Institutional Entrepreneurship for Digital Public Health Promotion: Challenges and Opportunities

Abstract

This commentary highlights the challenges and opportunities facing institutional entrepreneurship in the digital public health realm. The institutional entrepreneurship of public health researchers concerns the opportunity to improve the norms regulating social media companies by engaging the public and private sectors. Beyond the clarification of concepts, the contribution of the commentary is to demonstrate why public health researchers committed to institutional entrepreneurship should mind the mental model they employ to think about business regulation. The popular Chicago School model negates the legitimacy of corporate policy making that trades profits for public health. Thinking this way obscures the relevance of institutional entrepreneurship by stipulating that corporations should answer to shareholders and government but not civil society. Though digital health communication is consistent with the Chicago School picture, the alternative public–private model reinforces opportunities for digital health communication as well as institutional entrepreneurship. The commentary proposes a toolkit for public health researchers to consciously open up to opportunities for institutional entrepreneurship in digital public health.

Keywords

behavioral theories e-health health policy internet mobile health social media theories

In a recent contribution to the American Journal of Public Health, Guest Editor Lorien Abroms (2019) calls upon public health researchers “to insist on the creation of public–private partnerships, through either voluntary or policy initiatives, that would require both [social media] companies and government agencies to dedicate ongoing resources for partnering around public health issues” (p. S131). This prescription summons public health researchers to step into the political arena to help shape standards in the social media industry.

Public health researchers who respond to this call act on a sense of “responsib[ility] for building and shaping our social institutions” (Abroms, 2019, p. S131). Such norm-making activities have been usefully labeled “institutional entrepreneurship” in the management literature (Battilana, Leca, & Boxenbaum, 2009), and this commentary’s contribution is to elucidate the challenges facing institutional entrepreneurship in the digital public health realm, especially for researchers pursuing the potential of digital health communication.

Before presenting the commentary’s primary argument concerning the influence of mental models on the potential for institutional entrepreneurship, key terms are defined and distinctions drawn between institutional entrepreneurship and digital health communication, on one hand, and communications versus platform policies, on the other.

Institutional Entrepreneurship Versus Digital Health Communication

Despite—or perhaps because of—the overwhelming influence of social media platforms, legal regulation as it exists today has not caught up with the challenges posed by the pervasiveness of this new technology (Tusikov, 2017). Though social media companies have adopted voluntary guidelines to take down posts that promote dangerous behaviors, among other measures, guidelines such as these remain too often unenforced around the world (Abroms, 2019). It is in light of the regulatory voids existing between status quo practice and regulation (both legal and voluntary) that Abroms argues public health researchers ought to spur public–private engagement that is responsive to public health commitments.

To be sure, public–private engagement in the digital space may be pursued without the norm-making purpose of institutional entrepreneurship. Digital health communication connects to the public and private sectors with powerful and positive health impacts (Abroms et al., 2019; e.g., Crutzen et al., 2011). The difference between digital health communication and institutional entrepreneurship is that the former utilizes social media channels as a conduit without necessarily entertaining a norm-making aspiration as to social media companies’ policies and platform design. The entrepreneurship of the institutional entrepreneur, in contradistinction, exists in the commitment to innovate the rules of the game for the sake of public health outcomes. Digital health communication ordinarily does not entail institutional entrepreneurship because such communication campaigns can be effectively disseminated through social media platforms as already marketed. For example, RTI International (2019) has published a “Digital Health Communication Toolkit” to facilitate the successful use of “[d]igital tools such as websites, mobile phones, social media platforms, and email.” This toolkit does not mention—and does not need to mention—norm-making because social media platforms can be accessed for their astonishingly nuanced power to disseminate targeted information with existing norms in place.

