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Reducing Alcohol Abuse A Critical Review of Educational Strategies JOHN L. HOCHHEIMER INTRODUCTION Public concern about the control of alcohol abuse by individuals has had varying levels of intensity and focus throughout American history. The zenith probably occurred during the years immediately preceding the passage of the 18th Amendment to the U.S. Constitution' when ad- vocates of temperance placed sufficient political pressure on the federal and state governments to embark the nation on the "noble experiment." Although the overall effects of Prohibition were mixed, the public came to believe that government-mandated abstinence was not a viable policy. To induce people to moderate their drinking behavior, it was thought John L. Hochheimer is a graduate student at the Institute for Communication Research. Stanford University. This paper was written with the guidance of Nathan Maccoby. Director Institute for Communication Research. I would like to thank Judith A. Courtney of McCann-Erickson, Inc., San Francisco; Dean Gerstein of the National Research Council; John Kaplan of the Stanford University School of Law; Robin Room of the Social Research Group at the University of California; John Pierce of the Institute for Communication Research at Stanford University; and Larry Wallack of the Social Research Group at the University of California for their help, comments, suggestions, and patience throughout the construction and various revisions of this paper. For Janet K. Alexander. who is dearly missed. 286

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A Critical Review of Educational Strategies 287 that a program of education was needed to supplement government regulation of alcohol. Many policy makers now perceive alcohol abuse to be a public health problem that requires responsible input from the medical and behavioral sciences. They believe that if the public can come to understand some of the personal and social problems associated with alcohol, this under- standing will modify people's concerns about the consequences of their own alcohol consumption and ultimately change their drinking behavior. This model (knowledge leads to attitude change, which leads to behavior changeK-A-B) has been the foundation of most of the public infor- mation campaigns that have been launched against alcohol abuse. This paper examines attempts to educate people so that they can voluntarily choose healthy alcohol consumption behaviors. Why should we bother with attitudes at all, since what we are really after is behavior change? Have there not been 30 years of attempts to modify drinking behaviors through the mass media with no demonstrable effect (Blanc 1976, Blane and Hewitt 1977, Goodstadt 1978~? Is that not sufficient evidence against an educational approach? The basic premise of this paper is that it is possible for people to consciously choose to change their behaviors if they are effectively ed- ucated. This requires information not only about some of the problems associated with alcohol abuse, but also about how people can change behaviors associated with consuming alcohol. Although it may be true that previous education campaigns focused on various aspects of alcohol abuse have had minimal, if any, effect (Blanc 1976), as this paper shows, their apparent failures were due, not to the lack of viability of the approach, but to insufficient attention to some of the principles of mass persuasion and social learning theory that have been applied with some degree of success in related areas. In brief, the argument is as follows: Many people used to (and still do) believe that mass education campaigns do not work because audi- ences are not interested. But studies show that people will listen and respond if (1) the campaign aims to provide practical education some- thing people believe they can readily use and (2) the campaign operates by means of tested communications principles. In order to set practical goals for mass education campaigns, we need to have a good idea of how people behave and why or how behavior changes with education. "Hierarchies of effects" identified by com- munications theorists provide a series of models of behavior change that may be put into operation and tested for applicability to specific in- stances. These hierarchies involve knowledge, attitudes, and behavior.

