Running head: MARKETING HEALTHCARE TO EMERGENT POPULATIONS
Missing the Mark in Marketing Healthcare Services to Emergent Populations:
Why We Go Wrong and How We Might Do Better
Roger Gans, PhD
Department of Communication, University of Texas at Arlington
Published online, International Journal of Healthcare Management, 5/13/2020
LINK TO PUBLISHED ARTICLE
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 1
Whether because of economic conditions, war, genocide or other reasons, many people are
relocating from their under-developed (or under-duress) countries of origin to urban and
suburban areas in more peaceful and affluent countries. The close geographic juxtaposition of
these newly emerging populations alongside established native populations can lead to
significant disparities in the promotion and delivery of healthcare services. An example of this,
Hispanic populations are growing rapidly in and around affluent communities across the United
States of America. This article explores how under-representation, cultural dissonance,
stereotyping, and stereotype threat may be interacting to influence both the content and the
effects of health promotion strategies aimed at these newly emerging markets. It concludes with
suggestions that may lead to better-targeted marketing strategies that are more equitable as well
as more effective for reaching emerging markets in a range of national contexts.
Keywords: Hispanic Americans, healthcare marketing, healthcare disparities, cultural
competence, Dunning-Kruger Effect, stereotype threat, health promotion, Hofstede’s dimensions
of national culture
Wordcount: 2541 (not counting abstract, tables, figures, references)
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 2
Missing the Mark in Marketing Healthcare Services to Emergent Populations:
Why We Go Wrong and How We Might Do Better
Whether because of economic conditions, war, genocide or other reasons, many people
are relocating from under-developed (or under-duress) countries of origin to urban and suburban
areas in more peaceful and affluent countries. The rapid growth of Hispanic populations in and
around affluent communities across the United States of America (U.S.) is an example of this
phenomenon. The close geographic juxtaposition of newly emerging Hispanic markets alongside
established “traditional” (e.g., predominantly White) markets has led to increasingly noticeable
disparities in the promotion and delivery of healthcare services to these populations.
Although the U.S. Census no longer tracks the countries-of-origin of citizens identifying
as White, the majority of U.S. citizens are descended from White European immigrants, and
72.2% identify as non-Hispanic White (U.S. Census, 2018). Those identifying as Hispanic,
which includes anyone of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin comprise the largest ethnic minority in the U.S., at 18.1% of the total
U.S. population (OMH, 2019).
This article explores how cultural dissonance, unexamined biases and stereotype threat
are influencing both the content and the effects of health promotion messages aimed at Hispanic
audiences in the U.S. A theory-based assessment of the situation is used as a foundation for
suggested approaches to targeted marketing strategies that may be more equitable as well as
more effective for reaching emerging markets across a range of national contexts.
Figure 1, below, illustrates the increase of Hispanic populations within 13 of the most
affluent (based on median household income/MHI) majority-White counties in the U.S., showing
the increase in percentage of Hispanic individuals among the total population of each county.
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 3
[INSERT FIGURE 1 NEAR HERE]
In multicultural regions such as the counties described above, health services
organizations are finding greater difficulties in connecting with and establishing optimal
provider-patient relationships with their newly emerging Hispanic populations than with the
longer-established (and predominantly White) populations within their service areas (Markelz,
2016). As a consequence, Hispanic populations are not receiving the same quantity and quality
of care as the White populations sharing the same geographic boundaries (Aronson, Burgess,
Phelan, & Juarez, 2013; St. Germaine-McDaniel, 2013).
A cursory analysis of this issue underscores the need for greater cultural competence on
the part of health services providers (Flores, 2000). Differences of language, tradition, and socio-
economic factors cannot be ignored for effective communication of health risks and availability
of healthcare services (Fischhoff, Brewer, & Downs, 2011; St. Germaine-McDaniel, 2013). A
closer examination of the situation, however, suggests a challenging set of additional underlying
influences that may be contributing to the less-than-satisfactory connections between healthcare
providers and Hispanic patient populations.
Underserved, Under-Represented, and Under-Targeted
Hispanic adults receive fewer face-to-face or targeted media messages from healthcare
professionals than any other major U.S. ethnic group (Pew Research Center Hispanic Trends,
2008). The messages they do receive are likely to be mistargeted (St. Germaine-McDaniel, 2013)
and counter-productive (Burgess, Warren, Phelan, Davidio, & van Ryn, 2010).
