Your local professional society has allocated funding for a television advertising campaign to improve the health of children in the community and enhance the public image of pediatricians. Because you are known to have an interest in the effects of television on children, and on occasion you have spoken to parent and community groups about television, the president of the society has asked you to help plan the campaign.
President: I am really excited about this project. The local television stations have shown interest, and a public relations firm has agreed to help us. I even met some of the news anchors last week.
You: Before we get too far into this project, you should understand that using television for health promotion is not the panacea that many people believe and hope it to be. There seems to be a common belief that the mass media, and television in particular, are both the cause and the potential solution to many of our health and social problems. In reality, most mass media campaigns don't change behavior. There are relatively few examples of mass media programs that have demonstrated effects in changing health-related behaviors.
President: How can that be? We all know that companies spend millions of dollars on advertising that has resulted in sales of many millions more in products that people may or may not need. Here, we have something that people actually need!
You: There are some important differences between selling products and selling health on television. First, the folks on Madison Avenue have it easy compared to us. They are selling things that people want. Advertising helps drive consumption, which is the American way of life. Who wouldn't want the latest sports car, the most popular drink, or the most high-tech pair of basketball shoes? What are we selling? Sweat and breathlessness, abstinence, birth control pills and condoms, resisting peer pressure, skipping rich desserts. . . in many cases the antithesis of consumption.
Second, television is suited to quick fixes, and there are certainly no quick fixes for many of the health behaviors we would like to influence. Television advertising (as well as entertainment and news programming) emphasizes quick and painless solutions. The format of television promotes this approach: 15or 30-second commercials, sound bites, and 30minute entertainment programs. Think about how complex a process it is to teach someone how to lose weight, and then think about how you might try to do that in 30 seconds.
Third, successful television advertising is usually only one part of an entire marketing strategy. For example, although the slogan "Just Do It" has become a part of everyday life, and some would argue that athletic shoe ads have helped legitimize physical activity as being socially desirable, their real purpose is to sell shoes. The "physical activity" that is most important to the company is that consumers hustle down to the nearest athletic shoe dealer to purchase shoes. This is made into a relatively simple activity because most communities are full of convenient places to purchase shoes. If you don't have enough cash, you can float the expense on your credit card. The process is familiar, well understood, and most people have relatively high self-confidence in their ability to buy a pair of shoes. There are few barriers to overcome. This is in sharp contrast to what happens after you buy the shoes - there are lots of barriers and little facilitating infrastructure to help you actually become a regular exerciser.
Using the existing infrastructure may have been the key to the success of a recent collaborative advertising effort between Kellogg's and the National Cancer Institute (NCI). Kellogg's produced advertising and packaging for their high-fiber cereals promoting the potential cancer-preventing effects of a high-fiber/lowfat diet and the NCI Cancer Information Service toll-free telephone number. The campaign resulted in substantial increases in high-fiber cereal sales, increased reports of eating high-fiber diets to prevent cancer, increased knowledge about the protective effects of fiber, and increased calls to the NCI toll-free information line.1,2 The barriers to changing behavior were limited, and the required behavior change was relatively small due to the supporting infrastructure that was already in place.
Finally, you should be aware of one more major limitation. Even if you have the participation of local stations, it may still be difficult to gain access to your intended viewers. If this is a public service announcement (PSA) campaign, then you are limiting yourself to free air time. There are more and more groups asking for their PSAs to be aired, and we are competing with them for the attention of station "gatekeepers." We could put together the most theoretically sound and technically sophisticated PSA possible, and it still might not make it onto the air, or it could end up being shown only in the middle of the night. We also may be limited in the subject matter or presentation because of potential conflicts with station interests. For example, an antismoking PSA may be rejected because the station is worried about losing food advertising revenues from RJR Nabisco or Kraft and General Foods (Philip Morris), or a safe-sex PSA may be rejected because of fears of offending advertisers or viewers.
Paying for advertising time may be the only way to guarantee access to our target authence. Unfortunately, that could end up being prohibitively expensive, particularly to achieve enough exposure to have an impact. Then, even if we got the viewership we desired, those PSAs would be running in the middle of a constant flood of ads promoting less-than-healthy behaviors. It has been estimated that each year the average American child sees about 40 000 television commercials, many of which are ads promoting highfat, high-calorie, low nutritional value foods or glamorizing alcohol use. '
President: Do you think there is any role for television advertising in health promotion?
