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The Our Ad Project: eliminating stigmatizing and racialized imagery in pharmaceutical marketing

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The Our Ad Project: eliminating stigmatizing and racialized imagery in pharmaceutical marketing

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Content 1

The OUR AD Project

Casey K. Johnston
Social Work Doctorate Capstone Project
Submitted in Partial Fulfillment of the Requirements for the Degree
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work, University of Southern California
California SOWK 722: Capstone II
Dr. Renee Smith-Maddox
December 2021

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Acknowledgements
This project would not have been possible if not for the mentorship, support, and shared
wisdom of my committee, USC professors, colleagues, and individuals from the community who
shared their expertise and lived experience. I am particularly grateful to my committee chair, Dr.
Renee Smith-Maddox, whose unwavering commitment to innovation for social change and
social justice was ever-present. I would also like to thank Dr. Monica Perez Jolles for her
mentorship and guidance, particularly regarding implementation design. The wisdom and
support of my colleagues and peers truly bought this project to life and infused it with a spirit of
collaboration. Finally, I am grateful to my family. To my parents, who modeled a commitment
to service and community engagement throughout my life. To my husband, for the hours of
debate, discussion, self-reflection, and shared desire for a better world. And, to our daughters
whose empathy and curiosity ignites my heart and brings deeper meaning to every journey.

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Contents
Executive Summary……………………………………………………………………………….5
The power of storytelling………………………………………………………………….5
Project purpose…………………………………………………………………………….6
Project methodology………………………………………………………………………7
Introduction………………………………………………………………………………………..9
Conceptual Framework…………………………………………………………………………..10
Levels of racism………………………………………………………………………….10
Problem of Practice and Innovative Solution……………………………………………………12
Problem of practice………………………………………………………………………12
Stakeholder perspectives…………………………………………………………………14
The social significance of the problem…………………………………………………..16
Current efforts to address the problem…………………………………………………...17
The OUR AD solution…………………………………………………………………...20
The power of social media……………………………………………………………….21
Project Structure, Methodology, and Action Components………………………………………22
Implementation…………………………………………………………………………..26
Sustainment and measurement plan……………………………………………………...27
Communication strategy…………………………………………………………………29
Conclusions, Actions, and Implications…………………………………………………………30
Challenges, barriers, and risks…………………………………………………………...30
A vision forward…………………………………………………………………………30
References……………………………………………………………………………………32
Appendix A: 1974 Haldol advertisement……………………………………………………41
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Appendix B: OUR AD social media campaign prototype…………...………………………42
Appendix C: Collective Impact Framework…………………………………………………43
Appendix D: Conscious-Driven Marketing Principles………………………………………44
Appendix E: OUR AD Logic Model………………………………………………...………45

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I. Executive Summary
The power of storytelling. Storytelling and personal narratives are central to the human
experience. Stories build connection, inclusion, help to shape memory, and give power to lived
experience among individuals and communities. Worldviews and ideologies derive from the
content of stories and the meaning-making that takes place when stories are shared. Ultimately,
stories can shape normative beliefs and one's understanding of the world, the people around
them, the socio-political climate, and what change, if any, is required to envision and design a
more just world. As one reflects on the past year, what are the stories they incorporate into their
own understanding of the world? What are the stories they think of as they reflect on a global
pandemic? What are the narratives they believe about racial justice and police reform? What
stories bring them hope and a vision for a better future? And what voices, experts, and
perspectives do they seek when trying to find meaning among it all?
The profession of social work finds its strength in partnering with communities who have
too often been excluded from the mainstream narrative but whose stories shine light on the
vibrancy, complexity, resiliency, and anti-fragility within communities. The profession has
developed the Grand Challenges for Social Work which outlines 13 intractable societal problems
that require innovative reform. The narratives surrounding these Grand Challenges are central to
understanding the myriad of factors and intersecting variables that contribute to the wicked
problems. Too often, however, it is the voice of a select few who have the power to decide,
define, and design solutions to society's most complex social issues. This process not only
excludes power and voice from communities, but it also reinforces mainstream narratives that
too often perpetuate the status quo, contribute to bias, and fail to capture a more accurate
depiction of the problem and the range of solutions.
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Project purpose. This capstone project specifically focuses on racial health disparities
and the Grand Challenges posed by the profession to eliminate racism and close the health gap.
We cannot discuss the stories of the near hundreds of thousands of Black, Indigenous and People
of Color (BIPOC) who die annually due to health care disparities without having an honest
discussion about racism. In the wake of a dual pandemic, the Association of Social Work added
the 13th Grand Challenge to eliminate racism. Racism is central to our expanding health gap and
why we see differential access, treatment, and health outcomes across groups. The grand
challenge to eliminate racism calls for the social work profession to focus on the centrality of
racism and white supremacy, both within society and the profession (Teasley et al., 2020). Social
workers must not only understand the issues and root causes, but they must also name them and
make them visible as oppressive ideologies (Sleeter & Zavala, 2020).
Racial bias, or rather, the engrained stories held of marginalized groups, is believed to be
a driving factor in the unequal treatment and health outcomes of BIPOC. Dr. Dayna Bowen
Matthew (2015) argues that bias and discrimination are the single most important determinant of
health disparities that are not being widely discussed and represent a structural malady needing a
systemic cure. Bias is the automatic activation of the stereotyped beliefs we hold from the stories
we hear and retell. There is immense power in telling more accurate narratives, not only to
eliminate racial bias and the widening health gap but to disrupt long-held narratives that serve as
barriers to healing and collective truth.
The concept of OUR AD begins this endeavor by addressing one specific health
disparity—the overdiagnosis of schizophrenia among African Americans—and the
pharmaceutical industry's role in perpetuating a divisive narrative about African Americans that
have historical and present-day implications. OUR AD aims to center a more accurate story of
how long-held beliefs regarding African Americans and schizophrenia contribute to bias within
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the diagnostic moment and has significant implications for patient care and long-term outcomes.
OUR AD will discuss how the pharmaceutical industry helped to shape schizophrenia as a 'Black
disease' in the 1960s and reinforced and perpetuated longstanding and racialized narratives about
African Americans that continue today. As we look to address the Grand Challenges of
eliminating racism and closing the health gap, OUR AD believes there are gaps in examining the
intersection of pharmaceutical marketing and psychiatry in addressing the ongoing racial
diagnostic disparities in schizophrenia that have been steadily observed over the last three
decades.
Project methodology. OUR AD is a proposed social media campaign aimed at
eliminating pharmaceutical marketing that contributes to clinician bias and perpetuates racial
health disparities. OUR AD would use multiple social media channels to increase participant
involvement. Four design principles provide the infrastructure for the project, including
Collective Impact (Kania and Kramer, 2011), Design Justice (Costanza-Chock, 2018),
Conscious-Driven Marketing (Tate, 2015), and Equity-Mindedness (Bensimon et al., 2012).
OUR AD's use of a collective impact model emphasizes the importance of cross-sector
coordination to affect large-scale social change. OUR AD's coalition will include broad
participation across healthcare providers, conscious marketers, consumer advocates, academics,
and communities with a shared goal of promoting conscious-driven marketing (Tate, 2015) and
equity-mindedness (Bensimon et al., 2012). The principles of Design Justice are infused
throughout the project, from co-creation and development of OUR AD to the specific features
that promote participation and yield systematic engagement with the communities most affected
by racialized advertising.
OUR AD's design and theory of change is informed by Dr. Camara Jones's (2000) levels
of racism theoretical framework, which includes an examination of institutional racism,
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personally mediated racism, and internalized racism. Jones's framework highlights the
importance of addressing health disparities through increased accountability and reform within
institutions that hold structural power. This lens helps identify a strategic point of entry to
address the social problem while providing the rationale for focusing on an institutional force
like the pharmaceutical industry. Jones's framework ultimately informs the campaign design with
each design feature seeking to address a specific level of racism.
The campaign consists of five main pillars: identification, storytelling, participatory,
redesign, and impact. Identification involves the process of naming racialized pharmaceutical ads
and bringing attention to the associated injustices of the imagery. Once an ad has been identified,
storytelling activates the strength of OUR AD's cross-sector coalition by examining the ad from
multiple lenses, identifying the historical injustices associated with the imagery as well as the
present-day inequities that surround the issue. Participatory redesign invokes the voices and
strengths of the broader community and centers the voices and lived experiences of those most
adversely affected by racist marketing. Redesign allows for tangible participation and the use of
conscious-driven marketing and equity-mindedness to reimagine and create more truthful
narratives. The ultimate impact that OUR AD aims to achieve is to create a new standard for
pharmaceutical marketing that is free of stigmatizing and racialized imagery.
Social media serves as a powerful mechanism for change. With the continuous expansion
of technology and platforms, an online social media campaign can serve as an effective tool to
spread awareness, education, and illicit active engagement across networks and a broad group of
stakeholders. Social media has served as a catalyst in changing the dynamics of communication
(Latha et al., 2020). With content available 24 hours a day, social media serves as an
instrumental platform for real-time engagement within local, national, and international
communities. Social media can serve as a vehicle to empower networking, coalition building,
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and grassroots efforts for social change. Online platforms have proven to be powerful tools for
social movements, given the ability to facilitate social capital for campaigns and facilitate actual
behavioral change (Freeman et al., 2015). Additional benefits include relatively low startup cost,
high scalability, self-tracking, and built-in feedback functionalities (Latha et al., 2020).
OUR AD is positioned within a sociopolitical climate that is calling for greater health equity
and institutional accountability. Over the years, we have seen the impact and power of grassroots
efforts in addressing racial disparities. Digital platforms have become strategic and essential
tools for 21st-century social movements (Fleelon, McIlwain, & Clark, 2016). Social media
facilitates the necessary opportunities for broad participation and mobilization that can bring
social movements to scale and social capital to communities and coalitions.
II. Introduction
Assaultive and belligerent? Cooperation often begins with Haldol read a 1960s
pharmaceutical advertisement for the antipsychotic drug haloperidol developed to treat the
mental health disorder, schizophrenia (Appendix A). The ad depicted a picture of a Black man
with a clenched fist among a backdrop of urban unrest. The advertisement was infused with the
racialized and stigmatizing imagery that was not only held about African American men during
the Civil Rights Movement, but more generally, about African Americans throughout history.
Fast forward to today, and the racial diagnostic disparities for schizophrenia remain. A 2019
study shows that African Americans are diagnosed 2.4 times the rate of whites and experience
poorer long-term outcomes (Olbert et al., 2017). Implicit bias in the diagnostic moment is
believed to be a significant driver of the continued differences observed between groups
(Garrison et al., 2018; Merino et al., 2018; Medlock et al., 2017; Snowden, 2003).