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288 HOCHHEIMER Research shows that knowledge and attitudes can be influenced by in- formation programs through the mass media, while a combination of mediated and interpersonal persuasion works best in carrying change through all three levels, thus making the change most likely to stay in force. The Stanford Heart Disease Prevention Program (SHDPP), which this paper discusses in detail, was developed with these principles in mind. The program was based, in part, on McGuire's (1968) matrix of persuasive communication. This matrix, by including receiver and target variables, forces us to formulate a clear picture of who it is that we envision doing (or thinking or feeling) what as a result of the campaign. Principles of social learning and group influence tell us how interpersonal and institutional factors may be organized to reach campaign targets and receivers. The source, message, and channel parts of the matrix force us to envision how mass media can be used to advance these goals. Throughout a campaign, a smooth integration of the design (planning), program (implementation), and feedback (evaluation) functions is cru- cial to success. In examining mass education campaigns aimed at alcohol.consumption behaviors, we see that the absence of design research, good feedback, and clear targets vitiated their effectiveness. When viable objectives for an effective alcohol campaign are compared with other, successful health education experiences (for example, SHDPP and certain behavior mod- ification programs for smoking and weight reduction) the resemblances encourage investment in alcohol education. A properly staged series of projects in which emphasis is placed on affecting both knowledge and attitudes is a sensible step at this time. PUBLIC INFORMATION CAMPAIGNS: THE CLASSIC DEBATE For many years, the prevailing judgment of the social science community was that any public information campaign was doomed to almost certain failure. The literature was replete with campaigns that foundered on the rocks of audience noncompliance, believed to be due to three factors: (1) "chronic know-nothings," (2) de facto selectivity, and (3) selective exposure to new information. Hyman and Sheatsley (1947), in describing "Some Reasons Why In- formation Campaigns Fail," noted that a large proportion of the pop- ulation was not familiar with any particular event, despite the strength ~ Some modest behavioral effects can be initiated through the media as well (see Maccoby and Farquhar 1975 and Maccoby et al. 1977~.

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A Critical Review of Educational Strategies 289 of the messages and the breadth of their distribution. The lack of reaction by such "chronic know-nothings" to the specific messages of the infor- mation campaigns they surveyed was ascribed to "apathy." Hyman and Sheatsley argued that, although the various media disseminating the information (at that time radio, newspapers, and magazines) were ad- equate to ensure the broadest possible coverage, and the messages them- selves were sufficient to have some noticeable effect on the audience, "there is something about the uninformed which makes them harder to reach no matter what the level or nature of the information" (p. 413~. It was felt that the apathy of these people was insurmountable and, most likely, the creators of the messages could do nothing to overcome it. The literature often reports biases in the composition of voluntary audiences of public information campaigns (Sears and Freedman 1967~. This "de facto selectivity" has been noted as far back as Lazarsfeld and his colleagues' classic study (1948) of voting behavior: "Exposure is always selective; in other words' a positive relationship exists between people's opinions and what they choose to listen to or read" (p. 164~. Similar conclusions are reached by Lipset (1953), Schramm and Carter (1959), and Star and Hughes (1950~. Members of the audience who avail themselves of the information disseminated by a campaign were thought to be predisposed to seek information congenial with their existing attitudes. People apparently allow themselves "selective exposure" to new information, filtering it through existing cognitive structures and retaining or interpreting just that information which is congenial and supportive of previous attitudes. If new information conflicts with established beliefs, no message may be able to motivate the desired behavior change (Cartwright 19494. Klapper (1960) concluded that the mass media changed attitudes minimally and functioned primarily to reinforce previously held views. As recently as 1976, in evaluations of the "Feeling Good" television series (Swinehart 1976) and of campaigns to persuade people to use seat belts (Robertson 1976), social scientists still argued that people will not learn and that the reasons for the communicators' failure to persuade resided within the individuals themselves. The focus has not generally been turned around on the producers to find out whether poor message construction, poor use of the media' or inadequate evaluation proce- dures might have been the true culprits. Sears and Freedman's (1967) reanalysis of data, however, from some of the previously mentioned campaigns found the case for de facto selectivity and selective perception of information to have been greatly overstated. For example they show that in the Lazarsfeld et al. (1948) study, looking at the data from one perspective, only the Republicans

