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Reducing Underage Drinking: A Collective Responsibility 10 Media Intervention Impact: Evidence and Promising Strategies Charles Atkin Devising effective mass communication alcohol prevention interventions poses a difficult challenge to campaign design specialists and media professionals. This chapter reviews conventional strategies from the general health campaign literature and offers some promising innovative approaches that may achieve greater success in addressing the underage drinking problem. Unlike the current national drug campaign, which is funded sufficiently to disseminate a huge volume of prominently placed messages with sophisticated design and professional executions, underage alcohol campaigns are far more limited in quantity and quality. MEDIA CAMPAIGN DESIGN Disciplined campaign design begins with an assessment of the behavioral aspects of the youth drinking problem in order to determine which actions should be performed by which segments of the population. In particular, the designer needs to specify focal segments of youth whose drinking behavior is to be changed. For each segment, one can trace backward from the ultimate focal behaviors to identify the proximate and distal determinants, then create models of the pathways of direct and indirect media influence. The communication strategy involves specifying target audiences and target behaviors that can be influenced directly by campaign messages. In formulating the plan, the campaign strategist is faced with basic decisions about allocating resources among the prospective pathways, focal behaviors, types of messages, channels, and dissemination options. Should
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Reducing Underage Drinking: A Collective Responsibility the campaign seek to change fundamental behaviors, or chip away at more readily altered peripheral actions? Should the most resistant or most receptive segments be the focus of campaign efforts? What proportion of the resources should be devoted to direct influence on the focal segment versus indirect pathways via stimulating interpersonal influencers and leveraging or combating environmental determinants? Which influencers should be targeted? What is the optimum combination of awareness messages, instructional messages, and persuasive messages? How many messages should attack the competition (ranging from drinking initiation to drunkenness to impaired driving) versus promote healthy alternatives? Is it more effective to disseminate the messages via expensive TV channels or to utilize primarily minimedia? Should the campaign messages be scheduled in concentrated bursts or spread out over a lengthy period of time? In media-based campaigns, development of the strategy entails sensitive application of mass communication theories and best practices principles. The strategic guidelines presented in this chapter draw on models, processes, generalizations, and recommendations in the voluminous research literature on media health campaigns, particularly theoretical perspectives and reviews by communication researchers such as Atkin (1981, 1994, 2001); Atkin and Wallack (1990); Backer and Rogers (1993); Backer, Rogers, and Sopory (1992); Bracht (2001); Cappella, Fishbein, Hornik, Ahern, and Sayeed (2001); DeJong and Winsten (1990, 1998); Donohew, Sypher, and Bukoski (1991); Dozier, Grunig, and Grunig (2001); Hale and Dillard (1995); Maibach and Parrott (1995); McGuire, (1989, 1994); Singhal and Rogers (1999); Slater (1999); Stephenson and Witte (2001); Wallack and DeJong (1995); and Wartella and Middlestadt (1991). The applicability of the general principles depends on the specific context (especially types of audiences to be influenced and type of product being promoted), so effective campaign design usually requires extensive formative evaluation inputs and message pretests. Surveys, focus groups, and lab testing provide useful information to guide campaign development and to provide feedback on effective and ineffective components. Alcohol-related examples of formative evaluation are described by Atkin and Freimuth (2001). Direct Effects on Underage Individuals In general, health campaigns that are targeted directly to the focal segment of the population tend to have a modest degree of impact, with limited effects on fundamental behavior patterns. But impact is highly variable, depending on the palatability of the advocated behavior and the receptivity of the target audience. Recent meta-analysis studies of comprehensive community-based campaigns show that the media contribute to a 5 to
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Reducing Underage Drinking: A Collective Responsibility 10 percent change in behavior (Snyder, 2001). The meager literature on underage drinking prevention presented in this chapter is consistent with the limited-effects conclusion based on other health campaigns aimed at youth. The limited potency of the media leads to several implications for campaign designers. First, designers should set realistic expectations of success, especially in the short run. They should be prepared for a long haul because many campaigns take years to achieve and maintain significant impact. Second, designers should employ some of the promising ideas presented throughout this chapter, and take care to avoid wasting resources on ineffective strategies. They should give more emphasis to relatively attainable impacts by aiming at more receptive segments of the audience and by creating or promoting more palatable positive products. Campaign designers should augment the relatively small set of packaged campaign stimuli with message multipliers by stimulating information seeking and sensitization and by generating public relations publicity. Furthermore, they should use a greater variety of persuasive incentives to motivate the audience, and include more educational material to help them perform the behaviors. Finally, the meager direct effects may be overcome by shifting campaign resources to indirect pathways of facilitating and controlling the behavior of the focal segment via interpersonal, organizational, and societal influences. Most of these strategies involve a broader diversity of approaches than conventionally employed in