Before enactment of the Affordable Care Act, also known as ObamaCare, more than 31%
of Hispanic adults in the U.S. lacked medical insurance and 25% did not have a regular primary
care physician, the highest percentages among U.S. ethnic groups (Pew, 2008). As of 2017,
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 4
Hispanics remained the least-insured ethnic group in the U.S., with 17.8% not covered by health
insurance compared to just 5.9% of non-Hispanic Whites (OMH, 2019).
In addition to having less opportunity to communicate directly with healthcare
professionals, Hispanics in the U.S. have even less opportunity to connect with providers who
share their cultural backgrounds. While the overall Hispanic population of the U.S. increased by
243% from 1980 to 2010 (see Figure 1, above), the number of Hispanic physicians per 100,000
of the Hispanic population actually decreased by 22% (Sánchez, Nevarez, Schink, & Hayes-
Bautista, 2015). And although Hispanic adults make up 16.9% of U.S. workers, they make up
just 10.9% of people employed in hospitals and 9.8% of people employed in nursing care
facilities (Bureau of Labor Statistics, 2018).
Hispanic points of view are also not well represented in media communications.
Hispanics make up just 8.9% of the people employed in advertising, public relations, media
planning and related services in the U.S. (Bureau of Labor Statistics, 2018). Moreover, Hispanic
audiences are under-targeted by healthcare marketers. With Hispanics comprising 18.1% of the
total U.S. population (U.S. Census Bureau, 2018), pharmaceutical companies spend less than 4%
of their marketing budgets on Hispanic-focused ad campaigns (Cultural Marketing Council,
2015). Leaving questions about cultural competence aside, the practical and functional reality of
the situation is that the people who make healthcare policies tend to be disproportionately White
and Eurocentric—or, what might be termed to contrast with a Hispanic perspective, Anglo, a
term commonly used by Hispanics to refer to mainstream U.S. culture as well as to non-Hispanic
Whites (St. Germaine-McDaniel, 2013). Similarly, the people who craft and disseminate the
public communications intended to operationalize and implement healthcare policies—a separate
and distinct population—are also disproportionately Anglo.
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 5
It is important to note the significance of the fact that the healthcare policy makers,
marketing managers, message creators, and media buyers are each functionally distinct and
separate groups, because any lack of cultural competence in any of their individual outputs is
likely to be multiplied by the interaction between them. Although cultural competence is a
required component of U.S. medical education, there is wide variation in approaches to and
outcomes from cultural-competence training in the U.S., with considerable room for
improvement (Jernigan, Hearod, Tran, Norris, & Buchwald, 2016). There is no such requirement
among the other members of the marketing communications team (Honea, Castro, & Peter,
2017), but each must interact to turn an organization’s policy decisions into audience-targeting
strategies and messages. If there are multiple levels of cultural incompetence interacting in this
process, the product will be a truly broken healthcare marketing campaign.
Anglo-targeted policies, strategies and services may not translate. Long-established
healthcare systems tend to target their marketing strategies and messages toward their region’s
traditional healthcare consumers, i.e., Anglos. Marketing campaigns may be designed to promote
a regional medical center’s feeder-network of primary care physicians (e.g., “Your family
deserves a family doctor!”) or utilization of its most profitable service lines (e.g., “Don’t let
arthritis get you down. Replace that hip and go out on the town!”).
To address growing Hispanic markets, it has been common to simply translate the
English-language marketing messages into Spanish, with little or no consideration of whether the
underlying policies or persuasive message strategies might be effective with Hispanic audiences
(Markelz, 2016; St. Germaine-McDaniel, 2013). Differences in dimensions of national culture
have been shown to influence the effectiveness of doctor-to-patient communication in healthcare
settings (Mazzi, Rimondini, van der Zee, Boerma, Zimmermann, & Bensing, 2018; Meeuwesen,
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 6
van den Brink-Muinen, & Hofstede, 2009). Examination of some of these differences may offer
some insight into why translated messages often do not connect. Differences in cultural norms
between Anglos and Hispanics1 in the dimensions of Power Distance and
Individualism/Collectivism (Hofstede, 2011) are especially stark, as shown in Figure 2, below.
