76 Journal of Business Strategies AN EXPLORATORY STUDY OF INFORMATION USE BY NON- SURGICAL COSMETIC PROCEDURES CONSUMERS Timothy H. Reisenwitz Valdosta State University • Valdosta, GA Jie G. Fowler Valdosta State University • Valdosta, GA ABSTRACT This exploratory study investigated the amount of information used by consumers when engaging in non-surgical cosmetic procedures. Moreover, the primary purpose of the research is to investigate the linkage between non-surgical cosmetic procedures and the constructs associated with the “self,” such as attitude toward social media advertising, attitude toward traditional (mass media) advertising, cognitive age, risk aversion, satisfaction, and self-image or self-concept. T-tests of the data yielded significant results for most of the variables. This research will hopefully aid marketers to better focus on important areas of information use by non-surgical cosmetic procedures consumers. These results are discussed, along with managerial implications, limitations and directions for future research. INTRODUCTION Lupton and Seymour (2003) describe that the body is an object that must be groomed and maintained in an optimal state to maximize benefit. From this perspective, the body is regarded as an always unfinished object and is viewed as mediating the negotiation of health and illness. Thus, cosmetic procedure is utilized to rectify perceived deficiencies in the human body (Davis, 2002). Through cosmetic procedure, individuals are able to exercise their intent to join a culture of beauty. Though the studies of the culture of beauty have typically prescribed to women, other research has noted that the culture of beauty is not limited to women and that both genders are increasingly utilizing technologies to change their physical appearance and alter the aging process (Beier, 2004). In general, there are two types of cosmetic procedures: non-invasive and surgical procedures. Non-surgical/non-invasive techniques consist of injections of chemicals/fillers into muscles or penetration of laser light to inhibit or intervene with certain body parts. Cosmetic surgery is a discipline of medicine focused on enhancing appearance through surgical and medical techniques (Mohan, 2018). Volume 35, Number 2 77 According to the American Society of Plastic Surgery (2008), American consumers spend more than twelve billion dollars annually on cosmetic procedures. Throughout the last decade, the consumption of cosmetic procedures has consistently been growing. In 2011, more than 12.6 million procedures were performed, which included breast augmentation, rhinoplasty, liposuction, eyelid surgery and tummy tucks. In addition, the top five non-invasive cosmetic procedures were Botox, soft tissue fillers, chemical peel, laser hair removal, and microdermabrasion. In 2016, 17.1 million cosmetic procedures were performed (American Society of Plastic Surgery, 2016), among which 15.4 million were minimally invasive procedures. Non-surgical procedures are considered the fastest growing medical treatment in the U.S. (Grumbein & Goodman, 2015). Cosmetic procedures have been seen as a self-enhancement technology undermined by negative media news (e.g., deadly frozen face, addiction and deadly poison) (Giesler, 2012). However, it has begun to gain acceptance among consumers in recent years. This neutralized process may due to the social process of legitimation (Humphreys, 2010). For instance, Botox received approval from the FDA in 2002. Since 2007, it has become the most commonly used non-surgical cosmetic enhancement procedure in North America to soften a person’s frozen lines for up to four months (American Society for Aesthetic Plastic Surgery, 2009). The market success was led by the baby boomer female consumer segment. INSTITUTIONAL THEORY: CULTURAL AESTHETICS AND BODY PROJECT Vargo (2011) notes marketing’s foundation is derived from economic science which, in turn, is built on Smith’s (1776) normative views about what nations need to do to accumulate wealth in the context of the Industrial Revolution. Institutional economists emphasize the role of the human agency in devising institutions. North (1990), for example, describes institutions as humanly-devised constraints that structure political, economic, and social interaction. They are consistent with both informal constraints (e.g., sanctions, taboos, customs, and traditions) and formal rules (e.g., constitutions and laws). Essentially, the development of institutions is critical, in part, because humans have limited cognitive abilities, which is contrary to the assumptions of neoclassical economics (Vargo & Lusch, 2016). Economic sociologists further argue that economic action is embedded in ongoing social ties that at times facilitate and at times derail exchange (Granovetter, 1985). The concept of embeddedness states that economic action is embedded in the social structure 78 Journal of Business Strategies (Uzzi, 1997), which is contrary to the agency theory that focuses on self-interested