Communications Versus Platform Policies

Whereas digital health communication goes with the grain of social media companies’ business models, the task of institutional entrepreneurship meets resistance in its private engagement, even if carried out successfully. Consider Facebook’s willingness to refer users who enter opioid-related searches to the Substance Abuse and Mental Health Services Administration (Abroms, 2019). This initiative helps counteract communications otherwise flowing through Facebook’s platform that are potentially dangerous to health, including communications promoting the sale of opiates. The public health activism that achieved this communications policy required Facebook’s legal counsel to ascertain legal risks entailed by changing the platform to give the user an affirmative yet unsolicited nudge (Thaler & Sunstein, 2009). That Facebook now makes these referrals as a matter of course demonstrates that institutional entrepreneurship in the domain of digital health communications policies can overcome inherent institutional resistance and make a positive difference vis-à-vis the prior status quo.

Abroms (2019) recognizes, however, that the responsibility of social media companies for the health of their users may go beyond communications policies. Recent studies confirm that the public health risk posed by platforms like Facebook goes deeper than content-level risks that result from communications policies (Atroszko et al., 2018; Guedes et al., 2016). The for-profit orientation of the platforms means that the risk of user addiction is unfortunately a feature and not a bug (Grau, Kleiser, & Bright, in press), and children are all too vulnerable (Bowles, 2018). Consider recent revelations that YouTube’s “algorithm [has been] recommending inappropriate videos to kids, including explicit sexual language and jokes about pedophilia” (Lakshmanan, 2019). Though there is a communications dimension to the problem, it goes beyond communications to concern YouTube’s platform, which, with its “Up Next” steady stream of videos, is intentionally designed to keep users, including children, engaged as long as they will watch. Rather than permit parents to opt out of “Up Next” for children, YouTube promoted a new one-click option to block recommendations from specific channels (Lakshmanan, 2019). Public health researchers may not be satisfied with this compromise.

The worry is that the institutional entrepreneur’s initiative to alter the design of a platform to reduce health risks, such as YouTube’s recommendation algorithm, represent a manifestly more burdensome request of a publicly traded for-profit corporation than do ad hoc corrections in communications policy. Communications issues can be patched with take-down policies, filters, and informational supplements, like the referral to Substance Abuse and Mental Health Services Administration. To speak out against platform-level risks, however, is to call into question the very premises of the social media business model (Di Gangi & Wasko, 2016). This creates a special quandary for researchers answering public health needs through digital health communications: Is it possible to at once engage the corporation critically, with respect to its platform policies, while relying on the same platform to facilitate lifesaving health communications?

Mental Models Matter

The key unacknowledged difficulty for those digital health communicators with ambitions as institutional entrepreneurs is easy to miss. The concern resides within the metaphors and mental models that structure the sense one makes of the governance of business regulation, usually unconsciously.

A recent study by psychologists at Stanford University found strong empirical support for the proposition that the metaphors and mental models that we rely on to make sense of the world shape the problems we interpret to exist and, consequently, the responsive actions we are compelled to take. The behavioral experiment presented participants a vignette about crime in the fictional city of Addison, followed by questions about their policy responses to the vignette (Thibodeau & Boroditsky, 2011). The two alternative treatments in one of the studies differed only with the one-word metaphor—“beast” or “virus”—that was used to characterize crime in the city:

“Crime is a beast ravaging the city of Addison.”

“Crime is a virus ravaging the city of Addison.”

The rest of the paragraph read by participants described past policy failure and increasing crime rates. When asked how they would respond to this situation, 71% of the participants who received the “beast” metaphor chose to respond with an enforcement rather than a prevention policy, compared with 54% of those primed with the metaphor of a virus. The public health metaphor (virus) apparently nudged participants toward a public health solution: prevention. Shockingly, the researchers found “the differences in opinion generated by the metaphorical frames were larger than those that exist between Democrats and Republicans, or between men and women” (Thibodeau & Boroditsky, 2011, p. 10).

What should give one pause is the blindness of study participants for the influence of the metaphor on their policy judgment. When asked, they explained their responses to the vignette on the basis of statistics that everyone read, without mentioning the treatment metaphors that framed and tilted judgments. This cautionary tale—backed by many confirming studies in the behavioral sciences (see Thaler & Ganser, 2015; e.g., Slovic, Finucane, Peters, & MacGregor, 2002; Kahneman, Knetsch, & Thaler, 1991) underscores the worry motivating this commentary that a public health researcher’s unconsciously internalized mental model about the regulation of business may stymie the norm-making pursuit of institutional entrepreneurship for public health, notwithstanding—if not because of—their efforts as digital health communicators.