health campaigns. Diversification of Campaign Approaches Over the past few decades, a relatively limited array of strategies typically has been utilized in media-based health campaigns. The field may be well advised to diversify the approaches to campaign design beyond conventional practices. Alcohol prevention campaigns rely on a narrow set of approaches (e.g., social norming, threat of physical harm), which may be improved by considering a broader set of communication tactics that are coordinated in a more conceptually sophisticated manner. In creating a media campaign strategy, there are many dimensions to consider, each with multiple options. For example, designers can choose among 10-15 direct and indirect pathways to be taken, about 30-40 basic persuasive appeals to be selected, perhaps 25-30 different channels to be utilized, 5-10 types of target behaviors to be advocated, 10-15 types of target audiences to be influenced, 10-15 kinds of source messengers to deliver the content, 5-10 types of instructional skills to be taught, and an array of stylistic executions to be created. A basic theme of this chapter is that disciplined diversification can yield greater success in alcohol campaigns. Rather than putting too many eggs in
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Reducing Underage Drinking: A Collective Responsibility one basket, it’s advisable to use a large variety of messages. Even excellent messages are subject to wear out with heavy repetition, especially if the message features highly distinctive stylistic devices (e.g., clever slogan, humorous portrayal). Most messages can achieve near-maximum impact after a relatively small number of exposures; presentation of additional variations will achieve greater incremental impact because the degree of effectiveness of alternative versions tends to be roughly equivalent. There are a large number of potentially influential persuasive appeals, so a scattershot of incentives can strike multiple responsive chords across segments with diverse predispositions. Similarly, there are a variety of focal segments of the population that the campaign might seek to influence, both directly and indirectly via messages targeted to audiences of influencers and policy makers. The next section suggests factors to consider in deciding which focal segments should be identified and given varying degrees of emphasis in allocating campaign resources. Priority Focal Audience Segments A typical health campaign might subdivide the population on a dozen dimensions (e.g., age, sex, ethnicity, stage of change, susceptibility, self-efficacy, values, personality characteristics, and social context), each with multiple levels. Combining these dimensions, there are thousands of potential subgroups that might be defined for targeting purposes. Because audience receptivity is often a more central determinant of campaign effectiveness than the potency of the campaign stimuli, there will be differential success depending on which segment is targeted. For example, one form of segmentation might be based on the stage of readiness for a change in health practices. To achieve the maximum degree of communication impact, campaign designers often attempt to pick off the easy targets. In the case of drinking prevention campaigns, two basic predispositional categories of young people are most readily influenced by media messages. These categories are described in the following paragraphs. Reinforcing the healthy core. Just as political campaigners try to protect their base constituency, health campaigners need to maintain the healthy practices of the “choir” by devoting a portion of resources to reinforcing messages. Adolescent-targeted campaigns seek to give support to youth who have delayed drinking initiation in order to maintain the “loyal franchise.” This segment merits moderate priority: On the plus side, these nonusers are favorably predisposed to abstinence messages; on the other hand, they are only slightly likely to use alcohol in the absence of campaign reinforcement.
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Reducing Underage Drinking: A Collective Responsibility Targeting “at-risk” preusers. Another key segment is younger adolescents who haven’t yet tried alcohol, but whose background characteristics suggest a probability that they might drink in the near future. Compared to the core, this segment of the population is higher priority because of the greater risk of alcohol use combined with momentary receptivity. However, it’s difficult to produce longer-term abstinence effects because situational forces and opportunities may change rapidly and because campaign messages might inadvertently accelerate temptation. Health campaigners face a more challenging advance-marketing task than commercial advertisers, who can readily induce youthful anticipation of forbidden fun when preselling beer, cigarettes, cosmetics, and motorcycles. Ignoring the hard core. On the other hand, frequent binge drinkers are not readily influenced by media campaigns. Although this segment is in greatest need of change, it may be fruitless to invest heavy resources to induce immediate discontinuation or moderation of drinking. As they mature or experience negative consequences, some of these individuals may progress to a readiness stage where they are receptive to cessation messages at some later point in time. Beyond this set of examples, campaigners also need to consider other demographic, social, and psychological-based subgroups (e.g., higher versus lower income, high versus low sensation seekers). Influencing these varied population segments requires a complex mix of narrowly customized messages and broadly applicable multi-targeted messages that use diverse appeals and optimally ambiguous recommended actions. Addressing the Competition Prevention campaign messages often focus on the harmful consequences of the unhealthy practice rather than promoting a positive alternative to compete with it. This is especially the case for alcohol, where the positive product (e.g., abstinence, delay, moderation) lacks inherently appealing features. Although threats can be effective if handled skillfully, the heavy reliance on negatively attacking the competition tends to restrict the strategic arsenal to a narrow array of options. The overly negative approach can be lightened by implementing two forms of diversification. First, the nature of attacks might be shifted from the conventional emphasis on severity of harm to a refutational discounting of supposed advantages of the unhealthy practice. Messages can acknowledge that the competition has certain attractive aspects, and then argue that each seeming positive consequence is unlikely to be experienced, not so positive after all, or relatively unimportant. The classic persuasion literature on one-sided versus two-sided messages indicates that it’s more effec-