human nature and dyadic ties. Similarly, sociologists define the institution as rules, norms, meanings, symbols which have a profound effect on the thoughts, feelings, and behavior of individuals and collective actors (Lawrence & Suddaby, 2006). The institution can be viewed as holding enduring social patterns and includes three dimensions that are cultured cognitive, normative, and regulative elements (Scott, 2001). This view shares with the notion of habitus, which is defined as a set of established rules and routines (Emirbayer & Mische, 1998). Although institution theory has been applied in various aspects of marketing research, the concept of institutional work has received little attention. The neo- institutional theory emphasizes the institutional change and stability that emerge. The concept of “work” refers to a future-oriented intentionality which emphasizes consciously and strategically reshaping social situations (Lawrence, Suddaby, & Leca, 2011). Actors or individuals can work to create, maintain and disrupt institutions (e.g., DiMaggio, 1988). Individuals who are constrained by institutions are nevertheless able to work to affect the institutions. This new stream of institution research focuses on boundary work, which represents the attempts of actors to create, shape, and disrupt established norms (Gieryn, 1999). This theory may be applied to the institutionalization of cosmetic surgery. The body is colonized (via medical modification) that deems the person’s way of life and determines if the person can be assimilated into the dominant group (Okopny, 2005). Individuals, for example, judge the person’s cultural identity based upon the “ethnic nose” (Okopny, 2005). As a result, cosmetic procedures involve cultural assimilation and reinforce the empowerment of women (Olopny, 2005). As Sullivan (2001) argues, the benefits of being attractive transfer to economic gain and so the beauty ideal is highly institutionalized. Beauty is a social construction because it varies between culture and shifts throughout time (Okopny, 2005). For instance, Asian women desire pale skin and many Westerners desire tanner looks. Li, Min, Belk, Kimura, and Bahl (2008) found that “whiteness” is considered an important element to construct female beauty in Asian cultures. The meanings of whiteness are influenced by Western ideologies as well as institutionalized Asian values, norms, and beliefs (Li et al., 2008). As such, Xu and Feiner (2008) use the term, “beauty economy” to describe beauty pageants, modeling, cosmetic, and cosmetic surgeries, etc. (p. 307). Further, women’s breast sizes are also influenced by institutionalized social, cultural, and political meanings (Millsted & Frith, 2003). The size of the breast is Volume 35, Number 2 79 seen as a measurement of her value and worth in the Western world (Millsted & Frith, 2003). Furthermore, large breasts can be considered being feminine, attractive, and sexy. To conclude, there are cultural enclaves (e.g., male gaze, attraction, empowerment) that impact the pursuit of beauty ideals (Little, 1998). Additionally, the institutionalization of cosmetic surgery has resulted with each generation of cosmetic augmentation, increasing the likelihood of future generations selecting the procedure, therefore increasing the overall medicalization of beauty (Voelker & Pentina, 2011). According to Gumin’s (2012) study of women who had cosmetic surgery, the majority of the participants did not expect cosmetic surgery to make them beautiful. Instead, many hoped the procedure to make them have a “normal” appearance. A paradigm for understanding the transformative body practice is the body project, where the body becomes the object to be focused upon, worked on, and improved (Shilling, 2012). As such, the “marketed self” has become an important asset in social relationships. PURPOSE OF THE STUDY AND HYPOTHESES It is clear that individuals see their own bodies as living records of consumption habits. They consistently negotiate disparities between their current status and the often-idealized conceptions of the body. Essentially, the body becomes central to the individual’s reflexive identity project and self-actualization. As such, the primary purpose of the research is to investigate the linkage between non-surgical cosmetic procedures and the constructs associated with the “self,” such as attitude toward social media advertising, attitude toward traditional (mass media) advertising, cognitive age, risk aversion, satisfaction, and self-image or self-concept. This research will hopefully aid marketers so that they may better focus on important areas of information use by non-surgical cosmetic procedures consumers. Media Impact Traditionally, advertising in the health professions was a contentious issue (Moser, 2008). However, most healthcare associations and societies have accepted advertising as one means of communicating to healthcare clients. More recently, for example, Moser (2008) found that consumers are generally