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III. Conceptual Framework
Dr. Camara Jones's (2000) level of racism theoretical framework provides a conceptual
model that captures the profound danger and societal implications when institutions, like the
pharmaceutical industry, leverage their power and resources to reinforce racist narratives. More
specifically, Jones's model illuminates how institutional racism becomes embedded within
micro-practices and self-fulfilling within oppressed communities. Jones's work can help us better
understand how racist marketing has the power to perpetuate bias and reinforce divisive
narratives throughout communities. Her framework also serves as a lens to craft impactful,
multilevel solutions that increase institutional accountability and empower collective action.
Levels of racism. Jones (2000) highlights three levels of racism--institutional, personally
mediated, and internalized. The pharmaceutical industry represents a contemporary structure
where institutional racism exists. The industry has the power to perpetuate historical injustices
and engage in practices that exclude power and voice from others. Pharmaceutical companies
measure success by profitability; thus, marketing ads often look to create new disease markets
and expand market share through their advertising (Metzl, 2012). Driving market share can yield
pharmaceutical companies to tap into existing cultural anxieties and stereotypes about race,
gender, politics, and class (Metzl, 2012). In doing so, they can affirm and perpetuate stigmatizing
biases about specific groups.
Marketing materials infused with racialized imagery can perpetuate personally mediated
racism among clinicians by reinforcing prejudiced beliefs about specific groups. Personally
mediated racism is manifested in various ways, including disrespect, suspicion, devaluation, and
dehumanization (Jones, 2000). Within the clinical interaction, these actions can significantly
affect diagnostics, prescribing, and treatment. Clinician bias is a form of personally mediated
racism, and marketing tactics can further influence these behaviors. In regard to schizophrenia,
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clinician bias contributes to diagnostic differences and treatment approaches between African
Americans and whites (Garrison et al., 2018; Merino et al., 2018; Medlock et al., 2017;
Snowden, 2003). While more subtle and nuanced than explicit bias, implicit bias has significant
implications for patient care. Over two-thirds of health providers hold some form of bias toward
marginalized groups (Hall et al., 2015). Biases inform the expectations and assumptions a
physician may have about their patient based on stereotyped and stigmatizing beliefs regarding
race, gender, age, and ethnicity. Biases toward African American patients commonly include
assumptions about health literacy, responsiveness to treatment, hostility, paranoia, superstitious
beliefs, and noncompliance with treatment recommendations (Snowden, 2003). These
stigmatizing beliefs can influence the course of treatment by both over-pathologizing certain
behaviors and minimizing others within the clinical assessment (Snowden, 2003). For African
Americans diagnosed with schizophrenia, these biases contribute to misdiagnosis, yield fewer
referrals to specialty care, deploy higher doses of antipsychotic medication and first-generation
agents with poorer side-effects, and utilize forced treatments including compelled medication,
involuntary civil commitment, and the criminal justice system (Hall et al., 2015; Snowden,
2003). Psychiatric assessment relies heavily on physician discretion and is commonly provided
within a one-on-one setting (Merino et al., 2018). As such, there are ample opportunities for
clinician bias to influence the assessment.
Clinicians possess significant power in the therapeutic interaction, and their ability to serve
as a gatekeeper to a clinical course of action makes them a significant determinant of equity.
Research shows that pharmaceutical advertising can have significant influence on physician
behavior (Mitchell, 2020). This highlights the importance of ensuring that marketing materials
are culturally responsive and accountable to the communities they serve. Internalized racism is
the internalized beliefs among members of the stigmatized race of their innate abilities, their
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intrinsic worth, their right to self-determination, and their range of allowable self-expression.
Clinical interactions informed by cultural bias, along with marketing that is infused with racial
undertones, stigmatizing language, and imagery can further perpetuate the effect of internalized
racism.
IV. Problem of Practice and Innovative Solution
Problem of practice. The Haldol advertisement was not just an image on paper; it had
implications for how schizophrenia would be understood at that moment in history and is
interwoven in the diagnostic disparities today. The diagnostic inequities surrounding
schizophrenia find their roots within the 1960s during the Civil Rights Movement. Prior to the
social unrest, schizophrenia was commonly associated with and diagnosed among white middle-
class women. Within a backdrop of protest and resistance, the diagnostic criteria shifted, and
African American men were routinely hospitalized for "hostile and aggressive" feelings and
"delusional anti-whiteness" (Metzl, 2010). Schizophrenia became a vehicle to control those who
threatened the social order of white America.
The politicization of schizophrenia was further reinforced and profited by the pharmaceutical
industry. The advertisements for the antipsychotic medication Haldol reinforced a narrative that
stigmatized schizophrenia as a violent condition and 'Black disease'. Schizophrenia was
ultimately racialized, politicized, and criminalized. Those in power allowed a political agenda to
pathologize resistance, they allowed corporations to profit, and amplified a divisive narrative that
continues today.
What is perhaps most disturbing of the Haldol advertisement is the narrative infused
through its imagery. The ad not only reinforced and amplified the racialized beliefs about
African American, but it also opportunistically positioned its medication as a viable solution to
the social unrest of the time. It highlights the strategy and exploitative practice of utilizing race
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and the engrained privilege and power institutions have to dictate, define, and perpetuate racist
narratives for monetary advantage. This encapsulates Jones's call-to-action that it is the very
institutions that must be disrupted to affect large-scale change and equity.
Some may argue that the advertisement represented an isolated incident, but we continue
to see marketing infused with racial undertones and stigmatizing imagery. Race remains an
essential marketing tool and is commodified and positioned as a unique selling proposition
(Johnson et al., 2017; Crockett, 2008). Traditional approaches in marketing often fail to consider
the structural racism embedded in marketing practice. Poole et al. (2020) argues that there needs
to be a fundamental shift in how race and racism is investigated within marketing. Specifically
an understanding of how racist narratives within marketing are often representative of underlying
systems of power and contextualized within relevant histories of racial oppression.
The Haldol ad tapped into a long-held belief that being Black represents an intrinsic
deficiency that requires a necessary remedy. Crocker and Grier (2021) note that the race
construct and false notions of racial difference have become embedded in the beliefs and
behaviors of society since slavery. From medical experimentation and exploitation to exclusion
and opportunistic practice, Harriet Washington in her book Medical Apartheid (2006) notes that
the American healthcare system has always mirrored our dark history of race relations. From the
19th Century to today, physicians and the general public have been exposed to and participated
in—even if unconsciously—a divisive narrative regarding African Americans and health.
Disease-ridden, unintelligent, poor health literacy, hostile, paranoid, superstitious, distrustful,
unresponsive to treatment, and above all, noncompliant, have long been the words to describe
African Americans and their health (Washington, 2008; Snowden 2003). Claiming biology has
always been the only suitable way for America to justify our history of racial injustice and the
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corresponding health disparities (Roberts, 2011). Schizophrenia was not untouched from efforts
to pathologize, criminalize, and politicize racial difference.
During the social unrest of the 1960s, biology—a disease of the mind—served as a
justifiable explanation for protest and the sociopolitical resistance among many African
American men. Just as drapetomania racially pathologized fleeing slaves, protest psychosis
pathologized the hope for equality and justice. The pharmaceutical industry took notice of the
evolution of schizophrenia, including the routine hospitalization of African American men and
the inclusion of aggression, hostility, and projection within the diagnostic criteria (Metzl, 2010).
Having the power to decide, act, and control resources, pharmaceutical companies added fuel to
the fire and dovetailed claims of biology. Through racist and opportunistic marketing,
pharmaceutical companies advertised their antipsychotic medications as viable solutions to
control and contain social unrest. Fast forward 50 years, and the over-diagnosis and misdiagnosis