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Reducing Underage Drinking: A Collective Responsibility tive to raise and refute the opposing side if audience members are sophisticated and knowledgeable about the topic, are predisposed against the position being advanced, perceive a manipulative intent, and are already aware of the pro-arguments. For example, a message might employ the straw man refutation technique by citing and disproving the inflated claim that “everybody drinks.” Second, the predominant anticompetition tenor of campaign messages can be diversified by shifting the emphasis from negative incentives associated with an unhealthy practice to mirror-image positive incentives associated with the healthy practice, which is one of the strategies described in the next section. Persuasive appeals. Unlike superficial awareness messages or simple exhortations, persuasive messages add a motivational element in the form of positive or negative reasons to perform the desired behavior. In selecting incentives, the key criteria are the salience of the promised or threatened consequences, the malleability of beliefs about the likelihood of experiencing these outcomes, and the potential persuasiveness of the arguments that can be advanced. Incentive appeals should build on the existing needs and values that are identified in formative evaluation, rather than seeking to change fundamental orientations. It is usually more effective to emphasize mild but likely consequences rather than remote or improbable consequences that are more strongly valued (e.g., hangovers versus alcohol poisoning). Thus, threats of death, illness, injury, or other serious physical harm have a significant but limited role in health campaigns. Alarming fear appeals can be quite influential if handled adeptly, but other incentives also should be emphasized: threats of a less severe nature, negative incentives beyond the physical health domain, and positive incentives. Intense Fear Appeals A pervasive strategy in health campaigns is to motivate behavior change by threatening the audience with harmful consequences from initiating or continuing an unhealthy practice. Fear appeals can be risky because there may be boomerang effects or null effects due to defensive responses by the audience members who attempt to control their fear rather than control the danger. The three crucial defensive mechanisms are selective avoidance of the message itself (due to unpleasant or alarming depictions), selective perception of the information (particularly the perceived likelihood of negative outcomes), and denial of applicability to self. Despite these problems, the research indicates that well-designed fear appeals are quite effective in changing behavior. Several types of message
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Reducing Underage Drinking: A Collective Responsibility content increase the odds of a functional response. First, provision of efficacy information is crucial; if the fear-arousing message (or companion messages in the campaign) presents credible and understandable ways for the individual to address the threat effectively, then constructive responses are more likely. Depending on the prior beliefs and abilities of the message recipient, there may be a need for self-efficacy instructional material (demonstrating how to perform behaviors and boosting the confidence that the individual can do so successfully) or response efficacy material (convincing the individual that the recommended behavior will reduce the danger). Second, messages need to overcome people’s natural tendency to be unrealistically optimistic about odds of avoiding negative events. This can be achieved by emphasizing susceptibility evidence and personal applicability, and by featuring negative outcomes that are less severe but more probable. It’s also advantageous to coordinate claims with reality forces that can’t be readily dismissed in order to avoid the perception of empty threats. Third, fear appeals are inherently compelling and thus have great potential to attract attention and impel greater involvement during processing. However, care must be taken to avoid overly disturbing depictions or noncredible content that might turn off the audience at early stages of message response. Minor health threats. Although serious harm is a major motivator, the severity × susceptibility formula also can be maximized by featuring non-severe outcomes that have a higher probability of occurrence. In the case of youth alcohol campaigns, minor negative incentives include diminished athletic performance, weight gain, or hangovers. Not only are these outcomes far more frequent, but levels of perceived susceptibility may be elevated due to observed or experienced conditions misattributed to alcohol rather than other origins. Other negative incentives. Beyond the realm of physical health, there are dozens of potential motivational appeals along the social, psychological, economic, or legal dimensions. In the social incentive category, alcohol campaigns can present negative appeals about looking uncool, alienating friends, incurring peer disapproval, losing trust of parents, or having a detrimental influence on others such as younger siblings. The constellation of psychological, cognitive, moral, and aspirational incentives might include reduced ability to concentrate, low grades, feeling lazy and unmotivated, losing control, making bad decisions, and anxiety about getting caught or experiencing harm, guilt, and loss of self-respect. Among the economic incentives are diminished job prospects, fines, cumulative cost of purchasing alcohol, and inability to spend on other needs and desires.
