The DRS project was among the first to systematically investigate the social processes involved in drug use among adolescents. The project created a culturally grounded prevention program from this research using a participatory action approach to message design (Gosin et al. 2003; Hecht and Miller-Day, in press). The curriculum was built around understanding the narratives reflecting youth, gender and ethnic/racial identities in the urban middle schools of Phoenix, Arizona, an area that was used to develop a branded, school-based substance use prevention curriculum. These narratives provided access to their shared experiences, knowledge and values. The voices of target group members are essential to design a culturally grounded intervention that incorporates traditional ethnic values and practices that promote protection against drug use.

Strong brands include various elements, such as brand name, logo, slogan, attributes, images, user identity and so on. Branding strategies make associations between and among these elements that are consistent with consumers’ values, norms or identity, thereby building strong relationships with consumers. To create culturally targeted branded prevention curricula, the DRS team considered not only symbolic representations of culture, such as visual image and language reflecting that of the participants, but also the variability inherent within a specific cultural group.

Finally, to ensure that the brand emerged from the culture rather than having culture added to it, community-based participatory research was used to develop the curriculum. (p.170) Teams of students, teachers and community members developed the lessons with us in an iterative process. We believe that fidelity and coherence are enhanced when group members participate in designing and producing the materials and messages themselves (Fisher 1987). We now describe these processes in more detail.

The role of narratives and identity in keepin’ it REAL

The keepin’ it REAL curriculum is a culturally grounded approach utilizing branding concepts and techniques to infuse cultural elements into the curriculum. First, the curriculum was developed based on cultural narratives. Narratives or stories were collected from adolescents in each ethnic group through narrative interviews (Hecht and Miller-Day, in press) and used to create the performance-based elements of the curriculum. As mentioned above, brand is not just image, but also stories or narratives associated with products/services. Narrative interviews are designed to elicit stories through questions that are not easily answerable in yes or no or didactic responses. For example, asking about what goes on in someone’s neighborhood is more likely to elicit a narrative response than asking if people know each other in their neighborhood. Other techniques (e.g. ‘tell me a story about …’, ‘recall a time when …’) also are used.

Since the mid-1980s the DRS project has conducted extensive research using a variety of techniques to identify drug resistance narratives in order to design, implement, and evaluate a substance abuse prevention program, keepin’ it REAL (kiR). This research identified the ways that offers were made (i.e. who, how and where) as well as how they were resisted and why. While the unique focus of this research was on describing the set of strategies adolescents use to refuse drug offers, it also helped us understanding their decision-making process. The narratives collected in this process not only provided the content of the prevention messages (i.e. examples of how to assess risks, make decisions and refuse drug offers) but they determined what the curriculum was about. In the process of this research, the lead author’s brother, Albie Hecht, who had vast experience branding while president of television and film for Nickelodeon (e.g. SpongeBob SquarePants) and creator of Spike TV (the first network for men), suggested that the refusal strategies needed to reflect a brand. Examining our preliminary descriptions, he suggested ‘REAL’ as an acronym to brand the refusal strategies in a term in common parlance in youth culture (‘get real’, ‘be real’). REAL summarizes four strategies we found used among youth from elementary through college ages: refuse (simple no), explain (no with an explanation), avoid (avoid the situation or offer), and leave (remove yourself from the situation).

REAL became the central brand image of the curriculum and was used to teach strategies for resisting drug offers and other skills. The narratives formed the basis of an award-winning series of five videotapes and public service announcements created by students at South Mountain High School in Phoenix, Arizona, teaching the resistance skills that form the core of the curriculum. The students developed scripts from prototypical narratives for each resistance strategy and produced videos that provided an overview of the program and taught each resistance skill through enactments or models (p.171)

                      Branding through cultural grounding: The keepin’ it REAL curriculum

Fig. 9.1 keepin’ it REAL logo. Reproduced with permissin from keepin’it REAL.

of successful drug resistance in recognizable locales, by youth similar to the students in age and ethnicity. Classroom-based materials and activities (e.g. role-plays created from the narratives) provide practices for assessing risk, making decisions and using the strategies (Gosin et al. 2003). Branding continued with focus groups of teachers and students. These groups suggested content and form for the lesson and led to the adoption of the phrase, ‘keepin’ it REAL’ as our curriculum name and logo (Fig. 9.1). Focus groups also were used to pilot test the lessons.