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290 HOCHHElMER had been selectively exposed, while viewing it from a different per- spective, only the Democrats had been selectively exposed. A reanalysis of data from a massive campaign in Cincinnati to "sell" the United Nations (Star and Hughes 1950) shows that education, not previous orientation, was the best predictor of who got the most from this cam- paign. Selective exposure may exist, but it is only one explanation of the campaign effects. Sears and Freedman found similar flaws in the assumption that people prefer only new information that agrees with their existing predisposi- tions. They cite five studies showing some preference for supportive information, eight studies showing no preference, and five studies show- ing preference for nonsupportive information. They concluded that "the available evidence fails to indicate the presence of a general preference for supportive information" (p. 208~. Sears and Freedman did find evidence that people prefer information that they expect to serve a practical purpose as opposed to less useful information. Past history of exposure to a particular issue being pre- sented was also found to be a significant factor. Their work supports the view that education, information utility, and previous exposure are only three of many factors that interact to influence people involved in any campaign. Mendelsohn (1973) goes further, arguing that discussions of the failure of public information campaigns have focused on the deficiencies of the audience to explain the presumed lack of effect, rather than on the creator of the message, the content, or the media. "With rare excep- tions," says Mendelsohn, "mass communications researchers have been documenting and redocumenting the by now obvious fact that when communicators fail to take into account fundamental principles derived from mass communications research, their efforts will be generally un- successful.... In short, very little of our mass communications research has really tested the effectiveness of the application of empirically grounded mass communications principles simply because most com- munications practitioners do not consciously utilize these principles" (p. 51~. He suggests that those involved in all phases of campaigns work together in the planning, implementation, and evaluation of campaigns in order to incorporate principles of communication effectiveness de- rived from research. In this way, those who create the campaign can come to understand and use social science principles, while social sci- entists can realize some of the constraints, norms, legal requirements, etc. of those who work regularly with the media. The "National Driver's Test" is an example of this kind of effective

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A Critical Review of Educational Strategies 291 integration. It had been established that most drivers tended to ignore the more than 300,000 messages disseminated each year about bad driv- ers, since ~ in 10 considered themselves to be good drivers (Mendelsohn 1973~. A new approach was necessary to overcome this indifference to traffic safety messages. Viewers would be given the opportunity to be- come aware of possible deficiencies in their driving behavior and would be given information on how to correct the deficiencies they discovered. A TV program was created with three specific objectives: (1) to over- come public indifference to traffic hazards that may be caused by bad driving; (2) to make bad drivers cognizant of their deficiencies; and (3) to direct viewers who became aware of their driving deficiencies into driver improvement programs in their respective communities. Men- delsohn notes that not only were the objectives realistic and specific, but they also lent themselves to objective post hoc evaluation. A massive national publicity campaign for the program was mounted. The program aired on the CBS television network prior to the Memorial Day weekend, when concern for traffic safety was greater than usual. The results were impressive. Over 30 million people watched the program (making it one of the highest rated public affairs programs to that date). Subsequently, CBS received mail responses from almost 1.5 million people. Of greatest interest is that, according to the National Safety Council, about 35,000 people enrolled in driver improvement programs shortly following the telecast. This represented an estimated threefold increase over previous annual enrollment. Those involved with the National Driver's Test concluded that in- novative programming, assisted by adequate promotion, can whet the public's appetite for useful information, overcoming the alleged apathy. Also, it is apparent that reasonable goals are amenable to rigorous evaluation and effective accomplishment. We know that it is possible to wage an effective campaign for public education through the media. What is known about the effectiveness of campaigns aimed specifically at alcohol abuse, however, is "for the most part . . . highly tentative" (Blanc and Hewitt 1977, p. 15~. ALCOHOL ABUSE CAMPAIGNS The same factors generally found by Mendelsohn (1973) to characterize ineffective public education campaigns permeate campaigns about al- cohol as well. Haskins (1969), for example, reviewed studies on the development and evaluation of mass mediated campaigns aimed at drinking and driving (among other safety campaigns). He found the