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Reducing Underage Drinking: A Collective Responsibility Messages can also highlight penalties for violating laws and policies, such as loss of driver’s license or suspension from school. Positive incentives. As in political campaigns that feature mudslinging, audiences consistently receiving negative messages about health practices are often turned off. To achieve greater diversification, the facile prescription is “don’t always say don’t.” Because campaign messages that attack the unhealthy behavior with warnings and threats are overused, there’s a need to give careful attention to implementing the positive approach. For each of the negative consequences of performing the proscribed practice, there is usually a mirror-image positive outcome that can be promised for performing the healthy alternative (e.g., enjoying moderation, maintaining abstinence, practicing safe driving). In the physical health dimension, messages can offer prospects ranging from enhanced athletic performance to survival. Positive social incentives include conforming to prevalent social norms (see next section), being cool, gaining approval and respect, forming deeper friendships, building trust with parents, and being a good role model. On the psychological dimension, messages might promise outcomes such as gaining control over one’s life, having a positive self-image, attaining one’s goals, feeling secure, or acting intelligently. Exaggerated rewards may work well as motivators, even though the likelihood is rare; just as negative strategies frequently use long-shot prospects of severe harm, positive approaches could promise lottery-type payoffs that are more believable to positivists. Multiple incentives. Dozens of persuasive appeals are potentially effective, and the degree of potency is fairly equivalent in many cases. Thus, campaigns can usually achieve greater impact by employing a variety of different appeals rather than concentrating on a handful of persuasive incentives or a single narrow strategy such as social norming. In prioritizing among incentives, the designer should consider the absolute potency and the relative contribution vis à vis other concurrent appeals and influence that already has been achieved in the past. Preproduction research can test basic concepts to determine the absolute effectiveness of each one and to examine optimum combinations, and pretesting research can compare the relative influence of executions of various appeals. Social Norming Strategies In the past decade, a majority of colleges have sponsored alcohol education and prevention programs (Werch et al., 2000), and an estimated 20 percent of colleges have used the social norms approach (Wechsler and Kuo, 2000). Most of these interventions have included media components,
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Reducing Underage Drinking: A Collective Responsibility typically using newspaper ads that highlight lower-than-expected statistics on campus drinking practices. The basic assumption is that students drink more heavily as a function of the inflated perception of normative consumption levels by fellow students, so provision of the actual figures should serve to correct the misperception. The portrayal of actual drinking rates for the overall student body (or key segments such as freshmen or fraternity/sorority members) is typically framed in a positive manner, demonstrating with survey evidence that most students drink moderately rather than using a negative appeal that portrays excessive drinking rates as deviant because relatively few consume at these high levels. Thus, the persuasive appeal emphasizes positive social incentives rather than negative threats of physically harmful outcomes. Dozens of campuses nationwide have implemented major media-based social norms campaigns, including extensive and sophisticated efforts during the early and mid-1990s at Northern Illinois, Arizona, Hobart and William Smith, Western Washington, and Washington State. Following the dissemination of norm correction information presented in student newspapers, posters, Web sites, and other channels (including classroom units and meetings with student groups), several evaluation studies show a substantial decrease in binge drinking rates within one year. An early and notable social norming campaign was carried out by Haines (1996) at Northern Illinois University. This broad-scale, multiyear intervention featured numerous messages in the student newspaper (classified and display ads, news items, and a column), flyers, posters, brochures, and various interpersonal components. After the first year, binge drinking rates dropped from 44.8 percent to 37.6 percent, a 16 percent reduction; alcohol-related injuries also declined. After six years of campaign efforts, binge drinking on campus had dropped further to 27.7 percent (whereas national rates stayed between 40 percent and 43 percent over this period). Over the full campaign, alcohol-related injuries to self fell by 31 percent and injuries to others decreased by 54 percent. At Hobart and William Smith Colleges, Perkins and Craig (2002) evaluated a comprehensive campaign utilizing posters, electronic media, and interactive Web site components (along with class projects and curriculum infusion). They reported a 21 percent reduction in drinking increases in the freshman year, a 56 percent to 46 percent reduction in binge drinking campuswide, and decreases in alcohol-related arrest rates over four years. These outcomes consistently decreased over a five-year period. Posters were used in a norm-setting intervention for college students at Washington State University (Barnett, Far, Mauss, and Miller, 1996). Unlike newspaper ads or radio spots that reach broad and diverse audiences, posters were tailored for specific subgroups such as fraternity and sorority members and dorm residents. The informational posters produced a de-