Two Ways to Think About the Regulation of Business

Drawing coarse lines, there are two basic ways to understand the regulation of business. In the “Chicago School” view that looms large in business schools and is widespread in mainstream culture and prominent in the rhetoric of large corporations like Facebook (see Bower & Paine, 2017; Khurana, 2010; Stout, 2013), businesses pursue profits for their shareholders and government takes care of regulation (Friedman, 1962, 1970). The alternative view holds that the regulation of business is a public–private enterprise, meaning that companies themselves can, should, and do regulate themselves in collaboration with government and other private organizations, including researchers and nongovernmental organizations. The catch will be that while the Chicago School view is consistent with digital health communication, it is positively hostile to institutional entrepreneurship. In contrast, a public–private conception of business regulation is open to both sets of activities.

The Chicago School Model of Business Regulation

As iconically presented by Milton Friedman (1970), the Chicago School world view conceives of the legitimate role of managers by picturing them as the employees of shareholders whose primary desire “generally will be to make as much money as possible” (p. 33). On this view, managers contravene their duty to shareholders when they engage in voluntary self-regulation that lowers profits—these management decisions amount to illegitimate “taxation” of shareholders and are morally tantamount to theft (Friedman, 1970). Corporations are expected to be profit maximizers, and the legitimate source of business regulation comes not from managers but from elected government officials (Friedman, 1970).

What does this model indicate about the professional purpose of public health researchers? The leading role of public health vis-a-vis business on this view is to respond to the negative health externalities that arise from the pursuit of profit. When regulation becomes inadequate, as often happens in the wake of new technologies (see de los Reyes, Scholz, & Smith, 2017), public health action means picking up the growing mess that business leaves behind, whether from e-cigarettes, social media, or something else. The public health campaign for smoking cessation may be the most famous example (e.g., Kottke, Battista, DeFriese, & Brekke, 1988). Important campaigns that utilize digital health communication, including those targeting opiate abuse (Abroms et al., 2019) or cyberbullying (Edgerton et al., 2016), are representative of the genre. According to the Chicago School model, public health can also play a policy advocacy role, calling for legal regulation of business (e.g., Macy, Middlestadt, Seo, Kolbe, & Jay, 2012).¹ What is ruled out is the legitimacy of the effort to change business norms by engaging business directly with a campaign to “tax” shareholders by voluntarily trading short-term profits for the desired higher standard (Andrews, 1972; see Table 1).

Table 1.

Mental Models of Business Regulation Compared.

Regulation	Chicago school model	Public–private model
Institutional division of labor	Government alone regulates business	Government, business, and civil society are all involved in business regulation
Compliance model for companies	Maximize profits and comply with legal regulation	Comply with legal regulation and additional standards, including profitability, according to management’s judgment in dialogue with relevant stakeholders
Conception of corporate social responsibility	Illegitimate “taxation” of shareholders to advance personal values of management	Voluntary restraint of short-term profit maximization as a matter of judgment responsive to stakeholders
Role for public health researchers	Responding to externalities of business	Responding to externalities of business and as institutional entrepreneurs improving standards followed by business
Consistent with digital health communication?	Yes	Yes
Consistent with institutional entrepreneurship?	No	Yes

Institutional Entrepreneurship in the Public–Private Model

The alternative to the bright-line institutional division of labor drawn by the Chicago School picture is to conceive of the regulation of business more fluidly, as an endeavor that permeates the public–private divide (Table 1). On this view, it is taken for granted that government could never regulate business adequately on its own (Andrews, 1972, p. 135). Moreover, the managers running companies are understood to have information and discretion that can render legitimate their “knowledgeable self-restraint” (p. 138).