[INSERT FIGURE 2 NEAR HERE]
In the diagram, the values for “Anglos” are taken from Hofstede’s (2011) measures of
U.S. national culture; the values for “Hispanics” are from his measures of Mexican national
culture. The dimensions of Power Distance and Individualism/Collectivism are highlighted
because they illustrate the cultural gulf that can exist between people of differing national
origins. The extent of the disconnect between common Anglo-sourced message strategies and
common Hispanic audience sensibilities is suggested in their positions in the two-dimensional
culture model presented in Figure 2.
The relatively low power-distance score for Anglos suggests Anglos routinely operate
from a belief that they can exert power over their condition in life; it is acceptable to question
authority and challenge fate. The high power-distance score for Hispanics, in contrast, suggests
an operating belief that their condition in life is pre-determined and should just be accepted;
questioning authority is discouraged. Anglos’ high score for Individualism suggests they
routinely operate from a belief that everyone should look after their own interests first; it is
important to make up your own mind. Hispanics’ low Individualism score (which reflects a high
degree of Collectivism on the “Individualism-Collectivism” continuum) suggests they routinely
operate from the belief that one’s decisions and actions should be based on the needs, beliefs,
1 Hispanic peoples in the United States, although from more than 20 Latin American countries of origin, are heavily
represented by Mexican culture, with Mexicans comprising nearly two-thirds of all U.S. Hispanics (Wilcox et al.,
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 7
and opinions of the “in-group,” which Hofstede (2011) defines as the family, community or
affinity group the individual most strongly feels a part of. Collectivists tend to follow the
traditions of their in-groups, and so they are less likely than Individualists to challenge the
accepted wisdom of their in-group elders or follow the advice of “out-group” experts.
People in individualistic cultures, such as Anglos, are more likely to be influenced by
medical professionals in their decision making, not just because they are more likely to actually
be in contact with medical professionals, but also because the influential messages they receive
are likely to be conceived and communicated from an individualistic perspective. But if those
messages urge individuals to exercise personal responsibility for their condition and initiate
actions not commonly accepted among their in-groups, the messages may not connect with
people from collectivist cultures.
Consequences of stereotyping may not be obvious. Aside from how healthcare services
are marketed, stereotypical assumptions about Hispanic populations can influence which services
are marketed toward Hispanics. Hospitals in the U.S. depend on revenue from provision of
services, with schedules of reimbursement determined by insurance companies and U.S.
government’s Centers for Medicare and Medicaid Services. Facing financial pressures regarding
reimbursement rates, hospital systems often focus their mainstream marketing efforts on their
most profitable service lines—e.g., cardiology, orthopedic joint replacement, high-tech elective
surgery (Ellison, 2019)—which may not be accessible or available for patients with less-than-
premier-quality insurance coverage. Influenced by the stereotype that Hispanics are largely
uninsured, providers may limit their Hispanic-targeted marketing promotions to clearly funded
services such as Medicaid-supported maternity and primary care services and grant-supported
cancer screenings. This kind of strategy can short-change the healthcare systems as well as the
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 8
regions’ Hispanic populations because, although Hispanic populations may be more likely than
Anglos to be uninsured, members of the Hispanic community are still far more likely to be
insured than to be uninsured (OMH, 2019; Pew, 2008).
This consequence of stereotyping may not be the most impactful however. Stereotype
threat is an increasingly studied phenomenon likely to occur “when cues in the environment
make negative stereotypes associated with an individual’s group status salient, triggering
physiological and psychological processes that have detrimental consequences for behavior”
(Burgess et al., 2010, p. S169). The result can be an amygdalic “flight-or-fight” response,
increased anxiety, and decreased working memory.
Stereotype threat can be triggered for Hispanic patients by all manner of cues in the
clinical environment or health promotion messaging that might escape the notice of Anglo
clinicians and message makers. For Hispanics, the cues can conjure “the stereotype of minority
patients as unintelligent, ‘second class citizens’, and unworthy of good care (i.e., wasting the
provider’s time)” (Burgess et al., 2010, pp. S169-S170).