of schizophrenia among African Americans remain.
Stakeholder perspectives. Efforts to address bias, specifically implicit bias among
practitioners and psychiatrists, have focused on cultural and antiracist training programs,
particularly among medical residency programs to raise awareness. While these programs serve
an important role, they often lack the scale and consistent integration to drive behavioral change
among practitioners (Medlock et al., 2017). Through interviews with medical directors,
practicing physicians, and academic faculty members, these trainings are only marginally
effective due to issues of implicit bias and structural racism that is often embedded within the
walls of healthcare. Despite efforts to highlight the impact of bias on racial health disparities, one
professor and practicing psychiatrist noted that residents and clinicians still work within a "white
infrastructure" that "trains the implicit biases that are seen within society as a whole”.
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African American patients, family members, and clinicians commonly discussed the
effects of microaggressions, the lack of diverse healthcare teams, and a general distrust in the
system. Emergency room and inpatient social workers, nurses, and attending physicians
highlighted stories of African American patients being overmedicated, over restrained, and
criminalized, likely due to strong implicit biases among clinicians. Within acute settings like the
emergency room and inpatient psychiatry, two interviewees noted that they have observed a bias
to "control Black bodies" fueled by "fear" and based on the assumption that African American
patients are “dangerous." This is consistent with research that shows implicit bias to be strong in
settings where clinicians experience high cognitive demand and time pressure (Dyrbye et al.,
2019; Burgess, 2010; Burgess et al., 2014). Many African American patients presenting with
psychosis or schizophrenia-like symptoms within these settings are met by a system focused
more on "containment verse treatment" shared one nurse.
Interviews with marketers, both in academic settings and within corporations, agree that
race remains an essential tool for marketing practice. Many report that the profession lacks a
framework that promotes equitable and antiracist practices. Grier, Thomas, and Johnson (2019)
emphasize that "marketing is missing a cohesive critical perspective that orients realities of
power, privilege, and oppression within existing marketing strategies" and lacks an overarching
framework that "promotes inclusive, fair, and just" marketing. Interviewees report that marketing
students, just like medical students, often operate from a "color-blind perspective". This can
provide significant limitations for student awareness of personal biases and their relationship to
the content or patients they are engaging with. One academic researcher and professor
advocating for an antiracist marketing framework within their institution reports that remedies to
reproduce institutionalized racism within marketing requires organizations to name their role in
perpetuating stigmatizing narratives and to closely examine and re-exam their assumptions.
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The social significance of the problem. There is growing concern in how pharmaceutical
marketing can undermine patient safety, impact public health (Brody and Light, 2011), and
leverage cultural bias to influence physician behaviors (Metzl, 2012). The Action Center on Race
and the Economy (ACRE) released a report in 2020 highlighting that the economic and health
disparities experienced among communities of color are a result of targeted racial discrimination
by the pharmaceutical industry (ACRE, 2020). In 2016, the Medical Futurist identified
'Empowered Patients' as one of the top ten disruptive drivers transforming pharma. In 2018, the
Edelman Trust Barometer showed that 62% of Americans do not trust the industry, and 80% felt
pharmaceutical companies put profits over patients. Respondents highlighted high drug pricing,
the opioid epidemic, and direct-to-consumer marketing as critical contributors to their distrust
(Reis et al., 2018). Results in 2019 showed that Americans believe that the industry prioritizes
profit over patients, marketing over innovation, and lacks transparency. The results for 2020
depict a similar trajectory, although notably, the main factor undermining trust now is a growing
sense of inequity.
The ethos of empowered consumers is being seen across sectors. Strong support in
addressing racial inequities was demonstrated during the Trump Administration when a joint
letter from the American Hospital Association, American Medical Association, and the
American Nurses Association responded to Executive Order 13950, Combating Race and Sex
Stereotyping. The authors, representing 5,000 hospitals, more than 1 million physicians, and 4
million registered nurses note that diversity, inclusion, and equity efforts are essential to
addressing the myriad of factors that influence a patient's health status and outcomes, including
"the social determinants of health, implicit bias, and historical systems that have led to unequal
access to care" (Pollack et al., 2020). They reported that the Order significantly undermines vital
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research being conducted within the National Institute of Health that aims to better comprehend
the effect of structural racism and implicit bias on health care.
Current efforts to address the problem. Academic training programs focused on
addressing racial bias are becoming more prevalent within medical schools and programs. There
is an increasing number of programs focusing on diagnostic disparities and the role of implicit
bias among clinicians. Many of these programs have been developed based on the growing
research demonstrating racial health inequities in nearly all dimensions of healthcare. Much of
this research demonstrates the long history of health disparities among African Americans with
calls to action for greater system-level accountability. Programs that focus on implicit bias as a
contributor to diagnostic disparities are predominantly seen in the academic space. These
programs primarily focus on increasing awareness and education among clinical trainees and
medical residents, including discussions on historical racism and injustice within healthcare.
Some of these programs have integrated important recognition of their own historical
participation in discriminatory and stigmatizing practices toward BIPOC within medical
associations like the American Medical Association (AMA) and American Psychiatric
Association (APA). As such, some of these programs incorporate important elements of equity-
mindedness.
The trainings within these programs are generally provided by clinicians for clinicians.
Voices of the beneficiaries, including patients and consumers, family members, and other
essential stakeholders, do not appear to be involved in content development or education
delivery. Generally, these training programs are siloed and not fully integrated throughout
institutions. Training programs are also often initiated based on student interest and advocacy.
Many programs are offered once within the 5-year residency program, limiting the ability to
evolve worldviews, to uncover biases, and to illicit behavioral change among students. While
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some programs provide pre- and post-surveys to participants, few metrics measure behavioral
change among trainees. Long-term sustainability and funding of training programs pose
significant challenges as well. Few of these programs include education regarding
pharmaceutical advertising specifically.
PharmedOUT is a nonprofit organization within Georgetown University's School of
Medicine founded in 2007 to serve the physician and healthcare community (pharmedout.org).
The mission of PharmedOUT is to actively investigate the use of marketing and other
promotional tactics that aim to influence physician behaviors. PharmedOUT is committed to
providing access to unbiased drug information and pharma-free clinical education to healthcare
providers. The vision of PharmedOUT is to ensure that the pharmaceutical industry's commercial
interests do not influence medical literature, medical training, therapeutic decisions, and
physician prescribing. PharmedOUT programs focus on three specific areas: publications that
focus on industry influence and ethics, pharma-free continuing medical education for healthcare
providers, and an annual conference aimed at strategizing ways to curtail industry influence
within the medical community.
PharmedOUT serves as an important resource within the medical community,
particularly in providing biased-free medical education and providing expert testimony to issues
related to pharmaceutical ethics. PharmedOUT has had difficulty publishing to medical journals
that receive significant support and funding by the pharmaceutical industry. By partnering with
other organizations focused on systemic accountability, PharmedOUT can strengthen their
presence, identify additional funding streams, and build a collective network and coalition. Most
importantly, PharmedOUT's impact can be further realized by identifying ways to partner with
and center the voices of patients and consumers in their work.
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The Bad Ad Program began in 2010 under the Food and Drug Administration (FDA)
Office of Prescription Drug Promotion (OPDP). The organization's mission is to provide a
regulatory tool for physicians and healthcare workers to report false or misleading prescription