The public–private model welcomes multistakeholder deliberation as a means to exchange information and tackle difficult questions of responsibility with the benefit of divergent perspectives (see Scherer & Palazzo, 2007). Over the past 30 years, multistakeholder initiatives that formalize industry standards have in fact become institutionalized as a standard feature of the governance context for global business across a number of industries, though not yet in social media (Mena & Palazzo, 2012). The public–private model of business regulation dovetails with a practice of institutional entrepreneurship that seeks to improve business norms for the sake of health outcomes (see Hingle, Patrick, Sacher, & Sweet, 2019; Maguire, Hardy, & Lawrence, 2004).

What strategic posture does institutional entrepreneurship then take toward the harms created by digital media? The central medium for transforming business practice is discursive engagement with relevant companies and other affected groups to modify communications and platform policies (Scherer & Palazzo, 2007). Institutional entrepreneurs for public health can engage the tech giants that dominate the digital ecosystem—Facebook, Google, Amazon, Apple, and Microsoft—to talk constructively about ways to curtail health risks that spillover from the all-encompassing platforms that make these companies the five most valuable global brands in business (Frangoul, 2017). Such engagement may be pursued with each company individually—inviting the company to lead by example (Brennan & Schroeder, 2014), or through multistakeholder initiatives that bring the set of tech giants—and perhaps other companies as well—into dialogue with the public health community in a way that allows companies to subscribe to new norms that establish a level regulatory playing field among competitors (de los Reyes et al., 2017). Such initiatives can also include government actors as a bolster to, or substitute for, voluntary self-regulation.

The starting point for institutional entrepreneurship in all cases is identifying the parties who are part of the problem and/or the potential solution and then opening the conversation (Jay & Grant, 2017). Therefore, this posture is open to stimulating change not only through companies but also through the community of consumers whose lives are being molded, surreptitiously and insidiously, by the corporate interests that control their smartphones and computers (Elhai, Levine, Dvorak, & Hall, 2016; Zuboff, 2015). Smoking cessation campaigns, such as those led by the UCSF Smoking Cessation Leadership Center, provide a powerful example of public health researchers organizing consumers to empower themselves. Institutional entrepreneurship can thus find its way to the role of community organizer and empowering advocate on behalf of consumers, whether or not companies are willing to open a conversation with public health researchers.

The Magnetic Attraction to the Chicago School Picture

The Chicago School view of business regulation is business friendly by design, and social media companies have embraced its perspective. For example, Facebook CEO Mark Zuckerberg (2019) recently affirmed the Chicago School logic in a Washington Post editorial that argued governments rather than social media companies should be regulating their activities.

Like the “beast” metaphor brings to mind enforcement rather than prevention of crime, the Chicago School approach points to government regulation and avoids militating for voluntary self-regulation by social media companies. The effect of this mental model is to put a black box around corporations that redirects the concerned public to request any transparency and regulation of business from government rather than the companies themselves (see Pasquale, 2015). This black box shuts out the initiative to change social media norms from within these companies.

On the other hand, insomuch as public health researchers are engaging social media companies for digital health communication, the Chicago School picture is copacetic because the researcher is acting as a consumer of existing social media services. Moreover, the researcher is working collaboratively with companies that tend to embrace the Chicago School model in their spontaneous resistance to the voluntary sacrifice of short-term profits to accommodate public demands. The danger highlighted by this commentary is that the pursuit of digital health communication initiatives by public health researchers stands to promote adaptation to, if not adoption of, the Chicago School narrative. Public health researchers are positioned to be motivated (Kunda, 1990) to make a consequentialist trade-off: Driven by the laudable health outcomes that digital health communication generates in the short-term, they may overlook, tolerate, or leave to someone else to worry about the harms these platforms generate over the longer term. The Chicago School model reinforces this trade-off by hiding the existence of a trade-off with the message that there are no legitimate regulatory requests to make of business: business answers to profits and hard law.

Digital Public Health Institutional Entrepreneur’s Toolkit

Public health researchers can engage the social media space as consumers of existing platforms and make positive contributions through digital health communication. The power of the platforms that deliver these health messages comes, however, with significant public health risks and negative outcomes. This commentary is written in support of the potential for public health researchers to help address these risks proactively by finding a way to work with companies to generate better standards and best practices. This is moving faster than the speed of law to bring the wisdom of public health into the governance of the digital media space.