The result was three versions of the curriculum that ethnically matched each of the main ethnic groups in the school population (i.e. Mexican-American and white/black versions) and a multicultural version that cut across these groups. As a result, kiR consists of three parallel versions of a ten-session classroom curriculum: a Mexican-American centered version targeting the largest ethnic group in the schools; a non-Mexican-American centered version that targeted the second and third largest ethnic groups in the schools (black/white); and a multicultural version that incorporated five lessons each from the first two versions and appealed to all three of the primary ethnic groups. The emphasis on Mexican-American youth culture responds to the needs of an under-researched community and at the same time provides a useful example of a specific culturally grounded program.

The keepin’ it REAL curriculum: multi-delivery strategies

One of the aims of branding is to build relationships between consumers and products by reflecting consumer voices and adding meanings and values to their objects. The kiR curriculum used multi-delivery strategies and tactics to reach the target audience effectively so that they could interpret cultural elements in light of their motivations and aspirations.

Brand name or logo is an important branding element because it captures the central theme of the curriculum and effectively connects it to the target audience. Seventh-grade students in Phoenix, Arizona participated in creating the name, logo and slogan of the curriculum. The students determined that the best name for the curriculum was keepin’ it REAL because ‘it sounded like something we would say’ and recommended the use of ‘bubble letter’ artwork and skits because the graffiti style of writing related to their urban environment (Gosin et al. 2003). The curriculum used incentives with program name and logo such as pens, baseball caps etc. to reward involvement and reinforce the brand image.

The kiR curriculum was implemented with multiple delivery methods such as videos, role-plays, billboards, boosters and so forth based on the belief that effective communication tools that are consistent over different media and over time should be developed (p.172) for building and maintaining a strong brand (Aaker 1996). Similar information was included in each communication tool to offer consistency and facilitate building a strong and favorable brand (Keller 1998). The strategies were taught through the videos and class discussions. Other examples and exercises such as role-playing using culturally appropriate techniques and scenarios provided practice in using the strategies (Gosin et al. 2003). Billboards, radio and television public service announcements were created from the in-class videos to reinforce the program’s content (Hecht and Krieger 2006). Research suggests, however, that it is primarily the classroom videos that account for the success of the intervention (Warren et al. 2006)

Evaluations of keepin’ it REAL

A randomized trial was conducted among 35 middle schools (6035 students) that were randomly assigned to one of four conditions: Mexican-American curriculum, white/black curriculum, multicultural curriculum or control. A pretest was administered prior to the intervention and three posttests administered during an 18-month follow-up to examine the efficacy of the cultural grounding approach by examining its effects on substance use and comparing the effects of cultural matching (Mexican-Americans in the Mexican-American oriented program; African-Americans and European-Americans in the black/white program), inclusion or partial matching (all three groups in the multicultural program), and mismatches (Mexican-Americans in the black/white program; European-Americans and African-Americans in the Mexican-American program). Results supported the overall efficacy of the intervention but provided little substantial support of the cultural matching hypothesis (Hecht et al. 2003, 2006). The tests demonstrated that the Mexican-American and multicultural versions both produced significant effects relative to the control group (standard/existing intervention), indicating that it is not necessary to ethnically segregate students into narrowly matched programs. Instead, the process of incorporating a representative level of relevant cultural elements into the prevention message appeared critical (Hecht et al. 2003, 2006). In addition, the intervention proved effective even for those who had initiated use prior to the pretest (Kulis et al. 2007a) and was equally effective for males and females (Kulis et al. 2007b). Based on these findings, kiR was selected as a model program by the US Substance Abuse and Mental Health Services Administration’s National Registry of Effective Prevention Programs.

Comparing cultural grounding and branding

There are several ways in which branding and cultural grounding diverge. First, branding is typically developed by marketing and advertising practitioners while the cultural grounding approach is more interactive and participatory (e.g. community-based partici patory research). In the marketing domain, marketers recognize the important role of culture and they attempt to develop culturally specific programs, a practice commonly known as diversity marketing. The diversity marketing program has grown out of careful marketing research to identify different ethnic needs (Kotler 2002). (p.173) However, many culturally tailored marketing approaches seem to be superficial because they appear to be simple modifications of messages developed for a dominant culture (e.g. in the USA, European-American culture). For example, many African-American targeted programs have simply employed the images of black superstars such as Michael Jordan, Shaquille O’Neal, Halle Berry and so on (Kotler 2002).