drug advertising (fda.gov). Healthcare providers can report false or misleading advertising to the
Bad Ad website, generating an internal review process to assess compliance. Bad Ad's regulatory
decisions, include issuing the company a warning letter, revoking the ad, or disregarding the
submitted claim for lack of clear evidence.
According to a 2018 study, the Bad Ad program is relatively unknown within the medical
community (O'Donoghue, 2018). Bad Ad has historically focused on informal diffusion
channels, including peer-to-peer sharing among small social networks, promoting the program at
conferences, and directing healthcare providers to their website. Over the last ten years, the
program has received 2,000 reports of false or misleading advertising (Abrams, 2020). This
number is relatively low given the thousands of advertisements that are released annually. Bad
Ad would benefit from targeting a more comprehensive network of health professionals and
providing a more robust and accessible reporting system. Despite Bad Ad's focus on healthcare
professionals, they receive several submissions from non-healthcare providers. While many of
these submissions may not meet criteria for regulatory involvement based on Bad Ad's criteria, it
highlights a necessary need among consumers in seeking ways to be involved and engaged in
pharmaceutical accountability.
Color of Change is a nonprofit civil rights organization formed in 2005 after Hurricane
Katrina (colorofchange.org). It is the largest online organization advocating for racial justice,
with 7 million members. The organization focuses specifically on leading campaigns that build
political and cultural power within Black communities. Color of Change utilizes technology,
research, media, and community engagement to build movements that specifically aim to address
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systemic inequities. Examples of current campaigns include criminal justice reform, increasing
electoral participation, and changing how Black individuals are represented in news and
entertainment media. Ultimately, Color of Change seeks to build the necessary infrastructure to
support communities in building narrative power. Rashad Robinson (2018) defines narrative
power as the ability to change normative beliefs and behaviors, with narrative infrastructure
being the set of systems that are maintained to create change reliably over time. Robinson notes
that a critical aspect of building narrative power is building the infrastructure of accountability,
including limiting the influence of false and dangerous narratives propagated by oppressive
systems and leaders. Achieving narrative power requires an online presence that extends beyond
the number of likes or retweets alone but rather a presence that affects measurable change.
The OUR AD solution. This project aims to build upon the current momentum and
strong advocacy work being done to combat racial health disparities, implicit bias, and increased
pharmaceutical accountability. OUR AD represents one specific solution to help eliminate
pharmaceutical marketing that contributes to clinician bias and perpetuates racial health
disparities. OUR AD offers a solution that has pulled from the strength of existing programs
while fine-tuning and evolving design features to meet current gaps and opportunities. OUR AD
has identified a gap in increasing the need for greater pharmaceutical accountability by
empowering the voices of a diverse stakeholder group. It also functions under the premise that it
is not enough to identify and expose inappropriate advertising. Rather, there needs to be a
process for actual redesign that pulls from the strengths and lived experiences of the very
subjects the content targets.
A fundamental goal of OUR AD is to democratize the process of identifying racialized
pharmaceutical advertising while promoting participatory redesign. The OUR AD solution
would use multiple social media channels to increase participant involvement, including an
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online website and social media presence. The proposed project utilizes Kania and Kramer's
(2011) collective impact model, emphasizing the importance of cross-sector coordination to
affect large-scale social change. The goal of OUR AD would include using broad participation
across healthcare providers, marketers, consumer advocates, academics, and communities with a
shared vision of promoting conscious-driven marketing (Tate, 2015) and equity-mindedness
(Bensimon et al., 2012).
The power of social media. With over 4.1 billion people using social media worldwide,
OUR AD's campaign can broaden its reach across multiple networks and provide the necessary
platform for a participatory redesign. Leveraging a social media campaign pulls from the
instrumental and strategic work being done within grassroots efforts, particularly around issues
pertaining to racial justice. Social media creates participation opportunities that broaden
mobilization, strengthen connections, and help to scale movement endeavors (Mundt et al.,
2018). When utilized as a scaling tool, campaigns are strengthened by facilitating collective
meaning-making and can amplify their message across diverse platforms. By creating
opportunities for recurring interactions among activists, social media can serve as a power
vehicle that can adjoin to and, at times, even replace traditional intermediaries such as
mainstream media (Milan, 2015). Distinct from traditional organizing, Bennett and Segerberg
(2011, 2012) note that collective action is far more personalized within digital environments. In
social media spaces, political content is expressed via "personal action frames" inclusive of
multiple personal reasons for contesting the status quo. Movements that use social media
platforms "have frequently been larger, have scaled up more quickly, and have been flexible in
tracking moving political targets and bridging different issues" compared with conventional
movements.
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The accessibility of digital spaces has led to organizing around a much broader set of issues
than previously seen (Earl & Kimport, 2014). Since its inception in 2014, Black Lives Matter has
grown into a national network and demonstrated the impact of infusing grassroots efforts
throughout social media platforms. Part of the broader movement for Black Lives Matter
includes 50 organizations with a shared vision and platform for Black liberation and an end to
police brutality. Yang (2016) notes that the use of the hashtag ‘#blacklivesmatter’ provides an
opportunity for users to engage in "narrative agency" by creating their own stories and discourse
around the term and its meaning.
V. Project Structure, Methodology, and Action Components
OUR AD's design is driven by five key pillars, each corresponding to a specific level of
racism within Jones's framework and each utilizing specific design principles to achieve greater
impact. The four design principles that provide the infrastructure for OUR AD, include:
1. Collective Impact—The premise of a collective impact approach is that large-scale social
change requires broad cross-sector coordination around a common agenda for solving a
specific social issue (Kania and Kramer, 2011). Eliminating pharmaceutical marketing
that perpetuates racial bias will require participation among a broad group of stakeholders
with a shared vision of disrupting narratives within advertising that perpetuate bias and
health disparities while promoting conscious-driven marketing (Tate, 2015) and equity-
mindedness (Bensimon et al., 2012). The collective impact approach is anchored in a
shared understanding of the problem among stakeholders and a joint approach to solving
it. OUR AD's partnerships would include healthcare providers, conscious marketers,
consumer advocates, academics, and communities. (Appendix C).
2. Design Justice—Focuses on centering the voices of the communities most affected by the
social issue or the design process (Costanza-Chock, 2018). Far too often, the intended
23
beneficiaries of programs are excluded from the problem identification and solution
ideation stages. This often leads to reproducing the status quo and designing solutions
rooted in white supremacy, heteropatriarchy, capitalism, and colonialism, also referred to
as the matrix of domination (Collins, 2002). Design Justice is rooted in the ideals of
democratic inclusion and social justice and functions under the premise that there is an
ethical imperative to systematically advance the participation of marginalized and
excluded communities in all stages of the design process. Ultimately, design justice
provides a framework that asks how design processes work and how we want them to
work moving forward.
3. Conscious-Driven Marketing—A type of marketing practice that believes that all
marketing activities should align with a higher purpose beyond profit and market share
(Tate, 2015). Conscious-driven marketing promotes an approach where deep regard is
given to the client and their needs and that marketing information is delivered with
honesty, transparency, and congruency. Conscious-driven marketing promotes messages
infused with joy, hope, love, and humanity (Appendix D).
4. Equity-Mindedness—In addition to conscious-driven marketing principles, OUR AD is
focused on incorporating equity-mindedness into the storytelling and redesign phases.
Developed out of the Center for Urban Education at the University of Southern
California, equity-mindedness encompasses five strategic steps (Bensimon et al., 2012).
(1) Be race-conscious which includes naming the specific racial inequity and the