receptive to the use of dental advertising to communicate information about dental services. Kash, Boyer, and Beathard (2008) note that nursing homes adopted advertising after hospitals and other health-delivery systems, supposedly to remain competitive and to address 80 Journal of Business Strategies negative publicity from poorly-run facilities. The development and communication of a unique image showcasing quality-of-life values and strong service may help differentiate a nursing home from the competition. Masoni, Guelfi, and Gensini (2011) note that online advertising is attractive to healthcare organizations, yet it needs to be regulated due to inappropriate or misleading uses of search terms. The increase of the demand for cosmetic procedures is believed to result in part from the ease of access to relevant information through media (Nabi, 2009). Social media has become an important online channel where people look for information that is related to cosmetic procedures (Vance, Howe, & Dellavalle, 2009). In view of this, many cosmetic surgeons have actively adopted social media in their practices. In a recent survey, more than 50 percent of cosmetic surgeons have used social media sites to promote their services (Vardanian, Kusnezov, Im, Lee, & Jarrahy, R., 2013). The homepage, as a website entry point, serves to orient consumers and acts as a complex visual sign, presenting consumers with important aesthetic cues (Grumbeim & Goodman, 2015). However, there are limited studies examining cosmetic advertising per se. H1: Patients who use more cosmetic procedures information (word-of-mouth, mass media, and social media) have a greater attitude toward social media advertising of cosmetic procedures. H2: Patients who use more cosmetic procedures information (word-of-mouth, mass media, and social media) have a greater attitude toward mass media advertising of cosmetic procedures. Ageism And Cognitive Age Interest in cosmetic surgery is greater in older cohorts, i.e., interest may be more likely to translate into use with age (Slevec & Tiggemann, 2010). Butler (1969) created the term, ageism, to refer to the “systematic stereotyping of, and discrimination against people because they are old, just as racism and sexism accomplish this with skin colour and gender” (p. 243). Ageism is based upon a societal obsession with youthfulness. The loss of a youthful appearance is particularly damaging to women, who are socialized to be more concerned with their appearances than their male counterparts (Bartky, 1990). Schewe (1989) states that aging is an individual event as no two persons age the same way at the same time. The biology of aging is dependent on genetic inheritance and on the environment. Consumers not only inherit their physical Volume 35, Number 2 81 features, but also their susceptibility to disease and the predisposition to other facets of aging, such as wrinkling, weight change, and hair alterations. The environment also affects longevity (Schewe, 1989). Moreover, personal intervention of the aging process can be achieved by weight control, diet, smoking cessation, and a reduction of psychological stress (Schewe, 1988). Therefore, some individuals really do age more gracefully than others and it is improper to group people by chronological age and assume the same physiological and psychological changes have taken place. Cognitive age, in contrast to chronological age, is the age that an individual identifies with. It is linked to an individual’s self-perception and how old he or she feels, regardless of his or her chronological age (Le Serre, Weber, Legoherel, & Errajaa, 2017). The pressure to look youthful motivates consumers to mask, if not alter, the physical signs of aging with the use of interventions such as hair dye, make-up, and non-surgical and surgical cosmetic procedures (Clarke & Griffin, 2008). Based upon this discussion, consumers who use more cosmetic procedures information may be more engaged or involved in thinking about having a cosmetic procedure to look youthful and thus may have lower cognitive ages: H3: Patients who use more cosmetic procedures information (word-of-mouth, mass media, and social media) have lower cognitive ages. H3a: Patients who use more cosmetic procedures word-of-mouth information have lower cognitive ages. H3b: Patients who use more cosmetic procedures mass media information have lower cognitive ages. H3c: Patients who use more cosmetic procedures social media information have lower cognitive ages. Risk Aversion Perceived risk is “a function of the unexpected results of adoption and an outcome that deviates from expectation” (Hirunyawipada & Paswan, 2006, p. 187). Risk aversion exists when consumers, who are faced with uncertainty, attempt to lower that uncertainty (Adhikari & Agrawal, 2016). Satisfied patients of cosmetic procedures tend to generate positive word-of-mouth about the service (Wirtz & Chew, 2002). These former patients will likely be a source of information about favorable outcomes of cosmetic