Designing Health Communication Campaigns: What Works?

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Thomas E. Backer, Everett M. Rogers & Pradeep Sopory

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    Introduction

    Much has been written in the last 10 years about health communication campaigns, especially those using mass media as a prime component. This is so for several reasons: First, empirical evidence has shown these campaigns to be effective in initiating or changing important behaviors related to health; second, the sheer number of campaigns has increased in the United States and abroad; third, aggressive efforts to promote health and prevent disease have risen higher on the American social agenda; and fourth, interest in studying campaigns has heightened, in part because of the first three factors. This interest has been generated in both the social sciences and mass communication fields, and increasingly has involved the work not only of university-based scholars, but also of professionals based in independent research settings, in health care institutions, in federal health agencies, and in community nonprofit organizations devoted to health and social issues.

    Several good books are currently available about mass media health campaigns—Rice and Atkin's (1989) Public Communication Campaigns, Salmon's (1990) Public Information Campaigns, and Atkin and Wallack's (1990) Mass Communication and Public Health, for example. Each of these works presents studies and commentaries about health communication campaigns in a variety of topical areas.

    These books and others use the terms health communication, public communication, and public information campaigns somewhat interchangeably. Most of the campaigns examined in these works are centrally organized around mass media (television, radio, print ads, and the like), although they also typically include community action and interpersonal approaches as well. In this book, we restrict our coverage to communication campaigns that feature a mass media component and that are intended to have an impact on health behavior.

    As we contemplated writing this book, we began with a straightforward question: Why another book about these campaigns? This introduction analyzes what we believe to be this particular work's place on the bookshelf in terms of both the sources of its ideas and its overall aims.

    This volume is the first product of a sequence of studies conducted by Thomas Backer and Everett Rogers, the first with Pradeep Sopory, on three aspects of mass media health campaigns that have previously received little attention in the burgeoning literature on this subject:

    • The development of generalizations to answer the basic question, “What works?” through the comparative synthesis of campaign experiences in widely different topical areas. Until recently, the body of empirical evidence on successful health campaigns that include a mass media component was too limited and scattered to permit cross-comparison. Now there is much more evidence and experience to study, but most campaign scholars deal with one or a limited number of specific health topics in their studies. Further progress requires comparing campaigns on drug abuse with those on population control, AIDS, and so forth, to look for common principles and the most effective intervention strategies. Our first study undertook this comparative synthesis through an extensive review of the literature and interviews with prominent campaign designers. We deliberately used a qualitative rather than a quantitative approach, in order to identify broad generalizations about the basic question “What works?” with the hope that empirical investigation of some of these themes would follow. Moreover, many campaigns in recent years have begun with some reinventing of the wheel because their designers were not even aware of what had worked in other topical areas, so comparative synthesis is of practical and economic value as well.
    • Study of the characteristics, experiences, philosophies, and creative styles of campaign designers, those who shape campaigns and direct their subsequent operation. Strong personalities and well-honed philosophies about health behavior change and about mass media, high levels of personal commitment, and often considerable personal charisma tend to characterize those who work in the mass media campaign field. These factors are likely to have a significant impact on both the nature of campaigns and their success.
    • Study of the characteristics of organizations involved in health communication campaigns, and how these organizations work together to either facilitate or inhibit the success of mass media campaigns. The organizational and interorganizational dynamics of mass media health campaigns—which tend to be complex, highly interdependent enterprises—have a significant bearing on campaign outcome, but these factors are virtually virgin territory in research on campaigns.

    This book addresses the first two factors, and a work in preparation addresses the third (Backer & Rogers, 1992). Research agendas about mass media health campaigns can be set for years to come with the issues raised under these three themes. However, we also see some very practical purposes being served by our work. First, students of campaigns may find it useful to have the present book on the shelf next to one or more texts about campaign design, to provide a richer interpretive context for learning about campaigns. Second, designers of campaigns may find inspiration for the structure of future campaigns here, and also questions they can pose to themselves about how their values and styles influence the campaigns they conduct. Increasingly, ways of thinking about scientific research suggest that the challenge is not to eliminate such “personal bias,” which usually is not possible anyway, but rather to label it clearly, try to understand it, and actually use it in productive ways.