specific groups affected.
(2) Remain institutionally focused and systemically aware of how current inequities
are related to structural racism. This requires situating present inequities within the
24
sociohistorical context and recognizing how the inequity is a dysfunction of structures,
policies, and practices.
(3) Be evidence-based and pull data that demonstrates the profound impact of the
disparity.
(4) Remain systemically aware of how institutions are the source of dysfunction verse
the individual or community.
(5) Be action-oriented by raising awareness of the outcomes of racial inequities,
including building a broader understanding of the connection between inequitable
outcomes and systemic inequities, and cultivating evidence-based knowledge about
the nature of inequities in a way that motivates collective action.
The concept of OUR AD is driven and organized around five specific practices that
provide the campaign's underlying methodology and structure. These practices demonstrate the
systematic flow and exchange of information and the participatory nature of the project (Exhibit
B).
1. Identification—Involves the process of identifying and naming racialized pharmaceutical
ads and bringing attention to the associated injustices of the imagery across platforms.
The OUR AD coalition and followers can share identified ads across OUR AD's social
media platforms utilizing the hashtag #OURAD. Identification is anchored in Jones's first
level of racism—institutional—by focusing on the embedded practices within the
pharmaceutical industry. The process aims to involve beneficiaries and a broader group
of stakeholders in the critical critique of pharmaceutical marketing. This process provides
the opportunity to increase the accountability of institutions among empowered citizens
through collective impact and design justice.
25
2. Storytelling—Once an ad has been identified, storytelling activates the strength of OUR
AD's cross-sector coalition by examining the ad from multiple lenses. Storytelling would
include the process of 1) identifying the historical injustices associated with the imagery
and 2) the present-day inequities that surround the issue. Impactful storytelling should
address all three levels of Jones's framework and utilize mixed media to share a
compelling story of why the ad requires redesign. Advertisements that align with current
sociopolitical issues or receive substantial attention across platforms, will be prioritized
for storytelling.
3. Participatory—Active participation invokes the voices and strengths of the broader
community. Eliminating racialized imagery rooted in stereotyped, stigmatizing, and
historically unjust stories of BIPOC requires centering the voices and lives of those most
adversely affected by racist marketing. Driven by design justice principles, OUR AD
invites a broad group of stakeholders via online networks to reimagine and rewrite the
racialized ad. Participation evokes individuals to assess their own biases (personally
mediated racism, Level 2) and empowers individuals and communities to reclaim how
there are portrayed through media (internalized racism, Level 3).
4. Redesign—Participatory redesign empowers tangible participation and democratizes the
effort to provide renewed and more truthful narratives. Redesign allows participants to
reclaim their voice within imagery and marketing materials that have infused
stigmatizing and or racialized imagery and language. Participants will be encouraged to
utilize the principles of conscious-driven marketing and equity-mindedness. Ultimately,
participants will have creative freedom and use the #OURAD to make their posts
available across OUR AD's media platforms.
26
5. Impact—The ultimate impact that OUR AD aims to achieve is to create a new standard
for pharmaceutical marketing (Level 1) that is free of stigmatizing and racialized imagery
that perpetuates bias (Level 2) and contributes to ongoing racial health disparities (Level
3).
Implementation. OUR AD has utilized the Exploration, Preparation, Implementation,
Sustainment (EPIS) framework developed by Moullin et al. (2019) to plan for effective
implementation and program success. The EPIS framework is a multilevel approach to project
implementation that includes analysis and assessment of possible project barriers and facilitators
within the inner and outer context of the innovation. There are four phases of implementation
within the EPIS model and various strategies to support real-world application (Grimshaw et al.,
2001; Grol & Grimshaw, 2003). Prior research demonstrates that many implementation efforts
fail due to limited, ineffective, or informal implementation strategies (Davies et al., 2003).
OUR AD has assessed the existing gaps and opportunities in eliminating racial health
disparities within the exploration phase. Gaps were identified in addressing the role of
pharmaceutical marketing explicitly in perpetuating and reinforcing racialized narratives about
African Americans that perpetuate bias and racial inequities. The need for a collective impact
approach was also identified to ensure broad participation across multiple stakeholders in
increasing pharmaceutical accountability and promoting conscious-driven marketing and equity-
mindedness. Lastly, OUR AD identified the need to incorporate design justice principles by
devising a solution that empowers participatory redesign across online platforms and challenges
the status quo in how pharmaceutical advertising is monitored and regulated.
Within the preparation phase, OUR AD has focused on building a cross-sector coalition
with a shared goal of addressing racial disparities and increasing pharmaceutical accountability.
Through ongoing communication and interviews with existing coalitions, advocacy
27
organizations, marketers, academic institutions, government agencies, medical centers,
consumers and families, and social work professionals and leaders have helped to inform and co-
design this project. This phase has also included research and preparation on establishing an
online media campaign that is robust, sustainable, and has the capacity for broad reach.
Planning for implementation has included developing prototypes, online materials for
storytelling and redesign, developing a website, devising a communication plan and strategy,
obtaining funding to pilot the project, identifying measurable objectives, and continuing to
establish community partners. Funding predications for OUR AD’s first year, including a 6-
month pilot phase, is estimated to range between $60,000 and $90,000. These costs would
support social engagement, content creation, paid advertising, data analytics, project
management, execution, and reporting.
Sustainment will involve the final stage of implementation and includes the ongoing
monitoring of fidelity and outcomes. Program monitoring will pull from the principles of
collective impact (Kania and Kramer, 2011), including utilizing a shared measurement system,
engaging in mutually reinforcing activities that support sustainment, facilitating continuous
communication across the coalition, and development and integration of the core OUR AD team.
Sustainment and measurement plan. The role of continuous feedback loops across the
collective impact coalition will be imperative to ensure the execution of the mutually decided
goals and objectives. OUR AD would engage in bi-weekly meetings with the core team
(executive director, representative marketer, consumer advocates, resident psychiatrist, and
digital strategist) to ensure weekly execution plans, to make decisions regarding content and
storytelling, to monitor engagement and capacity for broader participation, and to expand
partnerships and stakeholder involvement.
28
Short-term success can be measured in three ways, including: (1) launching the OUR AD
campaign across social media sites and going live with the OUR AD website; (2) monitoring and
expanding partnerships across a broad stakeholder group, include existing coalitions, advocacy
groups, and other influencers or organizations with an online presence who agree to share
content and promote OUR ADs work across their networks; and (3) promoting the use of
conscious-driven marketing principles and equity-mindedness across online platforms to increase
awareness and support redesign efforts.
Intermediate success would be measured by daily monitoring of levels of engagement across
OUR AD's platforms and providing weekly reporting to the coalition. Data can be captured using
existing social media analytic tools. Pulled from the work of Freeman et al. (2015), levels of
engagement can be measured across three levels, including (1) low engagement – an agreement
or preference for content including 'likes' of content across all platforms as well as website visits,
(2) medium engagement – is measured followers sharing content with the capacity to influence
others, including sharing or retweeting OUR AD content, and (3) high engagement – includes
actual participation across stakeholders in the participatory redesign. Redesigned ads could also
be measured on levels of engagement once posted across OUR AD's platforms utilizing the same
criteria outlined above (e.g., low, medium, high engagement). While these measurements can
provide important insights into OUR AD's reach, level of engagement does not necessarily
equate to changed behavior.
Long-term success will include goals that specifically focus on changed behavior. This will
include (1) eliminating marketing that uses stigmatizing imagery about African Americans that
can perpetuate bias and racial disparities in health, (2) increased use and incorporation of
conscious-driven marketing and equity-mindedness across pharmaceutical advertising, and (3)