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Reducing Underage Drinking: A Collective Responsibility crease in perceived drinking in reference groups, and perceptual changes were associated with reduced drinking; however, the impact of the intervention on drinking behavior was modest. A poster-based campaign at University of Virginia was followed by decreases in drinks per week. For women and nonfraternity males, the drinking behavior of the entering freshman class increased less than in the prior freshman class (Odahowski and Miller, 2000). A randomized, controlled study of a campus social norm intervention (via feedback regarding personal drinking) showed a reduction in alcohol use among heavy drinking college students (Agostinelli, Brown, and Miller, 1995). At Rutgers University, social norming campaigners created a core message that was placed in the student newspaper and displayed on posters: a top-ten list of misperceptions at Rutgers, with three norm correction items (e.g., “everyone who parties gets wasted” versus data showing that two-thirds of students consume three or fewer drinks); this effort was supplemented by a public relations campaign that generated extensive local news coverage, and misperception information at a Web site (Lederman et al., 2001). More than four-fifths of first-year dormitory residents accurately recalled the campaign message, and accuracy of perceptions rose from 17 percent to 55 percent in one year. On the other hand, some campaign interventions have not yielded significant effects on student drinking patterns (Werch et al., 2000; Clapp, Russell, and DeJong, 2001). Using a carefully controlled field experimental design, first-year students at a southern university received a series of three greeting cards providing norming information (Werch et al., 2000). The evaluation showed no overall differences between experimental and control group students on alcohol use and risk-factor measures, although positive and negative effects were found for subgroups based on stage of readiness to engage in binge drinking. There is considerable debate regarding the adequacy of research evaluation, message content, and dosage across the numerous demonstrations of social norm campaign effectiveness (Keeling, 1999, 2000; Werch et al., 2000; Wechsler and Kuo, 2000; Campo et al., 2002). Among the methodological problems are lack of longitudinal cohorts, nonrandom assignment to experimental conditions, and focus on heavy drinkers (which increases the risk of regression to the mean over the intervention period). Nevertheless, it appears that well-designed norming campaigns can contribute to a reduction in quantity of drinks consumed by college students (Perkins, 2002; Haines, 1996). According to the latest data available at the National Social Norms Resource Center Web site, declines in heavy episodic alcohol consumption have been achieved on the following campuses: 44 percent in ten years at Northern Illinois, 40 percent over four
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Reducing Underage Drinking: A Collective Responsibility years at Hobart and William Smith, 28 percent over five years at Arizona (Johannessen, Collins, Mills-Novoa, and Gilder, 1999), 21 percent over two years at Missouri, 21 percent over four years at State University of New York-New Paltz, 20 percent over one year at Santa Clara, and 20 percent over three years at Western Washington. It should also be noted that a normative appeal was tested with a TV spot designed for young adolescents. Compared to an informational antidrinking message and a control message, sixth-graders viewing the normative public service announcement made lower estimations of peer acceptance of alcohol and were more resistant to influence when viewing beer commercials (Godbold and Pfau, 2000). Strategic Ambiguity The conventional rule of thumb in message construction is to be clear and straightforward, a proven technique for facilitating comprehension in educational and persuasive applications. In general, there is greater learning of material conveyed with simplified vocabulary, short sentences, sparse copy, graphic depictions, and a single major point per message. In certain situations, however, it may be advantageous to communicate basic content components with ambiguous visual and verbal message executions that produce differential interpretations among audience segments. During message processing, ambiguity should reduce counterarguing and reactance, and increase introspection and elaboration (thus minimizing the boomerang effect and maximizing audience involvement). This approach is typically implemented by featuring vaguely worded behavioral recommendations or by presenting suggestive portrayals, arguments, and evidence. The ambiguity allows the individual receivers to draw their own implications based on predispositions; the strategic aspect involves manipulating the message content in a manner that plays off the perceptual tendencies of various subgroups. Multitargeted messages. Strategically ambiguous executions are especially applicable to spot messages on TV, where targeting tends to be imprecise. If multiple audience segments will receive the message, it can be both efficient and effective to influence several simultaneously with obliquely targeted or multitargeted messages. The strategic ambiguity approach is employed quite shrewdly by the alcohol companies in their “private service” campaigns dealing with risky drinking. These campaigns use ambiguous slogans such as “know when to say when” or “think when you drink” to attain multiple objectives simultaneously: combat the drunk driving or alcohol poisoning problems among extreme drinkers (without significantly undermining consumption levels by
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Reducing Underage Drinking: A Collective Responsibility Message Sources The “source” of campaign messages combines both the sponsor (the sender who is responsible for placing the messages, typically an organization) and the messenger (the model appearing in the message who delivers information, demonstrates behavior, or provides a testimonial). Messages addressing underage alcohol problems may be sponsored by prevention-oriented organizations such as National Institute on Alcohol Abuse and Alcoholism or Mothers Against Drunk Driving, alcohol companies such as Anheuser-Busch or Seagram, or media institutions such as CBS or MTV. The perceived motives and credibility of the sponsor can affect how the message is processed and interpreted by youthful audiences. In a message response-testing study, Atkin et al. (1992) reported that brewer-sponsored “private service” ads that ostensibly promoted moderate or safe drinking were regarded by high school and college students as less informative, believable, on target, and effective than PSAs sponsored by government agencies or