You: Certainly. Given these limitations, there are a number of things television advertising can do well. Television can help legitimize an idea or problem (the "if it's on TV, it must be important" effect). An example of this is the legitimization of domestic violence as an important issue resulting from the media attention associated with O.J. Simpson being accused of murdering his exwife. Television can increase awareness, for example, getting the word out that youth violence is on the rise. Television exposure can help set agendas, convincing people of the relative importance of an issue that deserves their immediate attention. An example of this is the national prioritization of illicit drug use since the mid-1980s, substantially out of proportion to its relative contribution to morbidity and mortality, and during a period in which drug use was already declining.
Television can help motivate people to act, by making persuasive arguments for changing behaviors or encouraging perceptions of healthful behaviors as socially desirable, similar to the Kellogg's ad campaign for high-fiber cereals. Television can direct people to other resources, such as an AIDS information hotline, which can help them to act on the information you have given them. These resources also could be places to act, such as addiction counseling centers, smoking cessation programs, and public immunization clinics.
Television can act as a cue to push people to perform a skill they have learned previously, such as buckling their seat belt or performing a breast selfexamination, or even turning off the television set and exercising. To a limited extent, television can be used to teach specific health-promoting skills, such as reading food labels or child-proofing electrical outlets. However, for the most part, television advertising is unlikely to produce significant health behavior change on its own.
President: Are there examples of successful health promotion mass media campaigns that we can learn from?
You: A lot of what is known about designing successful mass media health promotion campaigns comes from the experiences of the Stanford Three Community Study, in northern California,4·5 and the North Karelia Project, in Finland.6 Both studies were started in the early 1970s to reduce cardiovascular disease risk factors in entire communities. The Stanford Three Community Study demonstrated that a carefully planned and implemented mass media campaign alone could produce significant change in some health behaviors. However, lasting and more complex behavior changes required additional, more intensive, interpersonal interventions. This has been the major theme that continues to come out of community health promotion. Success is more likely if mass media is linked to more intensive, social learning-based, interpersonal interventions such as classroom curricula, behavior change groups (for smoking cessation or weight control, for example), behavior change competitions, correspondence materials, and health fairs that provide the opportunity for more substantial skills training and reinforcement.
President: Fair enough. I now understand that if we really want to improve the health of our community's children, television should only he part of a more comprehensive program to promote behavioral change. We should include the schools, parent groups, all the pediatricians in the community, hospitals, businesses, and other groups so it becomes a community-wide effort, making available the resources necessary to help people actually change their behaviors. How do we start?
You: One of the more popular approaches to campaign development is called social marketing.7 Social marketing is an attempt to apply the practices used in commercial advertising and marketing to address social problems. The first order of business in social marketing is getting to know your authence. This is accomplished through extensive formative research. We know that media use and health-related behaviors, knowledge, and attitudes vary by age, sex, ethnicity, and geography. To implement an effective campaign, we should understand those differences and acknowledge them in our specific objectives and educational strategies.
One example of this was a recent report called "Reaching the Hip-Hop Generation" prepared by marketing professionals for the Robert Wood Johnson Foundation.8 To identify appropriate communication strategies for substance abuse prevention and other prosocial messages for inner-city African-American teens, they used focus groups and questionnaires in several large urban areas throughout the country. What they found was that although prosocial messages are literally being heard, no one is listening. Even worse, mainstream messages like "Just Say No" and "Stay in School" tended to be interpreted as threatening to their sense of community and were strongly rejected. Spokespersons such as Magic Johnson, Jesse Jackson, or even popular rap singers were perceived as being coopted by the mainstream culture when they delivered a prosocial, persuasive appeal. In addition, any persuasive message that appeared on television was automatically suspect, due to its mere presence on such a mainstream-culture medium. These findings now can be used to help understand why recent campaigns targeting this audience have been ineffective and to help shape the design of new campaigns. This is a useful example of what needs to be done for every target behavior and every target authence.
Once you know your authence, attention can be focused on the four P's: product, place, price, and promotion. The right product (eg, bicycle helmet use) must be easily available in the right place (such as schools, bike shops, hospital emergency rooms, and grocery stores) at the right price (inexpensive but also convenient, eg, fits in a school locker) and without psychological or social costs (such as teasing from peers or messed hair), and with the right promotion ("cool" looking or professional athletes use them). In practice, that boils down to a process of specifically defining the target problem and the behavioral skills necessary to resolve it (the "product"); segmenting the authence to select the most appropriate media (or other means) to reach the intended target authence with the most appropriate message or skills; integrating multiple strategies; understanding competing ideas and products (including other prosocial campaigns as well as barriers to adoption of your product); developing and pretesting ideas and products; and developing mechanisms for rapid collection and evaluation of feedback for ongoing campaign improvement.
President: Once we have identified the right product, place, price, and promotion strategies, are there some guidelines for designing effective promotional messages?