eliminating existing disparities in the over-diagnosis of schizophrenia in African Americans.
29
Communication strategy. As Robinson (2018) of the Color of Change notes, narrative
power is the ability to change the norms and rules our society lives by. It is not simply enough to
illicit empathy; advancing narrative power requires an infrastructure for strategic storytelling.
Robinson notes that this is particularly true if we want our storytelling to matter and affect
behavioral change. Narrative power is not "merely the presence of our issues on the front page"
but rather "the ability to achieve presence in a way that forces changes in decision making and in
the status quo, in real, material, value-added terms" (Robinson, 2018). OUR AD's
communication strategy will incorporate what Robinson outlines as the infrastructure required to
effectively build and leverage narrative power for long-term sustainability:
1. Follow-through on narrative and cultural dispersion and immersion—over time, across
segments and at scale. Robinson cautions that if the ultimate goal is getting an issue on
the front page (presence), rather than implementing our values and solutions in the real
world (power), organizations miss the point of narratives' role in affecting social change.
OUR AD must be relentless in its commitment to expanding its stakeholder group and
rallying its participants around a clear mission for greater pharmaceutical accountability
and more conscious-driven and equity-minded marketing.
2. People are the primary vehicle for achieving narrative change. Efforts require
investments in widespread narrative immersion and mobilization across stakeholders and
networks. Research has shown that utilizing multiple online platforms can significantly
impact campaign messaging (Snyder and Garcia-Garcia, 2016). This also facilitates
broader participation and centers efforts around inclusion and participatory action.
3. Efforts cannot forsake the power of brands. Brand narratives can influence people's
feelings, thoughts and behaviors. Infrastructure must be put in place that creates brand
narratives for stakeholders and participants to share within their own networks. These
30
narratives should be accessible to diverse groups and representative of the full range of
lived experiences. Ultimately, these narratives should be driven to activate those
communities and stakeholders essential to progressive success and institutional reform.
VI. Conclusions, Actions, and Implications
Challenges, barriers, and risks. While social media provides numerous benefits, there are
potential challenges and risks associated with utilizing online channels. Latha et al. (2020) note
that online campaigns cannot be the sole solution for changing behaviors. OUR AD's long-term
success will depend on efforts that go beyond redesign and strive to make system-level change.
Information shared to social media is also public and open to review, critique, and public
comment. For some participants, concerns around privacy and expressing their opinions in public
domains may deter engagement (Fire et al., 2014). Participation also requires access to
computers or devices and sufficient knowledge of how to navigate and interact with online
platforms. This may limit use among individuals who do not have access to technology or
specific age groups whose use of social media is not a normative outlet for engagement and
communication. Another consideration is the response from the pharmaceutical industry and how
they may leverage their own substantial resources and online presence to counteract efforts for
increased accountability and consumer engagement. Lastly, consideration of the type of content,
how storytelling takes place, and the imagery used will require thoughtful consideration.
Leveraging OUR AD’s coalition will help to ensure diverse representation and alignment with
the project’s shared vision.
A Vision Forward. Camara Jones (2020) notes that there is "particular danger when systems
of power are not concerned with equity". Jones describes her levels of racism framework using
an allegory called A Gardener's Tale. The story provides an accessible way to understand the
various levels of racism within society. What is perhaps most profound and impactful of Jones's
31
framework is her use of storytelling. She exhibits the narrative agency and power required to
discuss racial health disparities in a way that propels action and responsibility. Jones uses
empathy with a parallel focus on power. This means "turning up the volume of our stories but
also changing the rules of cultural production and incentive structures" (Robinson, 2018). OUR
AD hopes to be a vehicle to help shift the narrative and to paint a more accurate human story that
depicts the layers, intersecting identities, and strengths within communities.
Tackling the Grand Challenges of eliminating racism and closing the health gap will require
bold, fearless, and innovative approaches to disrupt the systems that hold injustices in place. It
will also require renewed narratives and more truthful storytelling of how our history informs
present-day disparities and how systems sustain the inequities. Teasley et al. (2020) notes that
social workers must collaborate with communities in reciprocal and participatory ways to
generate new knowledge and problem-solving solutions. In doing so, the profession must adopt
an antiracist perspective beyond understanding the conditions that oppress "to specifically
understand how racism and white supremacy continue to remake themselves and flourish" within
society. Ultimately, the profession must be compelled to change systems to become antiracist,
sustainable, and just. OUR AD envisions a future where storytelling and personal narratives
remain central to our collective experience, and that these stories illuminate historic and present-
day truths for collective healing.
32
References
Abrams, T. (2020, July 15). From Our Perspective: Bad Ad Program at 10, Educating
Healthcare. U.S. Food and Drug Administration. https://www.fda.gov/drugs/news-events-
human-drugs/our-perspective-bad-ad-program-10-educating-healthcare-providers-
recognize-and-report-potentially.
Action Center on Race and the Economy: Poi$on. (2020, August 18). Retrieved September 30,
2020, from https://acrecampaigns.org/research_post/poison/
Bennett, W. L., & Segerberg, A. (2011). Digital media and the personalization of collective
action: Social technology and the organization of protests against the global economic
crisis. Information, Communication & Society, 14, 770–799.
Bennett, W. L., & Segerberg, A. (2012). The logic of connective action: Digital media and the
personalization of contentious politics. Information, Communication & Society, 15, 739–
768.
Bensimon, E. M., Malcom, L., & Longanecker, D. (2012). Confronting Equity Issues on
Campus: Implementing the Equity Scorecard in Theory and Practice. Stylus Publishing.
Bresnahan, M., Begg, M., Brown, A., Schaefer, C., Sohler, N., Insel, B., Vella, L., & Susser, E.
(2007). Race and risk of schizophrenia in a US birth cohort: another example of health
disparity? International Journal of Epidemiology, 36(4), 751–758.
https://doi.org/10.1093/ije/dym041
Brody H, Light DW (2011) The Inverse Benefit Law: How Drug Marketing Undermines Patient
Safety and Public Health. American Journal of Public Health 101: 399–404.
Burgess, D. (2010). Are Providers More Likely to Contribute to Healthcare Disparities Under
33
High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to
Biases in Medical Decision Making. Medical Decision Making, 30(2), 246–257.
https://doi.org/10.1177/0272989X09341751
Burgess, D., Phelan, S., Workman, M., Hagel, E., Nelson, D., Fu, S., Widome, R., & Ryn, M.
(2014). The Effect of Cognitive Load and Patient Race on Physicians’ Decisions to
Prescribe Opioids for Chronic Low Back Pain: A Randomized Trial. Pain Medicine
(Malden, Mass.), 15(6), 965–974. https://doi.org/10.1111/pme.12378
Bystydzienski, J. M., & Schacht, S. P. (Eds.) (2001). Forging radical alliances across
difference: Coalition politics for the new millennium. Lanham, MD: Rowman &
Littlefield.
Chan, L., O’Hara, B., Phongsavan, P., Bauman, A., & Freeman, B. (2020). Review of evaluation
metrics used in digital and traditional tobacco control campaigns. Journal of Medical
Internet Research, 22(8), e17432–e17432. https://doi.org/10.2196/17432
Chá vez, K. R. (2011). Counter-public enclaves and understanding the function of rhetoric in
social movement coalition-building. Communication Quarterly, 59(1), 1–18.
Chien, PL. & Bell, CC. (2008). Racial Differences in Schizophrenia. Directions in Psychiatry.
28(23):298-305.
Collins, P. H. (2002). Black feminist thought: Knowledge, consciousness, and the politics
of empowerment. Routledge.
Color Of Change. (2021, October 12). Color of change helps you do something real about
injustice.. Retrieved October 28, 2021, from https://colorofchange.org/.
Costanza-Chock, Sasha, Design Justice: Towards an Intersectional Feminist Framework
34
Design Theory and Practice (June 3, 2018). Proceedings of the Design Research Society
2018, Available at SSRN: https://ssrn.com/abstract=3189696
Crockett, David (2008), “Marketing Blackness: How Advertisers Use Race to Sell Products,”
Journal of Consumer Culture, 8 (2), 245–68.
Crockett, David and Sonya A. Grier (2021), “Race in the Marketplace and COVID-19,” Journal
of Public Policy & Marketing, 40 (1), 89–91, https://doi.org/10.1177/743915620931448.
Davies P, Walker A, Grimshaw J. (2003). Theories of behavior change in studies of guideline
implementation. Proc Br Psychol Soc. 2003;11:120.
Dyrbye L, Herrin J, West CP, et al. (2019). Association of Racial Bias With Burnout Among