procedures. Therefore, interpersonal experiences 82 Journal of Business Strategies may aid in reducing the perceived physical and psychological risks of cosmetic procedures (Park & Cho, 2010). Similarly, those consumers who use advertising, including social media, may be doing so to reduce their level of risk, and therefore, may be more risk-averse than other consumers: H4: Patients who use more cosmetic procedures information (word-of-mouth, mass media, and social media) are more risk-averse. H4a: Patients who use more cosmetic procedures word-of-mouth information are more risk-averse. H4b: Patients who use more cosmetic procedures mass media information are more risk-averse. H4c: Patients who use more cosmetic procedures social media information are more risk-averse. Satisfaction Satisfaction has been traditionally associated with the Disconfirmation of Expectations Theory, which is based on the assumption that consumers compare the result with their expectations. A result greater than expectations, or a positive disconfirmation, yields satisfaction, whereas a result less than expectations, or a negative disconfirmation, yields dissatisfaction (Castañeda, Muñoz-Leiva, & Luque, 2007). Zare-Farashbandi, Lalazaryan, and Rahimi (2017) found that having health- related information increases patients’ satisfaction regarding the treatment process. Additionally, Young and Im (2012) found that Web site design quality showed positive effects on perceived information quality and indirect effects on satisfaction and word-of-mouth (WOM) intention. H5: Patients who use more cosmetic procedures information (word-of-mouth, mass media, and social media) are more satisfied with the cosmetic procedure results. H5a: Patients who use more cosmetic procedures word-of-mouth information are more satisfied with the cosmetic procedure results. H5b: Patients who use more cosmetic procedures mass media information are more satisfied with the cosmetic procedure results. Volume 35, Number 2 83 H5c: Patients who use more cosmetic procedures social media information are more satisfied with the cosmetic procedure results. Self-Image or Self-Concept Theoretically, body image can be defined as “mental construction, embedded in a self-schema” (Myers & Biocca, 1992, p. 116). As such, a person’s body is meaningfully perceived in relation to a cognitive structure (Thompson & Hirschman, 1995). Belk (1988) conceptualizes possessions as extensions of self and categorizes the body and body parts as the most valued possessions that are central to our conception of the self. It has been suggested that some purchase decisions may be affected by the consumer’s self-image or self-concept (Sirgy, 1982). Self-concept, the sum total of an individual’s ideas, thoughts and feelings about himself or herself relative to other objects, is a multidimensional concept, which includes actual self-concept, how individuals perceive themselves to be, and ideal self-concept, how an individual would like to be perceived (Sirgy, 1982). Consumers generally have favorable attitudes towards products and brands that are consistent with their self-image and less favorable attitudes towards products and brands perceived to be inconsistent with their self-image (Graeff, 1996). Subsequently, consumers may be influenced to direct their purchase behavior toward products and services that will protect or enhance their self-concept (Litvin & Kar, 2003). Consumers internalize ideal body images as their own standards of physical attractiveness. As a result, because it raises both awareness and internalization, media exposure will enhance an ideal self-image (Park & Cho, 2010). Furthermore, Pentina, Taylor, and Voelker (2009) concluded that advertising’s unrealistic ideals of appearance (ideal self-image) may lead to an increase of an actual-ideal self- image discrepancy and may cause consumers, particularly young women, to choose unnecessary invasive cosmetic procedures that may lead to health complications. H6: Patients who use more cosmetic procedures information (word-of-mouth, mass media, and social media) have greater increases in self-image after the cosmetic procedure. H6a: Patients who use more cosmetic procedures word-of-mouth information have greater increases in self-image after the cosmetic procedure. H6b: Patients who use more cosmetic procedures mass media information have greater increases in self-image after the cosmetic procedure. 