Not seeing anyone who looks Hispanic in a waiting room can be such a cue. Simply
providing one’s name to the receptionist or hearing a healthcare provider mispronounce one’s
name can also activate the sense of being judged pejoratively. Seeing ads obviously intended for
Anglos can be such a cue. But even ads that seem purposely targeted towards Hispanics can also
trigger stereotype threat if the ads’ depiction of Hispanics does not ring true.
Activation of stereotype threat can impair patients’ ability to understand their healthcare
providers’ instructions, remember to provide important diagnostic information, ask important
questions, or seek medical treatment at all (Burgess et al., 2010). For Hispanic individuals,
inadvertent activation of stereotype threat can lead to avoidance of preventive care such as
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 9
routine screenings and annual check-ups, and over-reliance on emergency room services. For
healthcare providers, this can result in lost revenues, higher (and often non-reimbursable)
emergency department expenditures, and failures of public health policies. And it means bad
outcomes for both.
Suggested Solutions and Directions for Research
Finding ways to reduce healthcare disparities and better engage with underserved
populations is an important area of concern for healthcare communicators. Following are some
suggestions for addressing issues of cultural dissonance and stereotype threat.
Raise the bar on cultural competence. It has been famously documented that
incompetent people tend to think of themselves as above average (Kruger & Dunning, 1999).
Healthcare providers are not exempt from this issue when it comes to cultural competence and
cross-cultural communication (Dunning, 2011; Ehrlinger, Gilovich, & Ross, 2005). Providers
should be educated to assume they are probably not, in fact, culturally competent. For instance,
when a patient smiles and nods in response to a statement, it may not signify understanding or
agreement. Follow-up questions are often advisable.
Build a pipeline to support recruitment and hiring practices. Increased
aggressiveness in recruiting practices with greater focus on Hispanic physicians could help
increase utilization and effectiveness of care, but a longer-term perspective is required.
Healthcare policymakers should work to build the pipeline of future Hispanic healthcare
providers by promoting healthcare as a desirable and viable career path for Hispanic young
people starting in elementary school. Modest investments in in- and after-school health-science
programs and scholarships could pay long-term dividends.
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 10
Increase representation on both sides of the camera. Healthcare executives should
give greater consideration to hiring Hispanic marketing directors and Hispanic-led marketing
firms, and increasing representation of Hispanics as advertising actors, models, writers, and
Don’t rely on translated strategies and messages. Strategies designed to resonate with
people from individualistic cultures are not likely to connect with people from collectivist
Use Hispanic-preferred media and messengers. Hispanic media outlets are broadly
underutilized by healthcare advertisers, which can make it easy for your organization to stand
out. But don’t simply run your Anglo-focused messages in Spanish; start with research-driven
strategies, then use Hispanic writers, spokespeople, and media vehicles that can connect with
Portray Hispanic individuals as smart, healthy, and good decision-makers. One way
to combat stereotype threat is to provide positive alternatives to the stereotype. Align depictions
of traditional Hispanic healthcare decision-makers with healthy choices and behaviors. And
include positive portrayals of Hispanic families in run-of-market advertising, not just Hispanic-
Don’t skimp on your research. Assume your assumptions are probably wrong (see
Ehrlinger et al., 2005). Conduct ethnographic studies, surveys, focus groups, and interviews to
learn what the actual perceived needs of your particular market are, which messages are working,
and how best to connect with your audiences.
Construct messages from a Collectivist perspective. Emphasize extended family
responsibility (e.g., “Stay healthy so you can take better care of your family”), depict in-group
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 11
approval for healthy decisions (e.g., “You’ll make your abuela proud”), and use pluralistic
pronouns (“we,” “us,” “our”) rather than individualistic ones (“I,” “me,” “mine”).
Avoid stereotyping triggers. This is easier said than done, but it helps to realize you
may be blind to them. For best results, apply the suggestions above, with particular attention to
assumptions about your own cultural competence (see Kruger & Dunning, 1999; and Dunning,
MARKETING HEALTHCARE TO EMERGENT POPULATIONS 12
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MARKETING HEALTHCARE TO EMERGENT POPULATIONS 14
FIGURES AND TABLES
Figure 1. Growth in Hispanic share of population in 13 affluent counties, 1980 – 2014.