Resident Physicians. JAMA Netw Open, 2(7):e197457.
doi:10.1001/jamanetworkopen.2019.7457
Earl, J., & Kimport, K. (2014). Digitally enabled social change: Activism in the Internet Age.
Cambridge, MA: The MIT Press.
Fire M, Goldschmidt R, Elovici Y. Online social networks: Threats and solutions. IEEE
Commun Surv 2014;16:2019-36.
Fligstein, N. (2001). Social skill and the theory of fields. Sociological Theory, 19, 105–125.
Food and Drug Administration. (2021, July 5). fda.org
Freelon, D., McIlwain, C., & Clark, M. (2016). Beyond the hashtags: #Ferguson,
#Blacklivesmatter, and the online struggle for offline justice. Retrieved from
https://ssrn.com/abstract=2747066
Freeman, B., Potente, S., Rock, V., & McIver, J. (2015). Social media campaigns that make a
difference: What can public health learn from the corporate sector and other social
change marketers? Public Health Research & Practice, 25(2), e2521517–e2521517.
35
https://doi.org/10.17061/phrp2521517
Gara, M., Minsky, S., Silverstein, S., Miskimen, T., & Strakowski, S. (2019). A Naturalistic
Study of Racial Disparities in Diagnoses at an Outpatient Behavioral Health Clinic.
Psychiatric Services, 70(2), 130–134. https://doi.org/10.1176/appi.ps.201800223
Garrison, C. B., McKinney-Whitson, V., Johnston, B., & Munroe, A. (2018). Race matters:
Addressing racism as a health issue. The International Journal of Psychiatry in Medicine,
53(5-6), 436-444.
Georgetown University, PharmedOUT. (2021, July 7). Georgetown.edu/pharmedout
Grier, Sonya A. and Guillaume D. Johnson (2011), “Alisha in Obesity- Land: Is Food Marketing
the Mad Hatter?” International Journal of Case Studies in Management, 9 (4), 1–26.
Grimshaw, J. M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L., . . . O’Brien, M. A.
(2001). Changing provider behavior: An overview of systematic reviews of interventions.
Medical Care, 39(8 Suppl. 2), II-2-II-45.
Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation
of change in patients’ care. Lancet, 362, 1225-1230.
Hall, W., Chapman, M., Lee, K., Merino, Y., Thomas, T., Payne, B., Eng, E., Day, S., & Coyne-
Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its
Influence on Health Care Outcomes: A Systematic Review. American Journal of Public
Health (1971), 105(12), e60–e76. https://doi.org/10.2105/ajph.2015.302903
Johnson, Guillaume D., Kevin D. Thomas, and Sonya A. Grier (2017), “When the Burger
Becomes Halal: A Critical Discourse Analysis of Privilege and Marketplace Inclusion,”
Consumption Markets & Culture, 20 (6), 497–522.
Jones, C. (2000). Levels of racism: a theoretic framework and a gardener’s tale. American
36
Journal of Public Health (1971), 90(8), 1212–1215. https://doi.org/10.2105/ajph.90.8.121
Kania, J. & Kramer, M. (2011). Collective Impact. Stanford Social Innovation Review, 9(1), 36–
Latha, K., Meena, K. ., Pravitha, M. ., Dasgupta, M., & Chaturvedi, S. . (2020). Effective use of
social media platforms for promotion of mental health awareness. Journal of Education
and Health Promotion, 9(1), 124–124. https://doi.org/10.4103/jehp.jehp_90_20
Lawson, W., Johnston S., Karson, C. (2015). racial differences in antipsychotic use: Claims
database analysis of Medicaid-insured patients with schizophrenia. Annals of Clinical
Psychiatry, 27(4):242-252.
Li, H., Eack, S., Montrose, D., Miewald, J., & Keshavan, M. (2011). Longitudinal treatment
outcome of African American and Caucasian patients with first episode psychosis. Asian
Journal of Psychiatry, 4(4), 266–271. https://doi.org/10.1016/j.ajp.2011.08.004
Matthew, D. Bowen. (2015). Just medicine: a cure for racial inequality in American health
care. New York: New York University Press.
McGrath, J., Saha, S., Chant, D., & Welham, J. (2008). Schizophrenia: A Concise Overview of
Incidence, Prevalence, and Mortality. Epidemiologic Reviews, 30(1), 67–76.
https://doi.org/10.1093/epirev/mxn001
Medlock, M., Weissman, A., Wong, S. S., Carlo, A., Zeng, M., Borba, C., Curry, M., & Shtasel,
D. (2017). Racism as a Unique Social Determinant of Mental Health: Development of a
Didactic Curriculum for Psychiatry Residents. MedEdPORTAL : the journal of teaching
and learning resources, 13, 10618. https://doi.org/10.15766/mep_2374-8265.10618
Merino Y, Adams L, Hall WJ. Implicit Bias and Mental Health Professionals: Priorities and
Directions for Research. Psychiatr Serv. 2018 Jun 1;69(6):723-725. doi:
10.1176/appi.ps.201700294. Epub 2018 Mar 1. PMID: 29493411.
37
Metzl, J. (2012, June 01). Mainstream Anxieties about Race in Antipsychotic Drug Ads.
Retrieved October 02, 2020, from https://journalofethics.ama-assn.org/article/mainstream-
anxieties-about-race-antipsychotic-drug-ads/2012-06
Metzl, J. (2010). Protest Psychosis: How Schizophrenia Became a Black Disease. In Protest
Psychosis. Beacon Press.
Mitchell, A. P., Trivedi, N. U., Gennarelli, R. L., Chimonas, S., Tabatabai, S. M., Goldberg, J.,
Korenstein, D. (2020). Are Financial Payments from the Pharmaceutical Industry
Associated with Physician Prescribing? Annals of Internal Medicine. doi:10.7326/m20-
5665
Milan, S. (2015). From social movements to cloud protesting: The evolution of collective
identity. Information, Communication & Society, 18, 887–900.
Mintzes, B., Barer, M., Kravitz, R., Bassett, K., Lexchin, J., Kazanjian, A., Marion, S. (2003,
September 02). How does direct-to-consumer advertising (DTCA) affect prescribing? A
survey in primary care environments with and without legal DTCA. Retrieved October
02, 2020, from https://www.cmaj.ca/content/169/5/405
Moullin, J., Dickson, K., Stadnick, N., Rabin, B., & Aarons, G. (2019). Systematic review of the
Exploration, Preparation, Implementation, Sustainment (EPIS) framework.
Implementation Science : IS, 14(1), 1–1. https://doi.org/10.1186/s13012-018-0842-6
Mundt, M., Ross, K., & Burnett, C. M. (2018). Scaling Social Movements Through Social
Media: The Case of Black Lives Matter. Social Media + Society, 4(4),
205630511880791–. https://doi.org/10.1177/2056305118807911
O’Donoghue, A., Boudewyns, V., Aikin, K., Geisen, E., Betts, K., & Southwell, B. (2015).
38
Awareness of the Food and Drug Administration’s Bad Ad Program and Education
Regarding Pharmaceutical Advertising: A National Survey of Prescribers in Ambulatory
Care Settings. Journal of Health Communication, 20(11), 1330–1336.
https://doi.org/10.1080/10810730.2015.1018649
Olbert, C. M., Nagendra, A., & Buck, B. (2018). Meta-analysis of Black vs. White racial
disparity in schizophrenia diagnosis in the United States: Do structured assessments
attenuate racial disparities? Journal of Abnormal Psychology, 127(1), 104–
115. https://doi.org/10.1037/abn0000309
Olfson, M., Gerhard, T., Huang, C., Crystal, S., & Stroup, T. (2015). Premature Mortality
Among Adults With Schizophrenia in the United States. JAMA Psychiatry (Chicago,
Ill.), 72(12), 1172–1181. https://doi.org/10.1001/jamapsychiatry.2015.1737
Pollack, R., Madara, J., & Hatmaker, D. (2020, October 14). AHA, AMA and ANA urge president
to rescind executive order on race-and-sex stereotyping: AHA News.
https://www.aha.org/news/headline/2020-10-14-aha-ama-and-ana-urge-president-rescind-
executive-order-race-and-sex
Poole, S. M., Grier, S. A., Thomas, K. D., Sobande, F., Ekpo, A. E., Torres, L. T., Addington, L.
A., Weekes-Laidlow, M., & Henderson, G. R. (2021). Operationalizing Critical Race
Theory in the Marketplace. Journal of Public Policy & Marketing, 40(2), 126–142.
https://doi.org/10.1177/0743915620964114
Reis, T., Bersoff, D., Adkins, S., Armstrong, C., & Bruening, J. (n.d.). 2018 Edelman Trust
Barometer (Rep.).
Roberts, D. (2011). Fatal invention : how science, politics, and big business re-create race in the
twenty-first century. New Press.
39
Robinson, R. (2018). Changing Our Narrative About Narrative: The infrastructure required for
building narrative power. Hass Institute for a Fair and Inclusive Society, UC Berkeley.
Satcher, D., Fryer, G. E., McCann, J., Troutman, A., Woolf, S. H., & Rust, G. (2005). What If
We Were Equal? A Comparison Of The Black-White Mortality Gap In 1960 And 2000.
Health Affairs, 24(2), 459–464. https://doi.org/10.1377/hlthaff.24.2.459
Sher, L., & Kahn, R. (2019). Suicide in Schizophrenia : An Educational Overview. Medicina
(Kaunas, Lithuania), 55(7), 361–. https://doi.org/10.3390/medicina55070361
Sleeter, C. E., & Zavala, M. (2020). Transformative ethnic studies and schools: Curriculum,
pedagogy, and research. Teachers College Press.
Smith, D., Langan, J., McLean, G., Guthrie, B., & Mercer, S. (2013). Schizophrenia is associated
with excess multiple physical-health comorbidities but low levels of recorded
cardiovascular disease in primary care: cross-sectional study. BMJ Open, 3(4), e002808–.
https://doi.org/10.1136/bmjopen-2013-002808
Snowden, L. (2003). Bias in Mental Health Assessment and Intervention: Theory and Evidence.
American Journal of Public Health (1971), 93(2), 239–243.
https://doi.org/10.2105/AJPH.93.2.239
Snyder J, Garcia-Garcia M. Advertising across platforms: conditions for multimedia campaigns:
a method for determining optimal media investment and creative strategies across
platforms. J Adv Res 2016;56(4):352-367. [doi: 10.2501/jar-2016-042]
Tate, C. (2015). Conscious Marketing: How to Create an Awesome Business with a New
Approach to Marketing. In Conscious Marketing (1st ed.). John Wiley & Sons,
Incorporated.
Teasley, M. L., McCarter, S., Woo, B., Conner, L. R., Spencer, M. S., & Green, T. (2021,
40
April). Grand Challenge: Eliminate Racism Working Paper.
Washington, H. (2006). Medical apartheid : the dark history of medical experimentation on
Black Americans from colonial times to the present (1st ed.). Doubleday.
Yang, G. (2016). Narrative agency in hashtag activism: The case of #BlackLivesMatter. Media
and Communication, 4, 13–17.

