“The Heart Truth:” Using the Power of Branding and Social Marketing to Increase Awareness of Heart Disease in Women

Abstract

In September 2002, the National Heart, Lung, and Blood Institute launched The Heart Truth, the first federally-sponsored national campaign aimed at increasing awareness among women about their risk of heart disease. A traditional social marketing approach, including an extensive formative research phase, was used to plan, implement, and evaluate the campaign. With the creation of the Red Dress as the national symbol for women and heart disease awareness, the campaign integrated a branding strategy into its social marketing framework. The aim was to develop and promote a women's heart disease brand that would create a strong emotional connection with women. The Red Dress brand has had a powerful appeal to a wide diversity of women and has given momentum to the campaign's three-part implementation strategy of partnership development, media relations, and community action. In addition to generating its own substantial programming, The Heart Truth became a catalyst for a host of other national and local educational initiatives, both large and small. By the campaign's fifth anniversary, surveys showed that women were increasingly aware of heart disease as their leading cause of death and that the rise in awareness was associated with increased action to reduce heart disease risk.

Introduction

The year 2000 was a landmark year, not only as the beginning of a new millennium, but also as the start of a new era in tackling an important public health issue – women's lack of awareness about their risk of heart disease. A survey conducted by the American Heart Association that year showed that only 34 percent of women knew that heart disease is their leading cause of death. Most thought that breast cancer was their greatest health threat (Christian, Rosamond, White, and Mosca 2007). Yet at that time, one in three deaths in women was due to heart disease (National Heart, Lung, and Blood Institute 2007). In comparison, one in 30 women died of breast cancer (National Heart, and Blood Institute 2005). To most women, heart disease was not something they took seriously or personally, largely viewing it as a “man's disease.” Yet heart disease was and still is the leading cause of death in women. In fact, more women die of heart disease than all forms of cancer combined (National Heart, Lung, and Blood Institute 2007). Furthermore, for women living with the disease, it can cause significant disability, interfering with even simple activities such as taking a walk or climbing stairs. Compared with other groups, African American and Hispanic women have higher rates of some of the heart disease risk factors, (National Heart, Lung, and Blood Institute 2007), and are less likely to be aware of the threat posed by the condition (Christian, Rosamond, White, and Mosca 2007).

In recognition of the problem, and in response to the urging of national leaders in women's health, the Federal government, through the National Institutes of Health's National Heart, Lung, and Blood Institute (NHLBI), convened a Strategy Development Workshop in March 2001 to create an action plan that would help reduce the toll of heart disease on American women. The workshop participants – who included experts in women's health, heart disease, communications, and public health program development – unanimously recommended that NHLBI should undertake a national communications campaign to raise women's awareness about their risk of heart disease and educate them about how to reduce it (National Heart, Lung, and Blood Institute 2001a).

In October 2001, NHLBI awarded a contract to Ogilvy Public Relations Worldwide to use the tenets of social marketing and the principles of branding to help plan and execute such a campaign. (Total contract cost was $5.5 million. The contract was competitively renewed for three years in March 2005 for a total cost of $5.8 million). Under NHLBI supervision, a team of NHLBI and contractor staff was formed to plan and manage the campaign. Following 12 months of preparation, including audience analysis, formative research, materials testing and production, and partnership development, September of 2002 saw the launch of The Heart Truth campaign and its powerful new brand for women's heart disease – the Red Dress.

By its fifth anniversary, the campaign's careful planning and on-strategy implementation had begun to pay off. Surveys showed that women were increasingly aware of heart disease as their #1 killer, and that the rise in awareness was associated with increased action to reduce heart disease risk (Mosca, Mochari, Christian, Berra, Taubert, Mills, Burdick and Simpson 2006). Furthermore, the proliferation of other educational activities and the extensive involvement of corporations, the media, national organizations, and local communities indicated that The Heart Truth has been a catalyst in starting a national women and heart disease movement.

This case study presents an overview of The Heart Truth's strategic development and implementation – from the formative research that informed the campaign to the creation of the Red Dress brand and the national and local programs and partnerships that have helped to sustain it. The article also discusses results to date, lessons learned, and future directions. Please see the companion articles in this issue for a more detailed look at the research phase, brand creation and management, partnership development, and online strategies.

Campaign Planning and Development

Formative Research

The Heart Truth was the Federal government's first national campaign about women and heart disease and as such, gave NHLBI an opportunity to start at the beginning to build a campaign well informed by research. The two-fold objective of the campaign was to:

• Increase awareness among women that heart disease is their #1 killer.

• Encourage women to talk to their doctors, find out their risk, and take action to lower it.

To guide development and implementation, the campaign used the social marketing process described in Making Health Communication Programs Work (National Cancer Institute 2002), which has served as a key tool for many of the major national education campaigns sponsored by the National Institutes of Health, the Centers for Disease Control and Prevention, and others. The process includes four main steps – planning and strategy development; creation and testing of concepts, messages, and materials; program implementation; and assessing effectiveness/making refinements.