    In Part I, we address in some detail a related phenomenon that we think helps to account for both the visibility and the success of many recent health communication campaigns—the rise of a health issue on the public and media agenda. To understand the larger social and environmental context in which a campaign operates, we must analyze where a particular campaign topic sits on the public and media agenda. Because the central focus of this book's content is on substance abuse, we have provided some specific background about how drug abuse became an item high on the public and media agenda in the United States.

    When a health issue is high on the public and media agenda, “natural energy” is provided that can greatly help a campaign to be successful. While campaign designers may have little influence over the rise of an issue on the agenda, they certainly can benefit from understanding this element of timing and using good timing to their advantage. Knowing something about why an issue rises on the public and media agenda also can be invaluable to campaign design.

    In Part IV, we also outline briefly another topic our research has shown is having increasing impact on campaign design: the use of entertainment media and techniques, as focused in the “entertainment-education” strategy. This approach provides unique energy sources for helping to overcome some of the barriers to campaign success that have been identified in much recent research.

    Substance abuse—abuse of alcohol and street or prescription drugs—is a special emphasis of our analysis in this book. This is partly because campaigns on this subject are common today, and are the subject of much popular and scholarly attention, and partly because the funding support for the present work was provided by the Office for Substance Abuse Prevention (OSAP). Some special findings related to substance abuse prevention with high-risk youth are presented throughout this book, and are described in greater detail in the final report of our first OSAP study (Backer, Rogers, & Sopory, 1990), and in portions of our annotated bibliography (Backer, Rogers, & Sopory, 1991).

    We see these briefly presented findings on substance abuse prevention and high-risk youth as having value beyond their interest to those conducting campaigns in this particular subject area. A main tenet of this book is that most of the factors associated with effective mass media campaigns are not, in fact, highly specific to those campaigns' topics. And, as will also be made clear by the 29 interviews that form the heart of this book, campaign designers have many styles and precepts in common, even though they may work in very different subject areas. However, there are some elements of campaign design that are specific to a particular subject area. The brief summary given here about substance abuse prevention campaigns can help to reinforce this point. Readers interested in other campaign topics are encouraged to think creatively about how the factors identified here for substance abuse prevention and high-risk youth might need to be altered to reflect the realities in their own areas of interest.

    We stress substance abuse prevention campaigns in the present volume for another reason: The rise of drug abuse on the social and media agenda has increased both the demand and the opportunity for such campaigns. For example, DARE (Drug Abuse Resistance Education) campaigns began only in 1983 in Los Angeles, but reached 4.5 million schoolchildren in 1989–1990 (see Backer & Rogers, in press, for a detailed analysis of the DARE program). DARE, which has included a media component, centers on an interpersonal training strategy in which a uniformed police officer teaches a 19-hour curriculum about drug abuse to fifth and sixth graders. Why did DARE diffuse so widely in the United States and in so few years? One reason is that the U.S. population perceives the drug problem as very serious, as analyzed later in this book. In such a climate of urgency, there is a shared expectation between community and government that “we have to do something,” and the opportunity increases for such efforts to start, along with public demand that these programs be encouraged and supported.

    We have chosen two examples of “mass media health campaigns” to provide a brief overview for those who may not already be familiar with the content or context of these campaigns. Both campaigns happen to concern the physical health problem of heart disease. Both also include mass media components in the context of a larger community-based effort. The Stanford Heart Disease Prevention Program, launched in 1971 in three (later in five) California communities, and the North Karelia Project, begun at the same time, in the province of Finland with the highest rates of cardiovascular disease in the world, are our two widely known examples.

    We chose these two examples in large part because they are extremely well documented and they have been successful, and because a host of other campaigns to promote healthy life-styles have been designed using the approaches developed first by these two projects. So many campaigns have emerged from these two, in fact, that some of the “great-grandchildren” and “great-great-grandchildren” of the Stanford and North Karelia campaigns do not even recognize their ancestry! One of the authors once constructed a “family tree” for these health communication campaigns, but the chart became so busy after two generations that it became difficult to understand. The Stanford and North Karelia efforts and their empirical evaluations showed that campaigns could successfully fulfill their goals, a perception that in part explains why so many health communication campaigns have been conducted since the 1970s.