associations. Students displayed skepticism of the motives of the beer companies, perceiving their main goals to be improving the company image and promoting their products. The messenger in an alcohol message is helpful in attracting attention, personalizing abstract concepts by modeling actions and consequences, bolstering belief formation due to source credibility, and facilitating retention due to memorability. The leading categories of alcohol campaign messengers are expert specialists such as doctors, famous figures such as celebrities and trade characters, individuals with health-related experiences such as crash victims and overdose survivors, ordinary real persons, and leaders such as university presidents or government health officials. Although health campaigners conventionally favor certain types of messengers, none is necessarily superior to others in all situations. In selecting the appropriate messenger, the crucial factor is which component of influence model needs a boost. For example, celebrities help draw attention to a dull topic, experts enhance response efficacy, ordinary people heighten self-efficacy, victims convey the severity of harmful outcomes, and victims who share similar characteristics of the audience can help to augment susceptibility claims. Mediated Channels Conceptually, channel selection is dictated by the usage patterns of the target receivers and the nature of the message. Pragmatically, the limited resources of the campaigner also play a role. It’s usually more feasible to stage a pseudoevent that generates news coverage than to acquire time or space in the ideal media vehicle, it’s more feasible to achieve a minor
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Reducing Underage Drinking: A Collective Responsibility designated-driver product placement in an entertainment program than to capture the whole plotline, and it’s more feasible to place a PSA on a low-rated mature adult radio station than a hot teen station. In these circumstances, campaign designers should adapt the message to the channel that can be accessed and the audience that can be reached. Although the practical “take what you can get” philosophy often yields a less than optimal strategy, the tradeoff is that it can actually be implemented. TV spots. In disseminating messages, campaign designers most commonly rely on television spots. This vehicle has the advantage of broad reach and fairly high credibility. However, there are several crucial drawbacks. TV spots seldom can be targeted precisely to audience segments, and the brief format does not allow for in-depth information. Moreover, gaining access to free PSA time slots has become increasingly difficult, so placement of televised spots must rely on cooperation with national networks and local stations, or acquisition of sufficient support for paid time. Public service announcements have long been a mainstay in campaigns to prevent impaired driving. DeJong and Atkin (1995) reviewed the content of nationally aired PSAs during the period of heaviest dissemination in the late 1980s and early 1990s. Less than one-tenth of the spots were directed to youth, and these tended to focus narrowly on the high school prom and graduation occasions. Most of the spots emphasized either awareness of the problem of impaired driving or advocated individual behavior change (more than half promoted the designated driver concept). A remarkable two-thirds of the PSAs featured celebrities as the messenger delivering the content (most of these were network-sponsored messages promoting actors from network series). The spots rarely focused on environmental approaches such as building public support for changes in institutional structures, public policy, or law. Newspapers and TV news. Health campaigners have traditionally underutilized public relations techniques for generating news and feature story coverage in the mass media. Health topics such as alcohol are increasingly central among journalistic priorities for newspapers, newsmagazines, and television newscasts, along with the long-standing interest by specialty magazines and cable channels and by daytime TV talk shows; alcohol campaigns should take greater advantage of these opportunities for message dissemination. Public relations (PR) includes not only the passive distribution of press releases, but aggressive placement of guests on talk shows, provision of compelling story ideas to feature writers, and creative staging of pseudoevents to attract journalist attention (including the dramatization of health-related statistics using “creative epidemiology” techniques). The sponsor-
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Reducing Underage Drinking: A Collective Responsibility ing organization and source messengers of PR-oriented campaign messages are especially important; there is wider media gatekeeper acceptance when sponsored by high-profile and widely respected organizations that feature distinctive or compelling messengers (e.g., celebrity spokespersons, government officials, and charismatic experts who have gained prominence, along with victims and survivors who provide a human interest angle). In achieving impact on the audience, PR messages have several advantages over prepackaged stimuli such as PSAs, pamphlets, and Web sites. First, there is likely to be greater audience reach at a lower cost. In particular, placements in the mainstream media can attract attention from influencers and policy makers, which is useful for indirect and media advocacy strategies. On the other hand, there may be limitations on the frequency of disseminating certain ideas that are considered to be “old news” by the gatekeepers, and it may be difficult to reach key focal segments of youth unless diligent efforts are made to place the messages in alternative channels. Second, messages appearing in the news media (and some entertainment settings) tend to have greater credibility than messages such as PSAs that are packaged in an advertising format; this enhanced credibility should facilitate belief formation regarding health consequences and acceptance of recommended behaviors. Third, health issues gaining visibility in the mainstream news media can benefit from the agenda-setting effect, whereby problems and solutions are perceived as more urgent and significant. This is particularly important in media advocacy strategies targeted to opinion leaders