The campaign also drew on relevant constructs from behavior change theories and models that support the development of effective strategies for influencing attitudes and behavior. These included theories focused on determinants of behavior (Health Belief Model, Theory of Reasoned Action/Planned Behavior, and Social Learning Theory) and the Transtheoretical Model of stages of individual behavior change. Also used were theories of social change, communication, and influence such as Diffusion of Innovations Theory and Social Network Theory.

Planning began with a literature review of research articles on cardiovascular disease in women and related health and behavior research. This helped to inform the subsequent development phases.

Target Audience Selection: Women Ages 40 to 60

An audience segmentation and analysis was then conducted based on recommendations from the 2001 Strategy Development Workshop. Using a decision-making tool to review and consider the relative merits of different audience segments, the campaign team chose women ages 40 to 60, the time in life when a woman's risk of heart disease begins to rise dramatically. It was decided to give special emphasis to African American and Hispanic women because these groups are disproportionately affected by heart disease. The team then conducted a comprehensive review of mid-life women, including information on demographics; heart disease risk factors; lifestyle and psychographics; geographic and socioeconomic factors; cardiovascular health knowledge, attitudes and behaviors; and media preferences. The resulting audience profile helped to inform further formative research—an environmental scan, focus groups, and input from stakeholders—and drove the creation of campaign messages, materials, channels, and implementation strategies.

Environmental Scan

The environmental scan included a review and analysis of newspaper coverage of women and cardiovascular disease and a review of complementary and competing women's heart health programs and campaigns. The newspaper study, which covered 6,000 articles published during a six-month analysis period, found that fewer than 30 percent mentioned heart disease as a women's issue. (National Heart, Lung, and Blood Institute 2001b). The review of women's heart health programs showed that, although many initiatives at the time touched on women and heart disease in some capacity, there was no major national social marketing campaign designed to raise women's awareness of their risk of heart disease and prompt them to take action to lower their risk. (National Heart, Lung, and Blood Institute 2001c).

Focus Groups

To explore attitudes and behaviors and gauge the effectiveness of draft concepts and messages, two rounds of focus groups with women aged 40-60 were conducted in four geographically-dispersed cities. The groups were diverse in terms of race and ethnicity (Caucasian, African American, and Hispanic women in eight groups and African American women in two groups). The women in the groups were also varied in terms of marital and employment status, education, and income. All the women had at least one risk factor for heart disease, but not a heart attack or heart disease diagnosis.

In brief, the focus groups reinforced what had been learned from the other planning phases – that the campaign needed to deliver a strong and urgent “wake-up call” to women about their risk of heart disease and motivate them to find out their own personal risk and take action to lower it. Although the participants were selected because they all had heart disease risk factors, most seriously underestimated their own personal risk. The participants could recite most of the main modifiable risk factors for heart disease, that is, smoking, high blood pressure, high cholesterol, excess weight, and physical inactivity Most women in the groups were surprised that to learn that heart disease is the #1 killer of women (most thought it was breast cancer), with some expressing anger that they had never “been told that before.” (National Heart, Lung, and Blood Institute 2002).

Formulation of Core Messages, and Call to Action

Focus group concept testing showed that in order to convey a sense of personal risk and motivate action, the campaign should include specific message elements: (1) prominently state that “heart disease is the #1 killer of women;” (2) “put a face” on heart disease so that women will identify with the idea that it could happen to them; (3) show the consequences of heart disease by using a hard-hitting approach; (4) give a sense of hope that women can lower their risk and empower them to do so; (5) provide a clear call to action, coupled with a sense of urgency (National Heart, Lung, and Blood Institute 2002). These message elements were embodied in the campaign's core messages and call to action: Heart disease is the #1 killer of women, but many women don't take their risk seriously or personally; heart disease can cause heart attack and death, but can also lead to disability that can significantly decrease one's quality of life; having just one risk factor increases one's chance of getting heart disease and the risk rises dramatically with each added risk factor; talk to your doctor, find out your risk, and take action today to lower it; and Americans can lower their risk by as much as 82 percent by leading a healthy lifestyle, which includes following a heart healthy eating plan, getting regular physical activity, maintaining a healthy weight, and not smoking.

Strategic Approach: Creating a Women's Heart Disease Brand

The overall strategic approach, materials development, and campaign implementation were guided by the formative research results. The team concluded that the campaign should be a sharp departure from the education programs that existed at the time of its development. These were mostly “wellness” programs that took a soft approach and emphasized lifestyle changes using positive language and appeals. The new campaign would take a hard-hitting, more edgy approach, focusing on the consequences of heart disease and delivering a personal wake-up call that communicated a sense of urgency about both the problem (heart disease is women's #1 killer) and the call to action (see your doctor and find out your risk.)

The team sought to combine a traditional social marketing approach with a branding strategy that would develop and promote a women's heart disease brand The brand would be designed to give a unique identity to women's heart disease, create a strong emotional connection with women, and help create momentum for the social marketing process on which the campaign was based.

Two creative elements were central to this approach and together they comprise the women and heart disease brand. The first element was an emphasis on the serious nature of the message through a strong campaign name. The Heart Truth was designed as a play on “the hard truth,” providing a sense of urgency and reality about heart disease.