41
Appendix A

Source: Archives of General Psychiatry, Volume 31, no. 5, 1974, p. 732

42
Appendix B – OUR AD Social Media Campaign Prototype
43
Appendix C—Collective Impact Framework

Source: John Kania, & Mark Kramer. (2011). Collective Impact. Stanford Social Innovation
Review, 9(1), 36–.

44
Appendix D—Conscious-Driven Marketing Principles

Source: Tate, C. (2015). Conscious Marketing: How to Create an Awesome Business with a New
Approach to Marketing. In Conscious Marketing (1st ed.). John Wiley & Sons, Incorporated.
45
Appendix E— OUR AD Logic Model

Goal: Eliminate pharmaceutical marketing that contributes to clinician bias and perpetuates racial disparities

INPUTS ACTIVITIES OUTCOMES
What we invest What we do Who we reach Why this project:
short-term results
Why this project:
intermediate results
Why this project:
long-term results

--Coalition and
stakeholder building

--Communication and
branding strategies
across multiple social
media platforms

--Continuous
monitoring of
pharmaceutical
advertising

--Identify pharmaceutical
ads that use racialized
and stigmatizing
language/imagery

--Use storytelling to
name the historic and
present-day injustices
associated with the
imagery

--Promote broad
participation and center
the voices of
beneficiaries in redesign

--Redesign ads using
conscious-driven and
equity-mindedness

--Monitor impact

--Individuals and
communities
focused on racial
justice

--Existing online
networks and
coalitions

--Conscious
marketers

--Consumer
advocates

--Academic
organizations

--Medical
organizations

--Build partnerships
across a broad group of
stakeholders with a
shared vision for
promoting conscious-
driven marketing and
equity-mindedness

--Launch the OUR AD
social media campaign
across multiple
platforms

--Promote the use of
conscious-driven
marketing principles
and equity-mindedness
across online platforms
to increase awareness
and support redesign
efforts.

--Measure levels of
engagement:

-Low: agreement of
preference for
content (likes)

-Medium: sharing
content with capacity
to influence others
(retweets, shares)

-High: participation
in redesign

--Eliminate marketing
that influences racial
bias

--Increased use and
incorporation of
conscious-driven
marketing and equity-
mindedness across
pharmaceutical
advertising

--Eliminate existing
disparities in the over-
diagnosis of
schizophrenia in
African Americans.
Assumptions
• There is currently poor regulation of pharmaceutical marketing
• Racial health disparities will receive growing attention across practice levels
• Social media will provide the necessary platform for broad, multisector participation
External Factors
• Social medial infrastructure and climate
• Pharmaceutical industry practice and policy

Abstract (if available)

Abstract Racial disparities in mental health, specifically schizophrenia, are driven by many factors. Implicit bias among clinicians is one example that can lead to diagnostic and treatment disparities. Utilizing the Levels of Racism theoretical framework, this project examines the historical context in which these biases took root and how they continue to inform medical practice today. Through this historical lens, it becomes clear that efforts to address health disparities must look to the institutional powers that hold systems of oppression in place. As such, this project looks to take an innovative approach by examining the role of pharmaceutical marketing in perpetuating implicit bias among clinicians. Through a coalition of healthcare providers, patients, consumer advocates, family members, academics, and conscious marketers, this project will utilize a collective impact initiative to develop a shared vision for eliminating cultural bias within pharmaceutical advertising. The OUR AD proposal is a social media campaign aimed at eliminating pharmaceutical marketing that contributes to clinician bias and perpetuates racial health disparities. The goal of the campaign is to democratize the process of identifying racialized pharmaceutical advertising while promoting participatory redesign. The campaign consists of five main pillars, including identification, storytelling, participatory, redesign, and impact. The ultimate impact that OUR AD aims to achieve is to create a new standard for pharmaceutical marketing that is free of stigmatizing and racialized imagery.

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Asset Metadata

Creator Johnston, Casey Keating (author)

Core Title The Our Ad Project: eliminating stigmatizing and racialized imagery in pharmaceutical marketing

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2021-12

Publication Date 07/14/2023

Defense Date 11/19/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag antiracist,collective impact,design justice,design thinking,equity-mindedness,OAI-PMH Harvest,pharmaceutical marketing,schizophrenia,social media campaign

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Smith-Maddox, Renee (committee chair)

Creator Email caseyskeating@gmail.com,ckjohnst@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113279211

Unique identifier UC113279211

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Legacy Identifier etd-JohnstonCa-12089

Document Type Capstone project

Format theses (aat)

Rights Johnston, Casey Keating

Internet Media Type application/pdf

Type texts

Source 20230717-usctheses-batch-1068 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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