The culturally grounded approach typically employs community-based participatory research or a comparable method. With the findings of the research, it moves beyond the superficial dimensions of culture (changing the ethnicity or appearance of role models) to the fundamental aspects of culture such as cultural narratives, values, beliefs and norms (Resnicow et al. 1999; Kreuter et al. 2003; Castro et al. 2004; Hecht and Krieger, 2006). The culturally grounded approach requires health message designers to engage cultural group members and work with them to develop culturally targeted messages reflecting the deep structure of each culture (Gosin et al. 2003; Hecht et al. 2006). As Kreuter and his colleagues have argued, socioculturally-based programs and materials should understand culturally normative practices and beliefs – the inner workings of culture rather than just outward appearances (Kreuter et al. 2003).

Another difference is that branding often creates something new or unique to differentiate the brand from other competitors, whereas cultural grounding tries to have the brand emerge from the culture. Marketers attempt to associate brands with favorable images and build unique identities to differentiate their brands from other competitors (Kotler 2002: 326). They can differentiate their brand images using symbols, colors, slogans and special attributes. For instance, the image of Apple Computers was built around its unique symbol, the apple. Some companies employ color identifiers such as blue (IBM) or yellow (Kodak), or a specific piece of sound or music. In contrast, the cultural grounding approach to branding tries to identify values, norms and identities embedded in the culture and derive the brand from those cultural elements. Cultural grounding does not necessarily create something new; instead, it tries to understand the existing thoughts and ideas embedded in each culture to derive the brand from them. For example, the phrase ‘keepin’ it REAL’, was developed by students to explain or brand the REAL program. The phrase, itself, was in common use within the culture and has (fortunately) remained in use.

Finally, branding often is associated with favorable images (how a person should be) while cultural grounding is more than just images. In the commercial sector, branded messages create the associations with the brand. Brand image encompasses all the associations that a consumer holds for the brand. These include colors, sounds, smells, thoughts, feelings and imagery (Batra et al. 1996: 321). For instance, McDonald’s advertising connects to an image of a ‘typical user’ with the character, Ronald McDonald, and a feeling of having fun with the symbol, golden arches (Kotler 2002).

Cultural grounding involves telling a story that reflects cultural elements based upon formative research with group members. As mentioned above, the kiR drug prevention curriculum is culturally grounded and derived from narrative theory and research. The program drew upon the stories that are salient to adolescents through the active participation of high school and middle school students (Hecht and Miller-Day, in press). Formative research was conducted to explicate adolescents’ experience of drug use and (p.174) drug offers (Hecht and Krieger 2006). The findings of this research led to the development of the kiR curriculum with students, teachers and community members utilizing narratives in which peer models of adolescents refuse drug offers to redefine the story of drug use norms and risk, as well as to develop communication competence and life skills (Hecht and Miller-Day, in press).

Challenges to cultural grounding to branding

Branding in the public health arena is inherently different from that in commercial marketing arena. Commercial branding typically suggests a benefit or an incentive, building the brand by presenting positive images of the product. However, while some health messages encourage the adoption of health behaviors, many stress avoidance of unhealthy behaviors. Members of the culture may not recognize the health brand as an incentive. Many health campaigns fail because what the campaigns ask the target audience to do is in opposition to their own self-interest or benefit and does not provide an explicit payback to compensate for what should not be done (e.g. quitting smoking) (Rothschild and Andreasen 1998). Health messages are challenged to show people being healthy as something to which people aspire. HIV/AIDS testing in Africa is the case for that issue. HIV/AIDS prevention campaigns are using advertising and mass media to emphasize the benefits of HIV testing such as a user-friendly, high-technical service, and support for those infected, yet people may refuse HIV testing, sometimes as a result of the threatened stigma, abandonment, violence or murder. The potential for negative consequences hinders them from obtaining the desirable treatments needed to combat the disease (Cock et al. 2002).