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292 HOCHHEIMER research on which campaigns and their evaluations were based to be scanty. The formative research2 that was available relied solely on lab- oratory experiments and verbal measures. Evaluative studies were found to lack control groups and statistical analyses. He found that the message strategies relied heavily on negativistic, threatening fear appealsan approach that may not necessarily be the most successful.3 Haskins reaches the same conclusion as Mendelsohn: campaigns should make "systematic use . . . of known communications research, accompanied by appropriate pre-testing research at various stages of the development process" (p. 65~. Concerning the formation of alcohol abuse campaigns, only two areas have been studied (Blanc 1976~. One seeks to ascertain how receptive different segments of the potential audience would be to various mes- sages pertaining to alcohol use. The National Highway Traffic Safety Administration (NHTSA) tried to assess the extent and conditions of adolescent and adult involvement with alcohol. Those involved in social or business occasions in which alcohol was served at least once in the last 3 months were considered at highest risk for being in a drinking- driving situation: they comprised 54 percent of adults, according to the study. Of these, 43 percent (about 23 percent of the total sample) felt that they may have been driving while intoxicated once in the previous year. Of these people, 75 percent had taken some action to prevent the situation from occurring. From survey data, Grey Advertising (1975a) was able to identify and classify four basic groups according to the degree and nature of coun- termeasures they were willing to perform to evade or prevent drinking and driving. "Social conformers" are primarily upper-class persons who would take the least obtrusive actions (e.g., serving food at parties and/ or driving intoxicated guests home). "Cautious pre-planners" tend to be older women of lower socioeconomic status (SES) and are more likely to prevent drinking and driving. "Legal enforcers" were found to be older, middle-SES people who would be likely to use legal coun- termeasures, such as calling the police, as a way of attempting to prevent intoxicated people from driving. "Aggressive restrainers" tend to be younger men who would be willing to physically restrain their friends from driving under the influence of alcohol. In their first evaluation of the formative data, Grey Advertising 2 Early informal measures of effects that can be used to plan future messages, channel strategies, etc. 3 Only under certain conditions is strong fear arousal the most effective use of fear appeals (Chu 1966~.

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A Critical Review of Educational Strategies 293 (1975a) recommended that instead of using a shotgun approach to their campaigns as they had done in the past, NHTSA would do better to aim at drinking adults, rather than the entire population. They further recommended that NHTSA develop different strategies to sanction giv- ing and receiving help in alcohol-related situations for "social conform- ers" (motivating conformity) and "aggressive restrainers" (motivating friendship). In a second evaluation, Grey Advertising (1975b) suggested a basically similar approach for adolescents. NHTSA messages should be aimed at drinking youth as well as those adults in a position to influence them. Grey also advised that alcohol-related messages should attempt to es- tablish a peer group norm that to-give or receive aid when one is impaired by alcohol is acceptable behavior. In another study, the Addiction Research Foundation utilized sample surveys in Ontario, Canada, in 1975 to find how much concern there was about alcohol-related problems and what remedies the public per- ceived to be adequate (Gillies 1975, Gillies et al. 1976a,b,c). A "Social Policy and Alcohol Abuse Survey" was conducted in order to "ascertain the attitudes of a cross-section of Ontario adults toward existing and hypothetical regulatory measures related to the use of alcohol" (Gillies 1975, p. i). In general, the survey discovered a high degree of concern about the incidence and consequences of alcohol abuse and a variety of opinions about what should be done about it. There has also been some formative research on the development of messages for alcohol-related campaigns. Flynne and Haskins (1968), for example, wanted to find out if the statement of behavioral intention (confidence in driving after drinking) was indicative of actual willingness to perform the behavior. With such knowledge, campaign evaluations could be designed to determine whether messages aimed at reducing the unwarranted confidence of an intoxicated driver in his or her ability to drive were successful. Flynne and Haskins found that real-world obser- vation (rather than laboratory testing) of drinking behavior was nec- essary for effective pretesting of messages. Real-world driving behavior differed significantly from behavior manifested under experimental con- ditions; hence, any means of measuring the effects of the campaign other than direct observation of real-world behavior would be invalid. This finding applies to a program that was designed to eliminate indifference about drinking-driving messages; it resulted in the film, "A Snort History." The didactic approach that had characterized most such messages was avoided, because tests had shown that high-fear appeals had a boomerang effect. The 6-minute film told how alcohol affects judgment in that drinkers tend to become more optimistic about