    Many of the campaigns reviewed here are intended to bring about some type of preventive health behavior. Examples include smoking cessation, exercise, and dietary changes to reduce the risk of heart disease or cancer; drug abuse prevention; the designated driver concept to reduce drunk driving; sexual abstinence and contraception to reduce the likelihood of unwanted pregnancy; and safe sex to reduce the chance of HIV infection leading to AIDS. Preventive behavior is a particularly difficult goal to achieve through mass media campaigns. An individual must change behavior now by taking a preventive action (which is often unpleasant in nature) in order to lower the probability of some unwanted future event that may not happen anyway.

    For example, research on the effects of an auto seat belt campaign in Indiana found that while two-thirds of all Indiana adults were reached by the campaign's messages, no increase in seat belt use resulted (Gantz, Fitzmaurice, & Yoo, 1990). Why not? First, even though every vehicle in Indiana is equipped with seat belts, most people regard them as unpleasant to use: They soil or wrinkle clothes and they are constraining, uncomfortable, or even painful to wear. Further, most respondents in the Indiana study perceived that the likelihood of their having vehicle accidents was very low, so they rationalized seat belt use as unnecessary. Some Indiana adults even believed that seat belt use at the time of an accident would lower their chances of survival. So communication campaigns of a preventive nature, as many health campaigns are, face special difficulties in achieving behavior change, at least compared with “nonpreventive campaigns,” such as political campaigns or activities to diffuse and promote the use of a new product or service.

    Nevertheless, a number of more recent preventive campaigns, especially on health topic areas, have been relatively successful. Compared with the pre-1971 era of mass media health campaign experiences, when most evaluations showed that these campaigns failed, more recent campaigns, and especially preventive health campaigns, have had greater chances of success for the following reasons:

    • They have been based on vigorous, empirically validated social science theories, such as social learning theory, social marketing, the health belief model, and the diffusion of innovations.
    • They have utilized formative evaluation research in order to improve the effectiveness of the communication campaign before it was launched or while it was under way.
    • In comparison with earlier campaigns, they have had more reasonable objectives (e.g., a goal of achieving a 3% reduction in the risk of heart disease in a four-year campaign) that are more likely to be reached.

    Modern-day campaigns can still fail, as the Indiana auto seat belt campaign illustrates, but the likelihood of success overall is greater. Such optimism is probably one reason for the large number of mass media health campaigns that are currently being carried out.

    We would like to convey our thanks to Robert Denniston, our project officer at the Office for Substance Abuse Prevention (which funded the research on which this book is based), for his participation in shaping our work. We also thank the campaign experts who shared with us the lessons they had learned about health communication campaigns. Gratitude is also due to the staff of the Human Interaction Research Institute, for their assistance with our research and with preparation of this book. Finally, we acknowledge the USC Annenberg School for Communication and its dean, Dr. Peter Clarke, for many inputs to the present endeavor.

    So here is a book about mass media campaigns for health, based on theoretical perspectives and written by social scientists, that is intended to be practically useful to campaign designers and to students of health communication campaigns. We hope that our readers find its lessons learned to be interesting and of practical value in guiding future campaigns and their study.

    Thomas E.Backer
    Los Angeles, California
    Everett M.Rogers
    Los Angeles, California
    PradeepSopory
    Madison, Wisconsin
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    About the Authors

    Thomas E. Backer is President of the Human Interaction Research Institute, a nonprofit organization devoted to studies of knowledge utilization, planned change, and health communication. He is also Associate Clinical Professor of Medical Psychology, UCLA School of Medicine.

    Everett M. Rogers is Walter H. Annenberg Professor, Annenberg School for Communication, University of Southern California, and a member of the board of directors of the Human Interaction Research Institute.

    Pradeep Sopory received his master's degree in communications management from the Annenberg School at USC, and is currently a doctoral candidate in the Department of Communication Arts, University of Wisconsin—Madison.

    The authors have extensive experience in scholarly research and field interventions concerning the design and effects of health communication campaigns, both in the United States and abroad. Backer and Rogers are currently completing a project, supported by the Office for Substance Abuse Prevention, that investigates the role of organizational factors in the conduct of health communication campaigns.

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