This raises the question of ‘how health branding messages can deliver a promise or incentive (e.g. quitting smoking makes you healthier) that encourages healthy behaviors and/or discourages unhealthy ones. The cultural grounding approach suggests calling upon cultural identities and narratives that represent desirable health practices. For instance, peer pressure (e.g. norms) plays an important role in drug use among adolescents. The most common narrative among them presents drug users as mature and glamorous – cool guys in peer groups. This is reinforced in much of the media (DiFranza et al. 1992). Branding approaches are challenged by this narrative. However, peer influence may also be involved in drug abstinence (Robin and Johnson 1996; Elek et al. 2006). Kids who see their friends using drugs are more likely to follow whereas kids who believe their friends are anti-drug are more likely to abstain (Strasburger 2000). Narratives in which teens do not misuse substances and still have fun can be powerful means to shaping behavior. Here is the possibility that alternative identities and narratives may change normative behavior (e.g. drug use), if health messages are grounded in group members’ experiences.

To overcome the challenges to culturally grounded branding, we propose the following solutions for health implementers. First, they have to consider people’s perceptions of the identities and meanings in health messages. There has been a lack of understanding in cultural meanings and the preferred mode of communication at the level of message design. (p.175) Health message designers can use various methods (e.g. community-based participatory research) to understand how members of a group identify with health messages. Particularly, message designers need to focus on developing benefit-based messages so that their intended audiences are more prone to change than resistant to change. For instance, the Small Step campaign conducted qualitative research to identify barriers to healthy habits (US DHHS and The Advertising Council 2004). Based on the findings, the campaign encouraged adoption of healthy lifestyles to prevent obesity and consequent health risks. The campaign emphasized that a ‘small step’ in everyday lives leads to positive spin. Once the designers understand the way that they perceive the messages, they may link relevant benefits and incentives to the messages with various marketing and branding strategies and tactics.

Second, health campaign should be audience-driven by listening to group members to identify cultural norms and values counter to what they deliver in brands. If they do not understand what audiences want, message–audience nonfit may occur and lead to a boomerang or iatrogenic effect. Cultural adaptation is required to avoid this nonfit. We suggest that health message designers employ participatory and interactive research to reflect cultural norms and values embedded in each culture. By doing so, health messages can deliver the messages that resonate cultural identities and membership.

Third, health implementers should prepare for unintended effects. After the prevention program, the program should be evaluated to investigate if there are any unintended effects. The DRS research team measured the effectiveness of the culturally grounded prevention program at the immediate posttest as well as 14-month follow-up test (Hecht et al. 2006). The tests may increase the chances to detect unintended effects because these provide important information about the effect of the program on the rate and pattern of change in substance use over time (Hecht et al. 2003).

Finally, narratives can be an alternative to resolve challenges to branding approaches. As discussed above, a brand is not just images, but stories in public health context. If health implementers utilize the stories of the group members, they can effectively reflect the implicit assumptions of each culture. By doing so, these narratives can also provide ‘good reasons’ to justify their actions based upon the dominant stories within each group and do so with fidelity and in a coherent fashion.


The culturally grounded approach to branding is based upon an elaborated conceptualization of culture that considers cultural codes (system of meaning), conversations (way of interacting) and communities (membership). Cultural grounding starts with the experiences of group members and identifies their stories in order to capture these three features of culture. Traditionally, culturally adapted approaches just modified the universal messages; however, cultural grounding emphasizes messages that incorporate the deep structure of culture, such as values, norms and identity, while starting with the code, conversation and communities of a culture rather than adding these features later.

(p.176) The keepin’ it REAL curriculum is a culturally grounded approach to preventing adolescents’ substance abuse and provides a template for branded health messages. Through formative research the Drug Resistance Strategies project has developed health messages that are grounded in group members’ salient meanings, narratives and identities. The cultural narratives identified in this research led to highly salient health messages that provide ‘good reasons’ to justify actions as well as models for their behaviors. This multicultural curriculum, with its proven efficacy, provides a model of developing culturally grounded, branded health messages. There is, of course, much to learn in this area. keepin’ it REAL is meant to be an exemplar of a method for developing health messages that provides a starting point for developing culturally grounded health brands. We believe that this approach can be productively applied to public service announcements and other different types of health messages utilizing branding strategies with cultural and social forces.


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