and policy makers. Entertainment-education. The practice of embedding health-related material in entertainment programming (or creating entertainment programming as a vehicle for health education) has become widespread in developing countries (Singhal and Rogers, 1999). Because the interesting and enjoyable style of presentation attracts large audiences and conveys information in a relevant and credible manner, this approach has been quite successful in promoting health in Africa, Asia, and South America. Entertainment-education has been used sparingly in the United States, with narrow applications in efforts to promote the designated driver, safety belts, safer sex, and drug abstinence. An early example of entertaining alcohol education was the Be Smart Don’t Start campaign aimed at predrinkers (Atkin, 1989). A five-minute TV music video (suitable for inserting in Saturday morning programming) and two companion PSAs featured a popular preteen musical group delivering themes relating to health risks, nonuse norms, and resistance to prodrinking peer pressure. However, there have been no subsequent attempts to use this mode for alcohol prevention. Despite reticence on the part of the domestic entertainment industry (and recent controversy in the case of drug-related themes in TV shows), enter-
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Reducing Underage Drinking: A Collective Responsibility tainment-education has considerable promise for campaigns to prevent underage drinking problems. Interactive media stimuli. There are now thousands of Web sites and CD-ROM disks offering a wide array of health materials, and many campaigns are utilizing this channel. Alcohol Web sites have been created for both adolescents and college students. In addition to the provision of prepackaged pages and streaming video, the interactive capacity of these technologies offers a promising advance over standard media messages. Screening questionnaires can assess each individual’s capabilities, readiness stage, stylistic tastes, knowledge levels, and current beliefs, then direct them to narrowly targeted or individually tailored, customized messages that are precisely designed to address their needs and predispositions. Tailoring is particularly useful for social norm correction messages. This approach increases the likelihood of learning and persuasion, and it decreases the possibility of boomerang effects. Furthermore, entertaining interactive formats such as games are particularly well suited for youthful focal segments. Minimedia. Rather than confining strategies to the major mass communication channels, campaigns can broaden the approach to include secondary media such as billboards, posters, pamphlets, flyers, comic books, theater slides, and direct mail newsletters and cards. These modes of communication are especially appropriate for youthful audiences because the messages can be targeted more precisely to focal subgroups that the campaign seeks to reach. Although lacking the glamour of a TV spot or the depth of a fulllength booklet, these forms of communication can serve valuable functions in a campaign at a fairly low cost. The numerous alcohol prevention projects that have used minimedia indicate that campaign designers appreciate these inexpensive but potent channels. Multiaudience media. While certain media channels allow precise targeting, others such as broadcast news and public service spots, newspapers, general interest magazines, and billboards reach broader audiences. Messages in the general-audience media should be carefully designed to include components that will simultaneously influence several distinct audiences, as discussed earlier in the strategic ambiguity section. This approach typically encompasses a combination of fundamental themes, broadly appealing incentives, and multilevel implications in order to hit two or more birds with one stone. For example, a feature story might include elements that will alarm and motivate influencers, warn preusers, and increase fear among those practicing unhealthy behaviors.
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Reducing Underage Drinking: A Collective Responsibility Quantity of Message Dissemination The elusive ideal in campaign design is the magic bullet, where the right message appeal is sent through the right channel to the right target audience with impressive effects. Wallack (1989) refers to this unlikely scenario as the “media fantasy.” In reality, the media function more like a shotgun than a rifle, spraying tiny pellets across broad audiences. In certain respects, this scattershot approach may actually be functional for hitting the moving targets and reaching the evasive quarry; besides, it’s difficult to aim precisely with the modest budget for ammunition. The primary implication, however, is that a large amount of messages must be disseminated in order to achieve meaningful impact. Although not sufficient to ensure success without high-quality content, substantial quantity is almost invariably a necessary condition for effective campaigns. Quantitative factors. A great volume of stimuli is needed to attain adequate reach and frequency of exposure. Moreover, maximum saturation conveys significance of the problem, which is an essential facilitator of agenda setting and heightened salience. Prominent placement of messages in conspicuous positions within media vehicles serves to enhance both exposure levels and perceived significance. To provide a common thread unifying the varied messages, the campaign should feature continuity devices (e.g., logo, slogan, jingle, messenger), which increase memorability and enable the audience to cumulatively integrate material across multiple exposure impressions. Another quantitative consideration involves the scheduling of a fixed number of presentations; depending on the situation, campaign messages may be most effectively concentrated over a short duration, dispersed thinly over a lengthy period, or distributed in intermittent bursts of “flighting” or “pulsing.” Unfortunately, the limited resources available for most public service campaigns greatly restrict the quantity of messages disseminated. Unlike commercial advertisers who can place numerous messages in the media and rely on high-repetition, soft-sell strategies based on principles of mere exposure or other peripheral paths of influence, campaign designers need to achieve the most “bang for the buck” by making each message provocative, involving, and engaging in order to attract attention and facilitate processing. To maximize quantity, campaigners need to diligently pursue monetary resources from government, industry, or association sources to fund paid placements and leveraged media slots, to aggressively lobby for free public service time or space, to skillfully employ public relations techniques for generating entertainment and journalistic coverage, and to utilize the low-cost Internet channel of communication. Moreover, pseudoquantity can be