The toolkit that emerges from this commentary’s conceptual analysis amounts to three introspections meant to check one’s mental model and professional vision, plus one generic action framework. The first introspection addresses the need of the digital public health institutional entrepreneur to consciously check to make sure their mental model retains the openness to institutional entrepreneurship of the public-private model. One way of phrasing the introspection is as follows: “Have I started to assume that business answers only to financial concerns and law and that I am misguided to try to prevail upon companies to improve public health practices voluntarily?” Table 1 organizes a point-by-point comparison to capture the differences between the Chicago School and public–private mental models.

The second mental checkpoint is especially relevant for researchers already utilizing digital platforms to disseminate public health communications: “Can I take steps to use my voice as a digital health communicator to address public health concerns created by the platforms that carry the digital health communications I support?”

The third point is a nudge to public health researchers to keep in mind the potential to get involved in the community organizing of platform users as a form of democratic governance: “Are there communities I can help better understand and organize around the impact of digital media platforms on health, especially for children?”

The generic starting point to take action as an institutional entrepreneur is to identify the parties who are, with respect to any public health issue, part of the problem and/or the solution and then to find ways to open channels of communication among interested parties. This is enough to at least point one’s attention in the directions that offer the potential for positive change.

Conclusion

Notwithstanding social media companies’ own pronouncements in support of a Chicago School conception of business regulation, Facebook and others have shown some willingness to tinker with their communications policies to counteract specific health risks, and this willingness invites public health researchers—even or especially those actively engaged in digital health communication—to step up as institutional entrepreneurs advocating for improved communications policies. To answer both Abroms’s (2019) call to institutional entrepreneurship and Abroms et al.’s (2019) call to digital health communication requires the public health researcher to simultaneously go with and against the grain of the status quo. This is a tall order but achievable so long as researchers rehearse the toolkit and resist the perspective that business regulation is for government only, rather than a worthy and legitimate public–private endeavor that should include the public health community for its distinctive insight and interest.

Such dual engagement is most readily achievable in the domain of communications policies where social media companies have some track record of voluntary amendments. When it comes to platform-level risks, however, such as the depression that social media addiction apparently triggers (Banjanin, Banjanin, Dimitrijevic, & Pantic, 2015), social media companies have shown far less initiative to respond to health concerns. In this domain, wearing two hats at once—digital health communicator and institutional entrepreneur—is tough, in part because the success of digital health communication depends on the very user engagement levels that yield health concerns connected to addiction. Pursuing institutional entrepreneurship that challenges platform-level health risks may, therefore, validly appear to be counterproductive to one’s goals as a digital health communicator. With such cognitive dissonance, there is an inclination to accept the implications of the Chicago School picture—leave regulation to government, at least when it comes to platform design.

This is a challenge for every public health researcher who is drawn to the enormous potential of digital health communication yet also feels compelled to contribute to the healthy regulation of business. Efforts that organize public health researchers to attend to both sets of issues, such as the annual Digital Health Promotion Executive Leadership Summit organized by The Public Good Projects, the Society for Public Health Education, George Washington University Milken Institute School of Public Health, and University of Maryland School of Public Health, chart a constructive path forward and remind researchers that the regulation of business is a multistakeholder discursive endeavor that craves for the public health insight that only researchers can deliver.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gastón de los Reyes

Supplement Note

This article is part of the Health Education & Behavior supplement issue, “Advancing the Science and Translation of Digital Health Information and Communication Technology.” The printing and dissemination of the supplement was supported by the Office of Behavioral and Social Sciences Research, National Institutes of Health (Contract No. HHSN276201800167P). No federal funds were used in the development of these supplement manuscripts, and the views and findings expressed in them are those of the authors and are not meant to imply endorsement or reflect the views and policies of the U.S. Government. The entire supplement is available open access at .

Notes

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