The second element was the creation of the Red Dress as the national symbol for women and heart disease awareness. The Red Dress, designed to emphasize that heart disease is not a “man's disease,” was pared with tag line, “Heart Disease Doesn't Care What You Wear – It's the #1 Killer of Women.” Testing showed that the Red Dress and its tag line connected on an emotional level with a wide diversity of women. It helped them to think about heart disease as a woman's disease. It also helped women make a personal connection with the issue and to link the idea of a woman's focus on her outer self with the need to focus on her inner self, specifically her heart health.

The Red Dress was introduced as a print public service announcement at the campaign launch in Washington, D.C., in September 2002. The complete brand subsequently took shape as a combination of the Red Dress symbol and the name of the campaign, accompanied by the words “Women and Heart Disease.” (illustration of brand)

The other campaign materials also took a hard-hitting approach. The creative design used compelling photos and stories of real women's struggles with heart disease which served to personalize the condition, demonstrate the reality of heart disease, and provide consistent branding across all materials. The featured women, shown wearing red dresses, were African American, Hispanic, Asian, American Indian, and Caucasian, and were of various ages and sizes. Educational materials in English and Spanish dealt specifically with the risks faced by women of color. Materials included: the Healthy Heart Handbook for Women, an in-depth guide to lowering heart disease risk; an easy-to-use “talk in a box” for local speakers; a video; a campaign Web site (www.hearttruth.gov); print public service advertisements and airport dioramas; fact sheets; and posters. The campaign's first year also included radio and television public service announcements.

Campaign Implementation

The campaign implementation was designed around a three-part strategy – partnership development, media relations, and community action. The strategies overlapped a great deal, with each one building on and reinforcing the others. Corporate partners, for example, included media companies which provided editorial coverage as well as introductions to their corporate advertisers who also became partners. Other corporations sponsored national and local community events which in turn attracted media coverage. Non-profit partners launched their own educational efforts which attracted national and local businesses as partners, generated media coverage, and reached millions of women in diverse community settings. In implementing all three strategies, the Red Dress symbol quickly became the campaign's central driving force. At the outset, the power of the Red Dress concept helped to stimulate a crucially-important partnership with the fashion industry that brought the brand to life and gave the campaign its first national media platform.

Partnering to Create a National Platform

In 2002, the campaign team approached leaders in the fashion industry about forming a unique partnership with The Heart Truth because of the industry's powerful appeal to women. Their positive response led The Heart Truth and the issue of women and heart disease to be adopted as the “cause” of Mercedes Benz Fashion Week in New York in February 2003. Nineteen top fashion designers, including Vera Wang, Donna Karan, Ralph Lauren, and Oscar de la Renta, contributed dresses to an exhibit displayed under the Fashion Week tents at Bryant Park. A leading jewelry designer created a Red Dress pin that was widely disseminated to the media and the public to gain more visibility for the symbol. With the spotlight on The Heart Truth, the new Red Dress symbol, and the women and heart disease issue at Fashion Week and during American Heart Month, which takes place every February, the campaign had a highly effective national media platform for its messages.

The attention to the issue also helped the campaign to engage the support of First Lady Laura Bush. On Valentine's Day, a week after the launch of the Red Dress symbol in 2003, Mrs. Bush appeared on all three network morning shows, wearing a Red Dress pin and talking about women and heart disease. These appearances initiated her role as the campaign's “ambassador,” which continued with numerous local awareness-raising events across the country, as well as national press conferences and media interviews, events at the White House, a unique First Ladies Red Dress Collection, appearances at Fashion Week, and heart health information on her section of the White House Web site.

To expand the national effort, and also provide a means to engage women at the local level, The Heart Truth joined with the American Heart Association and other nonprofit partners and media outlets to create a new annual health observance - National Wear Red Day (held on the first Friday in February). The first observance of the day, February 2, 2004, coincided with the first Red Dress Collection fashion show which kicked off Fashion Week that year. Media relations and marketing strategies were used to urge women across the country to wear red on that day to promote awareness of women's heart disease. The partnership with the fashion industry expanded and evolved into The Heart Truth's signature event, an annual fashion show in which top designers create red dresses worn on the runway by well-known women of many ages, ethnicities, and walks of life

Expanding Campaign Reach through Corporate and Media Partners

From its inception, The Heart Truth was envisioned to be a partnership-based campaign. Looking beyond the fashion industry, the team developed a plan to guide systematic efforts to seek partners in the corporate, media, nonprofit, and government sectors. An information kit for prospective partners outlined expectations, roles and responsibilities of partners and the campaign team.

The expansion of the Fashion Week partnership and its related promotional programming gave the campaign team a compelling selling point in engaging a growing number of corporate and media partners who recognized the potential impact of the Red Dress symbol and the significance of aligning with the issue. The team cultivated partnerships with major corporations, including Johnson & Johnson, Swarovski, Celestial Seasonings, and Diet Coke, which have sponsored the Red Dress Collection shows in various years. These corporations and others – from General Mills to RadioShack to Albertsons – have helped the campaign reach millions of women where they live, work, and shop through placement of the Red Dress brand and messaging in corporate advertising, sales promotions, in-store signage, and on product packages, and by sponsoring local events. For example, in 2007 and 2008, all brands of Cheerios cereal included the Red Dress image, information about women and heart disease, an appeal to consumers to join Cheerios in donating to the issue, and, in 2008, a cause marketing component to fund cholesterol screenings for low income women. The team has continued to expand existing partnerships and cultivate new ones in sectors relevant to women such as health care, clothing, cosmetics, nutrition, retail, and travel. The campaign Web site, www.hearttruth.gov, includes a listing of all corporate and other partners.