84 Journal of Business Strategies H6c: Patients who use more cosmetic procedures social media information have greater increases in self-image after the cosmetic procedure. METHODOLOGY The study sample was a regional convenience sample. The respondents consisted of undergraduate marketing research students and consumers who were approached by the undergraduate marketing research students. If the undergraduate marketing research students had experienced non-surgical cosmetic procedures within the past two years, they completed the questionnaire. Additionally, those participants that the students sought who also had experienced non-surgical cosmetic procedures within the past two years were asked to complete the questionnaire. The undergraduate marketing students were trained by the instructor regarding data collection procedures. The approach of marketing students finding representative respondents to complete the questionnaire has been successfully used in previous research (e.g., Arnold & Reynolds, 2003; Bitner, Booms, & Tetreault, 1990; Jones & Reynolds, 2006). Qualtrics was used to administer the instrument online. After the screening question asking the type of non-surgical cosmetic procedure and the month/year it was performed, an introduction to the questionnaire briefly described the study and the anonymity of the responses. The first section of the questionnaire included demographics questions (see Table 1). The next two sets of questions focused on multiple-item measures, cognitive age, and risk aversion. All multi-item scales were established scales, some of which were revised for use in the study. Cognitive age was measured by a four-item scale with eight choices, ranging from “teens” to “80’s” (Barak & Schiffman, 1981). The risk aversion scale was a four-item, seven-point, strongly disagree to strongly agree, Likert scale (Donthu & Gilliland, 1996). The next section of the instrument asked respondents to report their Internet usage in a series of dichotomous questions and frequency-level questions. This section was followed by a question asking respondents to indicate the information source(s) that were used to help with the non-surgical cosmetic procedure decision. In addition to choices of self, friends/relatives, and family, the major forms of the mass media and social media were included. Each information source was measured using a seven-point, strongly disagree to strongly agree, Likert scale. Volume 35, Number 2 85 The questionnaire continued with two identical sets of semantic differential scales, one measuring overall attitude toward the social media advertising of the non-surgical cosmetic procedure, the other measuring overall attitude toward the traditional (mass media) advertising of the non-surgical cosmetic procedure. These measures for attitude toward the advertising were identical four-item, seven-point, semantic differential scales. These items were drawn from the inventory of 64 bi- polar adjective scale items from Bruner and Hensel (1998), who noted that past generated scales, “have relied heavily on researcher judgment with respect to which specific adjective pairs are appropriate for a given situation” (p. 818). A similar five-item, seven-point, semantic differential scale was generated for measuring overall attitude toward the non-surgical cosmetic procedure. The next multiple-item measure explored the satisfaction of the non-surgical cosmetic procedure results using a five-item, seven-point Likert scale (Oliver, 1980). The measures for attitude toward the online advertising and the attitude toward the traditional (mass media) advertising of the non-surgical cosmetic procedure were identical four-item, seven-point, semantic differential scales. A five-item, seven- point, strongly disagree to strongly agree, satisfaction scale (Oliver, 1980) was adapted to assess satisfaction of the non-surgical cosmetic procedure results. Next, a six-item, seven-point, strongly disagree to strongly agree, self-congruency, self- image, or self-concept scale was also slightly modified for use in the study regarding the non-surgical cosmetic procedure results (Sirgy, Grewal, Mangleburg, Park, Chon, Claiborne, Johar, & Berkman, 1997). The final sample size was 103. There was no response rate, since all questionnaires submitted were from students and others who agreed to participate in the study. The sample size and subsequent group sizes were sufficient for analysis, since it is noted that a sample size of “at least 20 can be expected to provide very good results even if the populations are not normal” (Anderson, Sweeney, & Williams, 2009, p. 390). Reliabilities were run for the multiple-item scales (overall Cronbach’s alpha = 0.87). All values were above the minimum acceptable value of 0.70 (Nunnally & Bernstein, 1994), except for the risk aversion scale value of 0.65. The last item of the risk aversion scale was deleted for an increase in reliability to 0.74 (see Table 2). ANALYSIS AND RESULTS Several groups were formed based upon information sources: all information sources, word-of-mouth information sources (own experience, friends/relatives, and 86 Journal of Business Strategies family), traditional or mass media information sources (magazines, newspapers, television, radio, and billboard), and social media information sources (Facebook, YouTube, Instagram, and Google+). Next, the averages of all the variables in each of the four groups were computed. These averages became the midpoint for the dummy variables of high information use and low information use. These high and low information groups were then