You: Much of the specific content of promotional messages should come from formative research with children, teens, and parents in our community. However, message design can be guided by Bandura's cognitive social learning model,9 which has proven quite useful in designing health behavior change interventions. According to this model, we must focus on four factors in message design: attentional factors, retentional factors, motivational factors, and modeling.
Attentional factors are just what they sound like. You have to get a person's attention before that person can learn something. Empirical research has identified salience, conspicuousness, attractiveness, relevance, things of value to the person, things that influence a person's emotions, and even things like setting goals prior to starting an activity as factors that increase attention. This also includes the bells and whistles that television is generally pretty good with. It means that we probably want to stay away from a "talking head" approach in which a doctor in a white coat makes a verbal plea for better living. This also applies to influencing television "gatekeepers." The person who controls PSA scheduling for a local station may not be aware of the importance of our message and may be more interested in the production quality of our ad.
Retentional factors are those that increase memory of the message. Memory is enhanced by things such as repetition, linking instruction with a visual demonstration, association with notable images, analogies to familiar or otherwise meaningful activities, allowing people to make their own personalized interpretations of what they observe, and forcing them to practice what they have learned and providing frequent feedback about their performance.
Motivating the viewer is a key process in promoting a behavior change. Motivation can be influenced by things such as peer, parent, or teacher approval or disapproval, material rewards such as money, and perceived control and choice. We know that motivation and incentives play an important role in regulating behavior. However, the selection of weak or inappropriate incentives actually could undermine our efforts. The results of early smoking prevention research is an example. Many interventions emphasized the harmful long-term health effects of smoking such as emphysema, cancer, and death. While some of these programs resulted in improved knowledge, attitudes, and even reported intentions to not smoke, most produced little or no effect on students' actual smoking behavior. In this case, the perceived shortterm positive benefits associated with smoking may have outweighed the long-term negative consequences. The cognitive social learning model as well as empirical research suggest that the messages should emphasize immediate outcomes that are most salient to the target authence.
Similar problems appear to be true for many of today's most popular antidrug PSAs. Although ads such as "this is your brain on drugs" have achieved remarkable diffusion into our popular culture, they are unlikely to be effective in deterring drug use. They attempt to motivate people by scaring them. However, they tend to use unrealistic fear appeals. Persons at risk of illicit drug use tend to know others who use illicit drugs or they themselves have used them without serious adverse effects. As a result, references to a frying brain or a gun pointed up one's nose are likely to be perceived as irrelevant by the target authence. Not all fear appeals are ineffective. When realistic fear appeals are linked to specific ways to deal with these threats, they can be effective. However, fear appeals presented in isolation are generally ineffective.
Once motivated to act, those intentions must be converted into actions. This process is most influenced by actual practice, or rehearsal. Rehearsal is the most powerful way to increase a person's confidence co successfully perform a new skill and reap the expected rewards. In more intensive, interpersonal interventions, rehearsal usually is included as guided practice and role playing. For television advertisements, the next best thing to actual rehearsal is modeling or demonstrating others performing the behavior. This produces learning by imitation. Modeling tends to be the central element resulting in learning from television. To be effective, the person modeling the behavior should resemble the viewer enough and the setting should be realistic enough that the viewer is able to imagine himself or herself doing the same thing. The modeling should demonstrate explicitly how to perform the specific skills necessary, the performability of those skills (a realistic representation of how easy or difficult they are to perform), and the probable consequences (personal, social, or even material) that will result from performing them. Because health behavior change is difficult, this may include initial failures followed by subsequent successes because easy success would be unrealistic. In response to seeing others perform the desired behaviors and overcoming barriers, viewers may increase their confidence in successfully performing those skills themselves and in the immediate rewards they are likely to receive.
President: Is there anything else we need to include in our plan?
You: As formative evaluation is critical to campaign design, summative and process evaluations also should be priorities. I know that evaluations use valuable resources but they often produce even more valuable information. If we don't evaluate our interventions, how will we ever learn more about what works and what doesn't? It's amazing that so few health promotion campaigns are ever evaluated in any meaningful way. However, going back to our model of behavior change, the incentives are such that most organizations producing public service mass media campaigns have no motivation to perform any real evaluations. Such campaigns can achieve broad visibility and great public relations without ever documenting an effect (or lack of one, as the usual case may be). On the other hand, commercial marketers need to know the effects of their advertising because they are in the game for more than just good feelings. As a group with sincere interests in promoting child health and not just self-aggrandizement, I would hope that we too would be less interested in appearances and more interested in actual effects. Evaluations certainly can help us improve any campaign we design, now or in the future.
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