Partnerships with media corporations have also contributed significantly to expanding the campaign's reach. Woman's Day and Glamour, two of the country's top-circulation women's magazines, were among the campaign's earliest and most active media partners. They helped introduce National Wear Red Day and have consistently published articles, cover stories, and columns. Other media partners – Time Inc. Women's Group, Lifetime Television, and magazines reaching African American and Hispanic women - gave the campaign invaluable reach through introductions to their advertisers, sponsorship of local and national events, and placement of public service advertising and editorial coverage.

Engaging Non-profit Partners

The team's plan for partnering with non-profit groups emphasized identifying and attracting organizations committed to the health and well-being of women that had effective infrastructures capable of reaching women at the national and/or local levels. At its launch in 2002, the campaign had enlisted three critically-important “founding” partners – the Office on Women's Health (OWH) of the US Department of Health and Human Services (HHS), the American Heart Association, and WomenHeart: the National Coalition for Women with Heart Disease. In addition to serving as a founding partner, the OWH also became a funding partner. This HHS sister agency supported a major project to develop and disseminate heart disease education materials for health professionals, as well as regional and local educational activities. In February 2004, the American Heart Association adopted the Red Dress symbol and launched its own complementary campaign, Go Red For Women, which has been implemented nationwide through the organization's local affiliate structure. WomenHeart, devoted to serving women with heart disease, identified heart disease survivors to appear in campaign materials and events, and continued work in advocacy and education.

To expand beyond the founding partner group, the campaign team sought and gained participation of other relevant national voluntary and professional organizations such as the American College of Cardiology, Hadassah, and the General Federation of Women's Clubs. To varying degrees, they helped spread The Heart Truth message by holding workshops and disseminating materials at annual conferences, placing articles in newsletters, maintaining online links, sponsoring local events, and other means.

In recruiting partners, priority was given to forming relationships with media companies and national organizations that reach African American and Hispanic women, ranging from ESSENCE magazine to the National Association of Latina Leaders. This outreach culminated in The Heart Truth's Women of Color Initiative, launched in February 2004. Additional campaign materials were developed to support the effort, including Web content in Spanish and an online faith-based activities toolkit. As with other partners, the women-of-color organizations, in varying levels of intensity, used the materials to reach their audiences through local events, national conferences, and other activities. Seed funding from NHLBI provided the means for three partners with significant membership and outreach potential—the National Latina Health Network, The Links, Incorporated, and the National Coalition of Pastor's Spouses—to undertake more extensive projects. These groups committed to implementing a series of community events that include in-depth heart health education workshops, materials dissemination, and risk factor screenings.

Bringing the Campaign to the Local Level

Along with partnership development and mass media strategies, the campaign also employed systematic means of delivering its messages through community action in settings such as hospitals, churches, grocery stores, and shopping malls. National and local institutional, governmental, and corporate partners were enlisted to help support and implement this aspect of the campaign. A priority for the campaign team, reinforced by “popular demand” from partners, was to stimulate local action by making the designer Red Dresses and educational materials available in communities across the country. Two such venues were created to put the campaign on the road.

In the first venue, “Single City Events,” hospitals and other institutions paid to bring the dresses and campaign materials to their community for use in their own Heart Truth events – health fairs, fashion shows, celebrity teas, rallies at the Statehouse. In the second venue, The Heart Truth Road Show, (implemented as a corporate-sponsored program), a traveling exhibit was set up in high-traffic shopping malls and featured a display of the designer dresses along with free heart health screenings and information. The Road Shows targeted cities with populations at high risk of heart disease, reaching tens of thousands of women, many of whom were found to have one or more risk factors for heart disease.

The campaign directly stimulated or served as a catalyst for activities that reached women in local communities in myriad other ways. For example, through a project funded by the Office on Women's Health, “Heart Truth Champions” (nurses, health educators and other community workers) were trained to deliver campaign messages and materials at health screenings, hospital-sponsored workshops and other community activities. General Growth Properties Inc., the second largest shopping mall company in the country, promoted heart health in hundreds of malls in February 2006 and 2007 through Red Dress displays, pin giveaways, in-mall communications, and heart healthy choices in the food courts. Non-profit partners urged their local members to use the campaign Speaker's Kit to make presentations at their church, women's club, and work place. State health departments, Governor's spouses, and HHS Regional Offices created heart health Web sites, sponsored events, and implemented statewide Heart Truth campaigns. In the Washington DC area, the Office of Personnel Management sent email notices to Federal agencies encouraging them to inform employees to wear red on National Wear Red Day. As The Heart Truth's ambassador, First Lady Laura Bush took the campaign to local communities by giving media interviews and speaking at more than a dozen events in hospitals and other venues.