compared with the means of the multiple-item psychographic variables. The results are summarized in Table 3. There were many significant results. H1 and H2 were supported, i.e., patients who use more cosmetic procedures information have a greater attitude toward social media advertising and mass media advertising of cosmetic procedures, respectively (p < 0.00 and p < 0.05). H3, H3b, and H3c were supported, i.e., patients who use more cosmetic procedures information overall, mass media information, and social media information, have lower cognitive ages (p < 0.00). H4, regarding risk aversion, was not supported, i.e., patients who use more cosmetic procedures information are not more risk-averse. H5, H5a, and H5b, were supported, i.e., patients who use more cosmetic procedures information overall, word-of-mouth information, and mass media information, are more satisfied with the cosmetic procedure results (p < 0.05, p < 0.05, and p < 0.10). Finally, H6, H6a, and H6b were supported, i.e., patients who use more cosmetic procedures information overall, word-of-mouth information, and mass media information have greater self-image after the procedure (p < 0.00). DISCUSSION This exploratory study investigated the amount of information used by consumers when engaging in non-surgical cosmetic procedures. The results indicated that those using more information also had a greater attitude toward the mass media and social media advertising. The group using more mass media and social media information had lower cognitive ages. This indicates that those who feel younger, and who may want to look younger than their chronological age, used information to a greater degree to better address this desire. Those patients who used more information in the word-of-mouth and mass media sources were more satisfied with the cosmetic procedure. And finally, patients who used more information in the word-of-mouth and mass media sources experienced greater self-image after the procedure. Volume 35, Number 2 87 CONCLUSIONS In this study, the common thread for those variables with significant results was mass media. Marketing managers in the non-surgical cosmetics industry should primarily focus on those particular areas of the mass media that best communicate with the target market. For example, it is interesting to note that millennials, who are becoming one of the major target market groups for cosmetic procedures (Saade, de Castro Maymone, & Vashi, 2018), have been using a broad variety of media, which includes all four major forms of the mass media (Geraci & Nagy, 2004). In particular, the communication should consist of messages that address the non-surgical cosmetic procedure as enhancing a youthful self-image, based upon the results of the cognitive age and self-image variables in this study. Promotion can also emphasize the satisfaction that patients experience from these procedures. The present study has limitations, which suggest fruitful areas for future research. First, only an online survey was used to collect data, which can be supplemented by the qualitative method for more robust results. Moreover, it is critical to use in-depth interviews and observation to investigate these issues. Second, it may be beneficial to have a larger sampling frame, which may explain the perceptual differences towards cosmetic procedures, based upon the demographic and psychographic variables. Third, the administration of the questionnaire was to marketing research students as well as others who had experienced non-surgical cosmetic procedures within the past two years. This variation in questionnaire administration may have biased the results. 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Reisenwitz has a DBA in Marketing from Cleveland State University, Cleveland, Ohio, USA, and is Professor of Marketing in the Department of Marketing & International Business at Valdosta State University, Valdosta, Georgia, USA, where he teaches at the undergraduate and MBA program levels. His work is published in several journals, including Journal of Consumer Marketing, Marketing Management Journal, Journal of Medical Marketing, Journal of Marketing Education, Marketing Education Review, Journal of Business Strategies, and Academy of Educational Leadership Journal. Timothy H. Reisenwitz is the corresponding author and can be contacted at treisenw@valdosta.edu. Jie G. Fowler has a PhD in Marketing from University of Nebraska- Lincoln, Lincoln, Nebraska, USA, and is Associate Professor of Marketing in the Department of Marketing & International Business at Valdosta State University, Valdosta, Georgia, USA, where she mainly teaches marketing research, promotion, Volume 35, Number 2 93 and marketing channels. Her work is published in Journal of Advertising Research, Journal of Macromarketing, Qualitative Market Research, Journal of Business Strategies, Journal of Current Issues, and Research in Advertising. 94 Journal of Business Strategies Volume 35, Number 2 95 96 Journal of Business Strategies