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294 HOCHHEIMER their driving ability precisely when pessimism would be more prudent (Mendelsohn 1973~. Of those viewers tested, 43 percent reported the film left them feeling concerned about the effects of alcohol on driving; 30 percent said that they would consider changing their ideas regarding safe driving (Men- delsohn 1973~. Real-world observation would determine how much of this cognitive shift converts directly (without further trainings into changed behavior. Admittedly, these are less positive results than those from the "Na- tional Driver's Test." "A Snort History" does show, however, that information can be transmitted through different media with some pos- itive effect, holding the attention of the audience while getting the mes- sage across. (In fact, the quality of "A Snort History" was good enough to have it placed as a short subject in a Denver first-run motion picture theater, where it was not subject to diffusion of impact by conflicting messages.) There may be a study or two that further refines what has been determined by these studies; aside from what has been presented here, however, there has been no further analysis of to paraphrase Lasswell what do you want to say to whom, how effectively do you want to say it, and through what channel. Several assessments of program evaluation techniques (Douglas 1976, Driessen and Bryk 1972, Kinder 1975) have criticized the lack of meth- odological rigor. Some of the problems mentioned are: overly simplistic before-and-after designs; inability to control for confounding factors; the use of a variety of techniques in one campaign so that the effects of any one could not be singled out; and failure to consider the possible impact of a Hawthorne effects among people being studied. Blane (1976) found that few evaluations of public education campaigns related to alcohol abuse have been methodologically sound. Typically, a simple before-and-after design is used to assess changes in attitudes, knowledge levels, and behavior of a target audience. Changes are at- tributed to the intervention of the campaign, but due to the typical lack of control groups in the experiments, conclusions are weakened because of unmeasured factors that may have confounded the results. Blane and Hewitt (1977) have listed the following deficiencies in cam- paign evaluation strategies: , ~ . - -O' (1) Lack of integration of evaluation into the overall campaign design, which prevents a symbiotic relationship between evaluators and design- ers of the campaign. A two-way flow of information is necessary so the 4 Enhanced desirable behavior because of the knowledge that one is being observed.

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A Critical Review of Educational Strategies 295 program can be developed based on what is known from research and so feedback from the evaluative process can guide future refinement of the campaign. (2) Lack of sufficient precampaign testing of message content and appeal, which should be conducted with suitable samples from within the target audience. They make the following recommendations for improvement: (1) Statistical analyses of results rather than merely reporting before- and-after percentages of variables as being something meaningful. (2) Close coordination of campaign objectives and evaluation design. (3) Long-term evaluation to assess other than immediate campaign effects. (4) Use of unobtrusive and nonreactive measures. (5) Determination of actual exposure of the target group to the cam- paign as well as correlation of these data with data concerning changes in attitudes, knowledge, and behavior. (6) Attention to determining the possible negative, counterproduc- tive side effects of the campaign. Given the lack of both formative research and sufficient evaluation it is no wonder that previous public education campaigns aimed at re- ducing the incidence of alcohol abuse have had such inconclusive results. Proper use of the mass media for effective dissemination of messages is a multifaceted process that requires a great deal of planning, evalu- ation, and willingness to replan during the campaign if necessary. I have shown that an integrated approach can be helpful in certain campaigns. Rather than focus on other alcohol-specific campaigns to see how they might have been changed to be more effecive, I next review the elements of a well-designed campaign and what can be done to best implement them. I pay particular attention to health-related campaigns in which these factors have been manipulated to advantage. THEORETICAL PRINCIPLES OF BEHAVIOR CHANGE MODELS OF EFFECTS If we have learned anything from the experiences of those who have attempted to implement campaigns in the past' it is that good intentions and the utmost earnestness of convictions are insufficient catalysts for engineering meaningful change in behavior. We have had no adequate

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296 HOCHHEIMER way of determining whether previous educational strategies were ap- propriate, as good research designs for evaluation are "a recent and still rare phenomenon" (Blanc and Hewitt 1977, p. 15~. Similarly, there has not been a rigorous application of the principles established by either social scientists in general or communciations scholars in particular. Despite Mendelsohn's contention that it was the neglect of these prin- ciples that proved to be the undoing of much of the public information campaigns of the past, Blane (1976) reminds us that "the potential benefits of applying social science theory and methods to an understand- ing of the conditions under which public information and education messages (about alcohol use) are most effective in attaining social goals have been little explored" (p. 540~. So, if using what is known can be effective (Mendelsohn 1973), and if previous campaigns aimed at mod- erating the use of alcohol have not utilized what is known (Blanc 1976, Blane and Hewitt 1977, Goodstadt 1978, McGuire 1974), then there has not been an adequate implementation of communications principles (coupled with equally rigorous evaluation) to determine whether a well- conceived public education campaign to moderate the abuses of alcohol might have more positive results. I consider in this section an integrated community organization plan as a model for the dissemination of in- formation about how to moderate alcohol-related behaviors. The use- fulness of the model depends on the extent to which mass media, existing networks of social organization, and specifically created face-to-face instructional facilities are integrated. All the knowledge necessary for the immediate mass implementation of such a campaign with a guarantee of success is not currently available. What follows is a set of guidelines based on the most promising research on how to implement a com- munity-based strategy of health education. Such a program is likely at least to provide deeper insight into how to more successfully counteract alcohol-related health problems. The Stanford Heart Disease Prevention Program 3-Community Study, described in detail below, is an example of a successful community-based health education program. The theoretical model for the 3-Community Study was based on the work of Cartwright (1949~. He argued that for mass education to be effective, three kinds of changes must occur: changes in cognitive struc- tures (what people know), changes in affective structures (what people want to do), and changes in action structures (what they actually do). The cognitive component (which includes attention, knowledge, infor- mation, belief, awareness, comprehension, learning, etc.) refers basi- cally to how the focus of attention the "attitude object" is perceived. The affective component (including conviction, interest, desire, yielding, evaluation, etc.) pertains to a person's subjective like or dislike of the

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A Critical Review of Educational Strategies 325 specific data. The ratio of alcohol-related behavior to total behavior (neither is defined) in dormitories (Amherst, Massachusetts, project) evidently decreased from spring 1977 to fall 1977, but insufficient data are supplied with which to make a proper evaluation of this finding. It would appear that this program holds a great deal of promise in principle, since a well-integrated mass-media and group-counseling ap- proach is used. The major problems at this time appear to be that the questionable reliability and validity of the data hinder inferences about alcohol-related behavior change; the program has not been implemented for a sufficient amount of time for a meaningful assessment of behavior change; and the absence of a control group design makes it difficult to interpret the significance of the data that are reported. Those who wish to mount campaigns with the ultimate goal of chang- ing behavior must be willing to invest more than 6 months before de- ciding the success or failure of their efforts and to stay cognizant of the quasi-experimental nature of their effortsand hence the need for use of quasi-experimental design features as development of controls. As the Stanford Heart Disease Prevention Program's 3-Community Study showed, unlearning old behaviors (which may have taken years to de- velop) by replacing them with new ones is a process that will, in all likelihood, take a long period of time and require careful design in order to demonstrate effects. In brief, on the basis of general principles, the two projects from Massachusetts show the most promise. For example, student peers make credible, trustworthy sources to disseminate messages and to lead group discussions. The University of Massachusetts program uses small-group approaches led by trained peers to provide positive social situations for discussing alcohol and behavior. This combines the use of trustworthy, credible peers with the beneficial effects of the open participation of people in small, interactive groups. The CASPAR program also makes use of peers to disseminate information and lead group discussions. They differ greatly from the formal classroom situation (used in King County), which does not lend itself to frank discussions, peer assistance, or meaningful problem solving. Teachers may not be seen by students to be trustworthy sources of information, since an adversary relationship frequently exists between students and faculty. Furthermore, the reli- ance on a self-reports of alcohol use administered by teachers may be seen by students as a tactic to catch them engaging in a proscribed activity. This may heighten the lack of trust, which will not help to modify the problem. The reliance of the University of Massachusetts program on FM radio indicates the recognition by program planners that the use of television

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326 HOCH H EI ME R for information and entertainment is not ubiquitous. Rather, college students tend to rely more on radio than television (Comstock et al. 1978) than does the average person. In a college community that is not within a major metropolitan area (such as Amherst, Massachusetts), student participation in as well as the use of college radio may be quite substantial. This may be true of similar campus communities; it can easily be ascertained through a preintervention survey. There is insufficient evidence in NIAAA's reports of how closely these programs adhere to all the principles described in this paper. That would require minute descriptions of, for example, the procedures by which the usefulness of sources used was determined vis-a-vis their availability to program planners; the subjects' media use vis-a-vis the funds, facil- ities, and expertise available; and the usefulness of the programs versus the nature and extent of the target population's alcohol use. Rather than serve as a scorecard for NIAAA or other programs, this paper should serve as a guide to those implementing these and future programs in the creation of present and future interventions, taking local factors into consideration. STEPS FOR CONSTRUCTING A CAMPAIGN Ideally, the goal of a health intervention campaign is to change behavior in the direction of a healthier life. While laudable, such an undertaking is beyond the scope of the mandate, knowledge, and resources of this panel, even if we could predict a very high rate of success. We have to set our sights somewhat lower. Summarized below is a set of general guidelines for the implementation of a campaign to change health be- havior specific to alcohol abuse. First, clear and specific objectives must be set. What do we want to produce? To train adolescents in the judicious use of alcohol? To reduce the number of drunken drivers on the road? To train parents so that fewer of them will abuse their spouses and/or children? These are just three behaviors associated with alcohol abuse. Each is different and involves somewhat different populations, patterns of mass media use, messages, sources, etc. Each target behavior has a distinct impact on the costs of the project. The campaign's objectives determine the costs. To simply try to make people aware of certain slogans in a given community over a given length of time, a certain budget level may suffice (Wallack 1979~. If, however, the goal is to teach chronic abusers of alcohol to diminish their level of problem behaviors 10 percent, the cost factor will be much higher. The more comprehensive the goals, the higher the cost.

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A Critical Review of Educational Strategies 327 The next step is to decide how the knowledge, attitudes, and/or be- haviors associated with drinking should be changed and how to measure those changes. For example, do we propose to influence attitudes of others toward drunk drivers? To influence the drinking driver to stay off the road? Or to seek long-term help? Do we want to suggest that people think more negatively about intoxication? Will we advocate less frequent drinking to intoxication? Do we wish to eliminate intoxication per se, or to neutralize certain of its effects? Each goal requires a different strategy as well as different baseline measures and different outcome measures. Establishing interim criteria for success or failure is the next step. They will indicate whether and when we must "go back to the drawing board," and how drastically we must redesign. The criteria should entail a causal model of anticipated campaign effects, including the difficulties of each step. Where do we begin to test our program? Each locality has unique qualities: the population is somewhat different and the particular levels of alcohol consumption (as well as associated problems) may differ. In the field of marketing there are certain citiessuch as Columbus, Ohio, Phoenix, Arizona, and Portland, Oregon that manufacturers routinely use to test new products. They are usually chosen because they have demographic cross-sections that very closely match the U.S. population as a whole. In addition, they are isolated media markets, i.e., the local mass media have no direct competition from the media of other markets.6 This allows for greater experimental control of the target population's media input. In these larger cities, however, media and other costs are high. The Stanford Heart Disease Prevention Program 3-Community Study was conducted in towns with populations of less than 15,000 (Tracy, Gilroy, and Watsonville, California). Operating costs are much lower in these areas and their relative isolation made for easier experimental manip- ulation and monitoring. Each of the foregoing steps requires the expertise of people from various disciplines. As Mendelsohn (1973) recommends, research-ori- ented behavioral and social scientists, evaluation planners, and those experienced in working with the media and community organizations should collaborate in the implementation of the intervention. Involvement of these kind of experts is especially important in con- structing the baseline evaluation. Questions should be constructed with 6 Such as Newark, New Jersey, which has competition from New York newspapers, radio and television stations.

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328 HOCHHEIMER an eye to their relevance to the outcome goals. The baseline survey should seek to determine certain social and demographic characteristics of the target population. The credibility and usefulness of various sources, messages, and media should be ascertained. Will the people assemble in groups? What kinds of groups will they (not) attend? How regularly? Will they participate on their own? How likely are their family, friends, and/or work associates to be supportive of their partic- ipation in the program? What types of media do they generally rely on for information? For entertainment? This information need not be obtained solely by obtrusive means. For example, in several localities the names of those convicted of driving under the influene of alcohol can be obtained through police records. This minimizes a major cost since part of a target population could be readily identified. One can carry out the baseline survey with these people without telling them why they have been singled out. Although these people may have a greater vested interest in drinking-driving coun- termeasures, stigmatizing them as alcohol abusers should be avoided since their cooperation in the program is essential. The next step, once the baseline data have been gathered and ana- lyzed, is to plan a small-scale, rough draft of the campaign. This can be done fairly inexpensively. This prefield test is a good way to find out how effective, convincing, and credible the proposed messages and sources are. For example, in the Stanford Heart Disease Prevention Program, the "Heart Health Test" was tried out in a shopping center. This generated a lot of excitement among patrons; the study elicited responses from a good cross-section of the community because many people wanted to participate. Proper planning can make this kind of intervention fun for the community and useful for program planners. Evaluate the results of the prefield test. Which messages were found to be credible? Which were not? Were people interested in the goals of the campaign? If not, what could be changed to generate more interest or more public commitment? At every step in the process, evaluations should incorporate new information that may change the premises on which decisions are based. Any campaign plan should be based on the best evidence from previous experience. Each new campaign should generate new data to help refine the techniques and understanding of how to affect human behavior. Once the evaluations have been made, planners should compare the outcomes with the initial objectives and continue to make modifications in strategy as the evidence warrants. Concurrently, there should be an assessment of the social organiza- tions in the local community to see how helpful they can or want to be

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A Critical Review of Educational Strategies 329 to the goals of the campign. Usually, there must be some training of the personnel in the various techniques of the modification of the target behavior. If no such organizations exist? they may have to be organized by the program planners. Once the messages, sources, strategy, etc. have been well designed and tested, the campaign can get under way. CONCLUSION It was once believed that, of the masses of people who consume a lot of television, radio, newspapers, etc. every day, many, perhaps most of them, were impervious to any educational information carried by these media. It was slowly discovered that people can be educated to change their behavior if the right information is properly presented. What this required, primarily, was a lowering of goals, careful preplan- ning, judicious use of mass media (frequently in conjunction with com- munity-based counseling programs), and adequate concurrent, as well as post hoc, evaluation procedures. The Stanford Heart Disease Prevention Program was shown to to be effective on a limited basis. A similar program is now in the formative stage of testing to see whether such a program will work in larger com- munities in California and in Finland and Australia. The results will produce more evidence on how to educate people to be more aware of their well-being and how to act to lower their risk of a variety of dis- orders. This paper has argued that an equivalent strategy has never been attempted to combat alcohol abuse but, given proper application and enough time, it may be a viable approach. This paper does not advocate an all-or-nothing approach. Regulation of alcohol consumption and sale could be more effective if coupled with a properly planned program of public education. If laws are passed regulating people's alcohol behaviors but are not accepted by the public, enforcement will be much more difficult. If, however, the law is sup- plemented with community-based education programs founded on sound principles derived in the social sciences, then the changes for compliance and the reduction of the abusive behaviors will be greater. A concerted effort to affect such behaviors as alcohol abuse is a complex, long-term, expensive task. The evidence argues against beginning an intervention before investing considerable time, money, expertise, and patience in the project. Alcohol abuse campaigns that are formulated with little thought for implementation increase public cynicism and ap- athy; such campaigns may act to inoculate many people against well- planned programs in the future.

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