Media Strategies

In addition to engaging media corporations as partners, the campaign team developed and implemented plans for aggressive media relations for the campaign's major recurring events – National Wear Red Day and the Red Dress Collection fashion shows. Tactics to advance the Red Dress symbol included asking national and local TV news anchors to wear the Red Dress pin on National Wear Red Day. As mentioned earlier, partnerships with Lifetime TV and women's magazines played a significant role in gaining editorial coverage and public service advertising. Total media impressions increased during each year of the campaign as the team learned what worked and as the campaign signature events became better recognized by entertainment, fashion, and lifestyle media. National and local media relations during other times of the year focused on connecting the women and heart disease issue with related observances such as Mother's Day and coverage of relevant heart-related science findings and medical issues. Community-based campaign activities such as Road Shows, Single City events, and appearances by the First Lady also generated substantial coverage in local markets throughout the year.

Online Strategies

From the beginning, the campaign team sought to create and use online resources and marketing strategies as an integral part of The Heart Truth. Creation of a targeted campaign Web site was a priority during the materials development phase. To help personalize the issue and retain consistent branding across materials, the site uses the images and stories of a diverse group of women heart disease survivors wearing red dresses. It showcases campaign materials, events, and partners, and serves as the repository for program tools resources. Periodic partner emails keep users informed and involved. An email newsletter was added as a vehicle for attracting and informing interested individuals.

As the campaign matured and the online world evolved, the campaign team sought to promote products, messages, and events through a variety of social media channels and Internet marketing techniques, especially for the fashion shows and during the February observances of National Wear Red Day and American Heart Month. NHLBI's existing email update service, reaching more than 150,000 health professionals and consumers, was used for a series of messages promoting National Wear Red Day and the campaign materials. Starting in 2007, a small-budget advertising campaign through Google AdWords and public service banner ads on sites such as Oxygen.com and Elle.com were added to the mix of strategies. In addition, the team developed an outreach plan for evaluating and working with well-ranked and respected blogs. Based on the analysis, the team contacted a selected group of individuals who regularly blog about women's issues and health, and invited some of them to blog from the Red Dress fashion show. Furthermore, coverage appeared on many mainstream online news sites and sites covering style, fashion, and Fashion Week, as well as video sites such as YouTube and AOL Video. Although some of the coverage was the direct result of the campaign team's media outreach, much of it was generated “organically” as coverage of women's heart disease and Fashion Week created a “buzz” on the Internet and one site picked up information from another. While not all the coverage mentioned the connection between The Heart Truth, NHLBI, and the Red Dress, much of it did address the key issue of heart disease as the number one killer of women.

Results

Table 1 summarizes the campaign process and outcome results to date

Table 1. The Heart Truth – Topline Results at a Glance.

Process Measures
PARTNERSHIPS	MEDIA RELATIONS	ONLINE
Corporate:
40 corporate relationships formed; conservatively valued at about $65 million Campaign brand promoted on 2.65 billion cereal, beverage, other product packages Newspaper insert ads reached combined circulation of 590 million Magazine print ads valued at $4 million Non-profit/community: 23 national partners More than 350 Heart Truth-sponsored local initiatives such as Road Shows and other locally-sponsored events 54 trained Champions held 114 local events; reached 25,000 people Est. combined total of people reached via local events – 273,000	Coverage of issue increased 70% in year following launch of Red Dress (2003) Total campaign media impressions (as of March 2008) – 2.1 billion; focused in high-circulation lifestyle, entertainment, fashion, and women's media Includes coverage multiple times in major national broadcast and print media and top-circulation magazines, and media targeted to women of color 70 % of reporting communicated at least one of campaign messages TV PSAs – 206 million impressions in one year Dioramas – 616 placements valued at $15 million.	(All figures are for Feb 07 and 08 online promotions) 786 blogger posts; 16% of all traffic to site came from one blogger Paid ads on BlogHer.org – 1.2 million impressions; 22% click thru rate Google/other pay-per-click ads – 1.6 million impressions Public service banner ads - 130 million impressions Postings on YouTube and Flickr, widgets, other strategies resulted in 225,000 more audience interactions
Outcome Measures
AWARENESS OF HEART DISEASE AS #1 KILLER OF WOMEN	AWARENESS OF RED DRESS SY MBOL	AWARENESS ASSOCIATED WITH ACTION
34% of women aware of #1 killer in 2000; 46% in 2003; 57% in 2006 Awareness gap in African American and Hispanic women - awareness increased in these groups, but not as much as in Caucasian women	25% of women aware of Red Dress in ’05; awareness more than doubled (57%) by ‘07	Greater awareness of heart disease is associated with increased action to lower personal or family risk Personal action associated with increased awareness included increased physical activity; decreased intake of unhealthy food, weight loss Family action associated with increased awareness included family member visit to doctor for heart check.

Process Measures for Partnerships, Media, and Marketing

Since the campaign's inception, more than 40 corporate relationships were formed. These enabled the campaign to reach tens of millions of women through the types of promotional efforts described earlier. The partnerships resulted in underwriting of core program activities, as well as in-kind contributions such as advertising, in-store promotions, events, and visibility on product packaging. Since 2003, corporate partnerships, including in-kind contributions, for the Red Dress fashion shows and other programs, are conservatively valued at about $65 million. In addition, since 2003, The Heart Truth and the Red Dress symbol have been promoted on 2.65 billion product packages, including “yellow box” Cheerios, 8^th Continent Soy Milk, Celestial Seasonings teas, and Diet Coke. Other results from corporate partnerships include: national newspaper insert advertisements with a combined circulation of 590 million; more than 2.2 million Red Dress pins purchased and distributed by partner organizations; and print advertising placements by media and corporate partners totaling $4 million.

The campaign reached local communities through a variety of initiatives mentioned earlier, including the efforts of 23 national nonprofit organizations to disseminate the campaign to their chapters and members. From 2003 to 2007, The Heart Truth was brought to communities across the country through more than 350 targeted campaign initiatives such as Road Shows, Single City events, and the First Lady's activities. In addition, organizations and individuals conducted 376 events registered in the campaign's online Activity Registry, and 54 trained “Heart Truth Champions” held 114 local events reaching about 25,000 people. Although it is difficult to obtain regular reports from local event sponsors, it is estimated that the combined total number of people reached at community events is more than 273,000.

Media relations strategies resulted in a growing number of broadcast, newspaper, magazine, and online media impressions. A media audit conducted in 2004 showed that media coverage of women and heart disease increased by nearly 70 percent in the year following the launch of the Red Dress in February 2003. Since the campaign's launch in 2002, media impressions steadily increased each year and totaled more than 2.1 billion by the beginning of 2008. This coverage included women-targeted and health-focused stories in major national and local broadcast and print outlets and top-circulation magazines, with cover stories or substantial features in Glamour, Woman's Day, Prevention, Parade, USA Weekend, Time, and Newsweek. Not surprisingly, overall coverage of women and heart disease tended to be heaviest during February (American Heart Month) when The Heart Truth and partner organizations were most active. Coverage of the Red Dress Collection fashion shows tended to appear mainly in media focusing on entertainment, lifestyle, fashion, and women's issues, including Entertainment Tonight, Access Hollywood, Lifetime TV, the Style Network, US Weekly, People, and In Style. Coverage reaching women of color included features in Essence, People En Espanol, Catalina, Telemundo and Univision.

A media content analysis conducted for 2007 campaign coverage showed that a majority of the coverage featured The Heart Truth initiatives and/or the issue of women and heart disease as the sole focus of reporting, with less than 20 percent consisting of only a minor mention. Close to 70 percent of all reporting communicated at least one of the tracked campaign messages. The main drivers of the coverage were the celebrities involved in the Red Dress fashion show and First Lady Laura Bush. The 2007 show included four celebrity television program hosts and this gained coverage not only associated with the fashion show itself, but also on their respective shows (National Heart, Lung, and Blood Institute 2008a).

Because of difficulties inherent in targeting and placing public service advertising, this tactic had a limited role in the campaign; TV and radio public service ads were created and aired mainly during the first year. TV ads garnered about 206 million impressions in one year, and radio received about 187 million impressions during the first two months (the only period during which they were tracked). Airport dioramas, less expensive to produce than TV or radio ads and easier to place, had a long “shelf-life” in the airports. From 2003-2005, 616 dioramas were placed in airports and shopping malls representing a paid equivalent of more than $15 million (based on a conservative estimate); some ads were still appearing in 2008.

In February 2007 and 2008 the online marketing strategy included outreach to selected bloggers resulting in a total of 768 posts. Demonstrating the potential power of a single blog, in 2007, fully 16% of all traffic to the campaign Web site came directly from one influential blogger. In addition, in both years, a small-budget paid ad campaign on BlogHer.org - a network of more than 1,000 women-targeted blogs - resulted in more than 1.2 million impressions and an average click-through rate of 22% (average click-through rate for commercial ads is .05 percent according to Nielson). In both years, Pay-per-Click ads on Google and other search engines drove traffic to the campaign web site and resulted in more than 1.6 million online impressions. Furthermore, a public service banner campaign in 2007 and 2008 generated more than 130 million impressions. On YouTube and AOL video, videos generated a total of 90,000 viewings in the two years. In 2008 several new strategies were added: a photo gallery on Flickr generated 9,410 photo views and a “widget” (interactive virtual tool, also called a “gadget” that users can download, in this case, a countdown to National Wear Red Day) was seen more than 125,000 times and users placed it on more than 300 personal and public Web pages. The campaign team concluded that, overall, the new media platforms such as blogger outreach, link-building, pay-per-click ads, widgets, and banner advertising were a cost effective means of extending the reach of the campaign to its targeted audience.

In addition, since the beginning of the campaign, close to 2 million campaign materials were disseminated by NHLBI's Health Information Center and generated more than $1.6 million to cover the costs of printing and distribution.

Outcome Measures of Awareness and Behavior Change

Almost from the beginning, in addition to generating its own substantial programming, The Heart Truth served as a catalyst for a host of other national and local educational initiatives, both large and small. Thus national surveys and other activities to track awareness and behavior change have measured effects that are likely due to the combined efforts of The Heart Truth, its partners, and many other groups.

The American Heart Association tracked trends in women's awareness, knowledge and perceptions of heart disease through similar surveys of nationally-representative samples of women in 1997, 2000, 2003, and 2006. In 1997, awareness of heart disease as the leading cause of death among women was 30 percent. In 2000, awareness had increased to 34 percent. By 2003, when The Heart Truth had been operational for about a year, awareness showed a larger increase - to 46 percent of women. By the next survey in 2006, awareness had climbed to 57 percent, a substantial increase over prior years. Although awareness increased in African American women (from 15 percent in 1997 to 31 percent in 2006) and Hispanic women (20 percent in 1997 to 29 percent in 2006), it was considerably lower among these women compared to Caucasian women (33 percent in 1997 and 68 percent in 2006) (Christian, Rosamond, White, and Mosca 2007).

The powerful appeal of the Red Dress is evident in the results showing the growth in awareness of the symbol. Two years after the Red Dress launch, a Harris Interactive survey using a nationally-representative sample was commissioned by campaign partner WomenHeart in 2005. It showed that 25 percent of American women could identify the Red Dress as the national symbol for women and heart disease. Furthermore, 60 percent of the women surveyed agreed that the Red Dress made them want to learn more about heart disease and 45 percent said it would prompt them to talk to their doctor and/or get a check up. A survey conducted for the American Heart Association in 2005 showed similar results. The majority of women (81 percent) in this survey reported they had seen, heard, or read information about heart disease in the past 12 months, and when asked if they were aware of information about the “red dress” symbol, 23 percent said yes (Mosca, Mochari, Christian, Berra, Taubert, Mills, Burdick, and Simpson 2006). Surveys using nationally-representative samples commissioned by campaign partners in 2006 and 2007 showed that women's recognition of the Red Dress symbol increased to 39 percent and 57 percent respectively. As a new health symbol, the Red Dress achieved rapid and widespread recognition among American women.

The 2005 American Heart Association study also evaluated whether women's greater awareness of heart disease as their leading cause of death is associated with increased action to lower personal or family risk. The study concluded that awareness does lead to self-reported preventive action. It is associated with personal risk reduction through healthy behavior change, including an increase in physical activity, a decrease in intake of unhealthy food, and weight loss (Mosca, Mochari, Christian, Berra, Taubert, Mills, Burdick, and Simpson 2006). The study also reported that women's awareness is associated with a positive impact on their families, including, for example, an increased likelihood of taking family members to the doctor for a heart check up. Continuing to assess trends in awareness is important in its own right. In light of the connection between awareness and preventive action, assessment of awareness also can provide insight into possible future trends in risk-reducing behavior and outcomes among women (Christian, Rosamond, White, and Mosca 2007).

In addition to an increase in awareness and associated preventive action, there has also been progress in reducing heart disease deaths among women. In 2003, of the women who died, one in three died of heart disease (National Heart, Lung, and Blood Institute 2007). In 2004 and 2005, one in four died of heart disease. Furthermore, the last six years have seen a steady decline in the number of heart disease deaths in women. Deaths have declined in each of the six years from 2000 to 2005, a consecutive yearly decline which has not occurred before (National Heart, Lung, and Blood Institute 2008b). Although the decline in mortality is most likely associated with factors such as improvements in treatment, and cannot be attributed directly to The Heart Truth and other campaigns, the increase in awareness and risk-reducing action associated with the campaigns suggests that these educational initiatives have played a role.

Lessons Learned

As The Heart Truth was launched into the marketplace, attracted partners and media attention, and grew and evolved in ways both expected and unexpected, the campaign team learned many lessons that may be useful to others engaged in campaign planning and implementation. The team considers the following to be among the most meaningful of the lessons learned.

Investing in formative research pays off (once again)

The Heart Truth is one of many, many social marketing programs that used the results of formative research to great advantage. Investing in a full six months of research at the outset of the campaign enabled the team to do a thorough job of investigating all the facets of the program. In addition, the 2001 Strategy Development Workshop that set the stage for the campaign provided a shared vision and clear objectives for the campaign, which helped the team to stay on course.

Staying on strategy is critical and sometimes means just saying no to opportunities that may seem attractive

As the campaign progressed, opportunities arose for expanding or changing messages, adding target audiences, embracing corporate and other partners, and pursuing many different tactics. A strong shared vision for the campaign and clearly defined objectives, audience, strategy, and tactics helped the team evaluate which opportunities to pursue and which to turn down. This was not always easy since, at first blush, many of the opportunities seemed reasonable, worthwhile, and sometimes exciting.

Risk taking is essential to break through in a crowded marketplace

In planning The Heart Truth, the team felt strongly that a unique, creative platform was required to grab women's attention. Launching the Red Dress as the national symbol for women and heart disease awareness through a partnership with the fashion industry was an unprecedented and high-profile strategy that certainly could be seen as a risk for a government agency. However, the appeal of an audience, concept, and strategy that were a “perfect fit” helped to make the case for moving forward.

A thoughtful and aggressive partnership strategy is essential from the outset, and requires time and money

The team invested time, energy, and resources to put in place a strong partnership model that reflected the campaign objectives and made the needs of the audience paramount. This helped to guide outreach, define roles and expectations on both sides, negotiate appropriate involvement, leverage partner opportunities that arose serendipitously, and turn down those that were off-strategy. As the campaign progressed, the team learned that an ever-growing share of resources would be needed to maintain existing partners while seeking new ones.

To engage and retain corporate partners, it is essential to understand their business and work to achieve a balance between their needs and the needs of the campaign

Moving beyond the usual expectation where partners simply serve as promotion/distribution channels for campaign materials requires an understanding of their marketing and advertising environment and business objectives in relation to the campaign. The team found it was essential to invest resources in creating specific programs, materials, and events that corporate partners could tailor to their needs and objectives, while staying true to campaign objectives. This ranged from large programs such as the Red Dress fashion shows and Road Shows to smaller efforts such as tailored messages for product packaging and turn-key kits of materials and events ideas for shopping malls.

Flexibility, creativity, and cooperation are key in working with all partners

Attitude counts. It is important for the campaign-sponsoring agency to listen carefully to partners' needs and be flexible and agile in meeting them. For example, the Single City events – an outgrowth of partner demand for a venue to bring the campaign to communities – delivered considerable local visibility and an enduring network of key supporters. At the same time, the sponsoring agency must remember the larger strategy over the long haul. The team found that corporate partner promotions and packaging could not always meet the demands of full visibility for the campaign and sponsoring agency. Flexibility was required in developing branding options for the name of the campaign and/or the Red Dress. It also helped to be creative in “partnering the partners,” that is, seizing opportunities for partners to work together. For example, the campaign was able to link two General Mills brands – 8^th Continent Soy Milk and Berry Burst Cheerios – to carry out combined promotions.

Conclusion and Future Directions

In the six years since its launch, The Heart Truth has been the catalyst for a growing movement in women's heart health. The campaign exemplifies brand-driven social marketing through the creation and careful stewardship of a powerful idea - the Red Dress. Introduced as the symbol for women and heart disease awareness in February 2003, the Red Dress has had a remarkable appeal to women of many ages, sizes, races, and ethnicities, and has fueled the campaign's momentum through corporate, media, and non-profit partners, and national and community action. The campaign achieved measurable results in a relatively short time and the team learned many lessons along the way that can be helpful to other social marketers.

In May 2008, NHLBI awarded a competitive contract to Ogilvy Public Relations Worldwide for support services for The Heart Truth for three additional years. The contract amount at time of award was $6.4 million, which, in 2011, will bring the total cost of the campaign contracts to $17.7 million for 10 years. (These costs do not reflect the considerable in-kind and monetary support from corporate, government, and non-profit partners, as discussed in the results section.) Moving forward, The Heart Truth will continue its objective of raising awareness about heart disease as the leading killer of women, while strengthening the behavioral message and action components by integrating them into national and community-level strategies. Through general campaign activities and tailored programs, women of color will continue to be addressed as a priority audience. The Red Dress brand will remain as the cornerstone of the campaign, serving to attract women's attention to new messaging, stimulate enduring partnerships, and foster national events and community action. Overall, in its third phase, The Heart Truth will emphasize social marketing approaches that strengthen existing programs and guide the creation and implementation of fresh ideas that will infuse the campaign with excitement and vigor.

Biographies

Terry Long served as the communications director of the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health where she directed media relations, education campaigns, and product marketing for NHLBI's research and education programs. She was the senior manager of The Heart Truth, NHLBI's national campaign to increase awareness about women and heart disease. Before joining NHLBI, she managed media relations, campaigns, and prevention programs for other agencies of the U.S. Department of Health and Human Services. She retired from the National Institutes of Health in May 2007, and is now a consultant in health communications.

Ann M. Taubenheim, Ph.D., M.S.N., is a public health advisor with the National Heart, Lung, and Blood Institute (NHLBI). She serves as project director for The Heart Truth campaign, including program planning and development, implementation, and evaluation. She also serves as the project officer for the NHLBI Health Information Center and leads the Center's work in developing new technologies for responding to public inquiries and marketing and promoting the Institute's health information to patients, health professionals, and the public.

Jennifer Wayman, M.H.S., is an executive vice president with Ogilvy Public Relations Worldwide, and co-director of Ogilvy's Social Marketing Practice in Washington, DC. She specializes in the strategic development, implementation, and evaluation of national social marketing and health communications campaigns, with an emphasis on women's health. Currently, she serves as corporate monitor for Ogilvy's work on the National Heart, Lung, and Blood Institute's The Heart Truth campaign, after serving as the project director for five years.

Sarah Temple is a senior vice president with Ogilvy Public Relations Worldwide, where she specializes in strategic health communications planning, public-private partnership development, and corporate social responsibility programming. Currently, she serves as the project director for Ogilvy's work on the National Heart, Lung, and Blood Institute's The Heart Truth campaign, and also serves as partnership director for the campaign, guiding outreach and engagement of all partners in the corporate, media, and nonprofit sectors.

Beth Ann Ruoff is a managing director with Ogilvy Public Relations Worldwide. As a member of Ogilvy's Strategy & Planning group, she is integral to shaping branding, communications, and social marketing strategies. Before assuming this role, she led Ogilvy's award-winning Creative Studio as creative director. Having served as the creative director on The Heart Truth, NHLBI's national awareness campaign about women and heart disease, since the start of the campaign in 2001, she continues in this role today.