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Reducing Underage Drinking: A Collective Responsibility boosted by sensitizing audiences to appropriate content already available in the media and by stimulating information seeking from specialty sources. The perpetual campaign. Although campaigns ostensibly have a beginning and an end, the realities of health promotion and prevention often require exceptional persistence of effort over long periods of time. Campaigners can seldom let up because focal segments of the population are in constant need of influence. This is particularly true for underage alcohol prevention campaigns because of the rapidly changing attitudes and behavior patterns of young people, and the constant stream of prodrinking messages from the alcohol industry and drinking peers. Each year, there are newcomers who are moving into the “at risk” stage of vulnerability, backsliders who are reverting to prior misbehavior, evolvers who are gradually adopting the recommended practice at a slow pace, waverers who are needing regular doses of reinforcement to stay the course, and latecomers who are finally seeing the light after years of unhealthy habits. Whether campaigns are aimed at predrinkers, alcohol experimenters, college freshmen, indirect influencers, or even policy makers/implementers, it is clear that one-shot interventions are likely to have minimal persisting impact; campaigns must be sustained, repeated, and updated indefinitely because of the nature of youth drinking. This is clearly demonstrated in the major multiyear trials, where reduction in drinking-related problems typically requires several years of intervention activities—and decay sets in during periods between campaign phases (Hingston et al., 1996; Holder et al., 1997; Perry et al., 1996; Perry et al., 2000). CONCLUSION AND RECOMMENDATIONS The research literature on media-based interventions to address underage drinking problems is extremely meager and narrow. The only significant bodies of studies deal with social norm campaigns on college campuses (which rely heavily on media channels) and comprehensive community interventions (where media tend to play a minor supplemental role). Thus, the chapter devotes considerable attention to promising strategies for designing future campaigns in the alcohol domain. Research and theory of media health campaigns indicates that relatively few messages score exactly on target, although some come close; the perfect message requires greater customization than normally can be attained through mass communication channels. Nevertheless, campaigners keep using the media because the extremely large audiences can be reached efficiently; even if a relatively small percentage are influenced, the small
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Reducing Underage Drinking: A Collective Responsibility impact may translate to millions of individuals practicing healthier behaviors. The odds of success can be improved if more effective strategies are employed in developing and implementing campaigns. This chapter has advocated greater diversification of pathways, products, incentives, and channels beyond the approaches conventionally used in health campaigns. This requires the disciplined formulation of strategies based on careful analysis of the situation, sensitive application of communication theory, and regular collection of formative evaluation information. In particular, the formulation of a comprehensive strategic plan is needed to effectively integrate the optimum combinations of campaign components that will directly and indirectly influence behaviors. Maximizing the likelihood of success requires a greater investment of resources in order to ensure heavy dissemination of media messages, paralleling the money and talent behind drug and tobacco prevention campaigns. The mass media can be utilized most efficiently to address drinking problems on college campuses. Students are widely exposed to campus newspapers and radio stations, and these vehicles can disseminate localized versions of prevention messages that are developed at the national level. The key to success is the creation of more effective persuasive incentive strategies, particularly a greater diversification of message appeals beyond the conventional social norming approach. There is a need to feature a greater variety of reasons to motivate students to drink responsibly, with both positive and negative incentives drawn from the health, social, psychological, and legal dimensions. Social norming messages should continue to play a major role, but there is a need for refining and fine tuning the basic themes and for diversifying the content to include norms related to various student body segments (e.g., females, fraternity and sorority members, freshmen), to protective behaviors, and to social interventions. Moreover, media advocacy techniques should be used in campus newspapers to mobilize initiatives for environmental change, particularly with messages targeted to those who are experiencing negative secondhand effects from excessive drinkers. To combat underage drinking in noncollege settings, a national campaign should be targeted to parents of teenagers and to community leaders, using TV spots, magazine ads, and news publicity items to provide support for localized environmental efforts. Specifically, the campaign would be intended to stimulate parents to prevent drinking activities by their teenagers and to mobilize community efforts to implement policies to reduce access to alcohol. Messages could feature evidence demonstrating the prevalence and seriousness of underage drinking, and efficacy components to bolster the confidence of adults in successfully addressing the problem.
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Representative terms from entire chapter: