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CHAPTER 9 A Public Information Program The federal government has long sponsored public information efforts directed to pregnant women. A basic premise of these campaigns has been that more informed mothers would take better care of themselves and thereby increase their chances of delivering healthy babies. In recent years, the materials and media messages that constitute these public information efforts have increased in number and sophistication. The committee believes that public information programs can contribute to the prevention of low birthweight. Such campaigns can help create a climate in which change and progress are possible, in addition to conveying specific types of information. This chapter descr ibes several elements that characterize successful campaigns and sketches the outlines of a public information program directed specifically at low birthweight prevention. The chapter concludes with a discussion of the Healthy Mothers, Healthy Babies Coalition. Conditions For Success A growing body of research suggests that public information programs can help achieve change in health-related behaviors, but their success depends on a variety of interrelated conditions. Social Support Perhaps most important, a public information program must enjoy wide social, political, and scientific support. A1SO' it should be part of a spectrum of related activities throughout society, not an isolated effort. Two public health issues--smoking and childhood immunization-- illustrate these fundamentals. The intense public information program on smoking and health that began after the first report to the Surgeon General in 1964, although contributing greatly to the success of this nation's effort to curtail cigarette use, was only one part of a broader strategy that included scientific research, legislation and regulation, and public debate.2 The decrease in American smoking prevalence since then is attributable in some part to all of these 202

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203 interrelated efforts, and probably cannot be credited solely to the public information campaign. Similarly, the effective childhood immunization initiative of the 1970s included a widespread public information program aimed at parents and children, but it also was built on solid scientific agreement that childhood immunization was effective and free of substantial risk, on state laws requiring proof of immunization in order to attend school, and on the easy availability of vaccines and services. 3 Scientific consensus must form the basis of public information programs designed to change behavior in health. Public disagreement among experts leads to confusion and less inclination to change behavior. For example, in 1980, the American Cancer Society, reacting to the Canadian Walton Commission Report on how frequently Pap smears should be obtained, recommended that after two negative smears, a woman could space future Pap tests 3 years apart. The American College of Obstetricians and Gynecologists reacted with a scientific opinion that disputed this stand and called for yearly Pap tests. The public was lef t confused.4 The success of an information program also depends on the availabil- ity of necessary services and resources to back up the campaign message. It is futile to urge immunization or prenatal care in the absence of easily accessible facilities to provide such services. Consistency of Effort Public information programs designed to change people's behavior must operate over an extended period with a fairly consistent and reinforcing set of messages.2 s There Is little likelihood, except in rare circumstances, that changes will be swift or dramatic; thus, small changes over time must be recognized as signs of success. Private advertising builds product acceptance through consistent reinforcement over time of product identity, which is intended to lead to increased use of the advertised item. 6 Millions of dollars are spent in long-term advertising campaigns to achieve small, incremental changes. For example, low tar cigarettes, which had a negligible share of the market in 1967, are the market leaders today.7 In the field of health, as In the commercial world, incremental changes in behavior signal progress, particularly if sustained over several years.2 use of Multiple Mass Media Long-range strategies to influence behavior change should take advantage of multiple media. Communicating a health message by means of only one medium limits the size of the audience. Thus, radio music shows may be the best way to capture the attention of teenagers, while television soap operas may be the preferred channel to reach housewives. The importance of using multiple media, each of which reinforces the messages of others, is emphasized in the literature about marketing

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204 family planning programs. In many of these programs, promotion to consumers typically includes advertising through the mass media, point of purchase promotion, face to-face salesmanship, and special events or other techniques to attract media coverage and improve public accep- tance. For example, in the 1970s, a successful marketing campaign in Sri Lanka helped increase use of a brand of condoms named "Preethi,. or "happiness." The sale of the condoms was supported through a mass media campaign including newspapers and radio ads, f ilms, and a booklet entitled Chow to Have Children by Plan and Not by Chance." Point of purchase displays were provided to the distr ibutors. the entire campaign, Preethi sales rose from 300,000 1974 to an average of 500,000 a month by 1977 en Audience Definition and Message Development As a result of a month in July Public information campaigns should begin with an explicit definition of audience. Sometimes, nearly the entire population is the target audience, as in many seatbelt campaigns. More often, a subgroup is the campaign focus--teenagers, smokers, the elderly, and so forth. Campaign messages must fit the defined audience. Messages designed to attract attention and motivate behavior change In particular target groups must be developed carefully and market tested to ensure their appeal to those groups. For example, through careful market research, the Healthy Mothers, Healthy Babies Coalition developed a series of posters and matching cards for distribution through clinics, WIC programs, and other places where higher isk groups receive prenatal care and information. The posters featured fantasy themes with beautiful women and healthy children in dreamlike settings. Because the presentations were deliberately outside the target women's day-to-day experiences, the posters and cards were subjected to pretests at clinics in several locations to see if they would be acceptable. These tests showed that the materials appealed to the test groups; almost 100 percent liked something about the posters, and 90 percent indicated that the posters were "eye catching.. Few respondents reacted negatively to the fantasy concept or felt that the posters were for someone unlike themselves. The recall and understanding of the messages were high.9 The posters and cards, used by more than 8,000 clinics, achieved widespread accep- tance by clinic populations, even where the clinic staff and profes- s locals had doubts about their acceptability. The public service announcements (PSAS) developed by the Office on Smoking and Health during the past 5 years have employed different messages for specific subsets of the general audience. A set of PSAS featuring Star Wars robots was aimed at children to reinforce the message that smoking is an unhealthy practice. For the teenage target audience, announcements featuring a rock group and an antismoking song were developed for use on rock programs to convey the message that smoking is not ~ in. n Other PSAs, featuring a conversation with the O.S. Surgeon General, were directed at the general adult audience to r einforce the message that smok ing increases the r isk of cancer, heart

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205 disease, and other health problems. Each message was aimed at a well-clef fined audience and tailored to attract the attention of that group. Messages also may get attention by surprising or shocking the audience.5 In the 1970s, the British Health Education Council developed a poster featur ing the prof Ale of a nude and obvious! y pregnant woman who was smoking. The poster achieved instant attention and notoriety. ItS message was simply, "Is It Fair to Force Your Baby to Smoke?" The poster and additional text triggered a greater than expected drop-off in smoking among pregnant women, a much higher message recall than normal, and a significant change in behavior that carried over after pregnancy.~ Quality of Mater ials one element that unfortunately receives limited attention in many health information programs is the quality of the materials and messages. Too often this lack of attention is the result of limited budgets for entire programs, of which the public information element is often only a small part. IN is especially important that mater ial developed to change health attitudes and behavior be of high, professional quality. Without this quality, some of the credibility of the message may be lost on the target group. A Public Information Program on Low Birthweight Prevention With these principles in mind, the committee considered the merits of a public information program in the United States directed at low birthweight prevention. It concluded that such a program would be useful and would complement the other strategies outlined in this report. In the sections below, some elements of such a program are outlined . Program Objectives and Audience A public information initiative directed at low birthweight prevention should be built around at least two objectives. The first is to call the problem of low birthweight to the public's attention and to reinforce its importance with the nation' s leaders. This objective is partially achieved through the release periodi- cally of major reports by various public and private organizations. Reports such as Healthy People, the Report of the Select Panel for the Promotion of Child Health, the Surgeon General's Workshop on Maternal - and Infant Health, the annual report by the Public Health Service,_ Health: United States, and reports from advocacy groups such as the Children' s Defense Fund r all have called attention to the national significance of low birthweight. These reports, aimed at the nation's opinion leaders, are major resource documents for administrators,

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206 planners, and legislators. Media representives, too, find such reports useful in developing general interest stories that give high visibility to the problem of low birthweight. Reports compiled and disseminated by the federal government often receive particularly widespread attention and therefore are excellent vehicles in which to define the problem and suggest preventive strategies. The committee recommends that the Office of the Assistant Secretary for Health develop and publicize a report every years on the nation's progress in reducing low birthweight. The report should explore relevant data, trends, and research that could contribute to easing the problem, and should describe successful programs completed or under way to reduce the incidence of low birthweight. The develop- ment, presentation, and dissemination of the report should be managed to reach as many concerned groups and individuals as possible. Additionally, the statistical profile of the nation's health developed by the National Center for Health Statistics, Health: United States, periodically should include a special supplement or profile on low birthweight and its prevention. The second objective of a national public information campaign should be to help reduce low birthweight by conveying a set of ideas to the public generally, with specific messages tailored to high-risk groups. The balance of this chapter is addressed to this second ob jective. The committee considered carefully whether a public information program should focus on only a few target groups and again reviewed the r isk factor and epidemiologic literature in this regard. Because many of the risk factors for low birthweight are widely distributed throughout the population, and because a substantial amount of low birthweight occurs among women judged to be at low risk, the committee concluded that the program should embrace a broad audience. At the same time, a subset of messages should be developed to reach several well-defined groups known to be at high risk of low birthweight-- pregnant smokers, young teenagers, and poor, socially disadvantaged women. The latter two groups in particular often live in environments in which health information is scant, health matters are of low priority, and motivation to plan for a healthy pregnancy is lacking. Any public information campaign designed to reduce the incidence of low birthweight should focus on the partners, spouses, boyfriends, and families of women, as well as the women themselves. Such individuals can play an important part In providing the support necessary to help women plan for pregnancy and undertake difficult behavior changes, such as reducing smoking or altering eating habits.S Messages A public information initiative directed at the prevention of low birthweight should have two themes, (1) planning for pregnancy and (2)

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207 adopting good health practices in the childbearing years, especially during pregnancy. Messages based on these themes should be supplemented by others that call attention generally to the implications of low b~rthweight. Some message topics are noted below; actual wording would require careful development and market testing: the problem of low birthweight--even in a society devoted to thinness, it is important that babies be born of adequate weight; the many benefits of planning for pregnancy and related family planning concepts; the r Asks of smoking in pregnancy; the benefits of good nuts itzonal practices before and dur ing pregnancy; the risks of both moderate and heavy alcohol use In pregnancy (and substance abuse generally); and the Importance of obtaining prenatal care and beginning such care early in pregnancy. Information Channels According to the market research performed for the Healthy Mothers, Healthy Babies Coalition, the channels for relaying these messages that offer the best chances of reaching two of the groups mer iting special attention--teenagers and poor, socioeconomically disadvantaged women-- are: (1) clinics where women from these groups often go for prenatal care, (2) WIC program offices, (3) schools, and (4) selected media. Family planning clinics are an additional locus for presenting these messages. Prenatal care and family planning clinics provide a captive audience that visits frequently, typically for a substantial amount of time. Suitable films, videotapes, posters, and publications should be made available in the clinics themselves to capitalize on this opportunity. Similarly, clinic staff should build the recommended messages into their health education and counseling activities. WIC program workers, who are often reported to have good relation- ships with their clients, appear to be in a good position to influence behavior. Most women who have direct contact with WIC have high regard for its staff services. This favorable environment should be exploited for relaying campaign messages. Schools are a natural setting for communicating impor tent health education and information themes to all young people. In Chapter 5,. this topic is discussed in greater depth. Undoubtedly, the mass media offer tremendous opportunities for reaching pregnant women. Television, in particular, has come to dominate our lives. Ninety-eight percent of all households in the United States have at least one television set. The average TV household views an estimated 6 hours and 26 minutes a day, with Sunday night as the most popular viewing time and situation comedies as the most popular type of program during prime time.~3

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208 Mindful of the pervasiveness of television, many groups have tried to use this medium as part of public information efforts. Because paid advert' sing is beyond the financial capability of most public infor- mat~on campaigns, and because of certain legal restrictions, most campaigns rely on PSAs, the traditional way to present public interest health messages on television. Unfortunately, the cost of production, the competition for air time, and the small likelihood of good placement and repeated airings often make this approach impractical and unattrac- tive as the prime effor t in a health promotion campaign. Integrating health-related messages into the story lines of certain television shows, such as soap operas, also has been proposed as a way to influence behavior . The committee f inds this intuitively appealing and urges that its merits be explored, particularly given the fact that many high-risk women belong to groups that are known to watch daytime television . I f the cooperation and co ~ Patient of network programming executives could be obtained, it might be possible to launch an effort to alert target groups to the set of messages outlined earlier. Related to this concept is the finding in one survey that the ABC-TV program ~~.Y.I.~ was mentioned most often by socially disadvantaged women respondents as a believable source of health information. It was aired at regularly scheduled times during breaks in afternoon soap operas. ABC-TV has since canceled the program, but has said that it might begin airing it again. Radio is another medium that should be used to communicate the campaign messages. Some 456.2 million radio sets were in use In 1980,~ 3 and surveys have shown that radio listening is especially prevalent in poor, socially disadvantaged groups. ~ 4 One of the attractions of using radio is that it is less cost, y than television. The print mass media, newspapers and magazines, also could be useful. Selected newspapers or magazines can be used to transmit messages to specific groups because of their specialized readerships. For example, Jet magazine is read widely by black women; so is the Sunday newspaper, especially the magazine sections. Similarly, comic books, photo stories, and simplified illustrated booklets and similar materials should be developed for use In a range of settings. All such materials require careful testing to make sure that they are effective in communicating campaign messages. Leadership and Organizational Structur e The comprehensive public information program advocated by the committee clearly needs an organizational home and a stable leadership structure. It must be well funded and should embrace a wide variety of groups and institutions to increase the number of ways In which the campaign messages can be disseminated. The committee suggests that the Healthy Mothers, Healthy Babies Coalition fulfill this leadership role. AS an established organization, it has many attributes that make it a logical leader for a public information program directed at low birthweight prevention. Indeed, many of the Coalition's efforts to

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209 date are highly relevant to the prevention of low birthweight, even though directed at more general issues of maternal-and infant health. The Coalition grew out of the recommendations of the Surgeon General's 1980 Workshop on Maternal and Infant Health, which called for the Surgeon General to use the influence of his office to develop a program of public information and education to enhance the health of pregnant women and infants. 5 In response to this recommendation, the Public Health Service and five other organizations set up a loose coalition of 36 voluntary, professional, and governmental groups to find ways of improving public education aimed at the nation's high-risk women, with a special focus on improving the outcome of pregnancy. The Coalition has now grown to more than 60 national organizations with networks in 25 states and is perhaps the largest attest thus far to concentrate the activities of so many groups on the common objective of improving infant and maternal health. Coalition active ties have included development of materials for clinics, including posters and information cards, as well as booklets, newspaper columns, and radio programs. The Coalition also has conducted market research on how women, especially low-income women, receive their prenatal informational 6 The Coalition has no permanent source of funding, however. Funds have been raised only for specific projects, not to build a stable institution capable of sustaining a long-term, high-quality public information program. The poster project, for example, was supported by a consortium of six organizations, each of which donated $25,000. This money covered design, production, and distribution of the posters, as well as a promotional campaign to let prenatal clinics know they were available. Although such project-specific fund~ng.~s useful, it does not ensure the survival of such campaigns over tome. The committee has concluded that the Coalition has the potential for playing a larger , more permanent role in improving maternal and child health and in reducing the incidence of low birthweight. Accordingly: The committee urges that the Healthy Mothers, Healthy Babies Coalition lead a comprehensive public information program directed at low birthweight prevention. The program should be aimed at the general public, but also include messages specially designed To reach low-' ncome women, teenagers, and pregnant smokers. It should follow the themes of planning for pregnancy and of adopting good health practices in the childbearing years, especially during pregnancy. The Coalition should establish a formal executive secretariat to provide stability and permanence. Both public and private funds should be provided the Coalition in amounts adequate to its task. Activities should include the production and distribution of high quality, well-tested public information materials, and special efforts should be made by the Coalition to urge that television programming include the campaign themes. Similarly, the radio and print media should be enlisted In this long-term, national effort.

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210 In urging a public information program directed at low b~rthweight prevention, the committee emphasizes again that this should be but one element in a more comprehensive program, that it must be sustained over tome, and that it must be integrated with complementary activities in the health care sector in particular. For example, public messages . . ~ . pointing out the Importance of prenatal care must coincide with a commitment to making prenatal care accessible; and messages to decrease smoking in pregnancy must be reinforced and elaborated in individual clinic and office settings. Finally, such a campaign must pay careful attention to audience def inition, message development, and use of multiple media to channel information. The Healthy Mothers/Healthy Babies Coalition, if more adequately funded, is a logical leader for the program. References Hamburg DA: Changing behavior for health. Am. J. Cardiol. 47: 736-740, 1981. Warner RE and Murt HA: Impact of the antismoking campaign on smoking prevalence: A cohort analysis. J. Public Health Policy 3:374-390, 1982. Hinman AR, Brandling-8ennett AD, and Nieburg PI: The opportunity and obligation to eliminate measles from the United States. JAMA 242:1157-1162, 1979. 4. Pap smear controversy pits cancer society vs. ob-gyns. Hosp. Pract. 16 :16-29, February 1981. Flay BR, D~Tecco D, and Schlegel RP: Mass media in health promotion: An analyst s model. Health EduC. Q. 7:127-147, 1980. 6. using an extended information processing Siano JJ: Consistency is key in building brand identity. Advertising Age, M 46-48, February 20, 1984. 7. Hutchings R: A review of the nature and extent of cigarette advertising in the United States. In National Conference on Smoking and Health: Developing a Blueprint for Action, Proceedings, pp. 249-263. New York: American Cancer Society, November 1981. 8. Social Marketing: Does it Work? Population Reports, Series J. No. 21. Baltimore, Md.: Johns Hopkins University, January 1980. 9 . Test Results of the Healthy Mothers Posters, Health Message Testing Service, Public Health Service, Bethesda, Md., February 1982 . 10. Morton Lebow: Administrator for Public Affairs, American College of Obstetricians and Gynecologists, Washington, D.C., personal communication. Atkin CR: Research evidence on mass mediated health communication campaigns. In Communication Yearbook 3, edited by D Nimmo, pp. 655-668. New Brunswick, N.J.: Transaction--Internat~onal Communication Association, 197 9 .

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211 15. 12. Juarez and Associates, Inc: Healthy Mothers Market Research: How to Reach Black and Mexican American Women. Final report submitted to the Office of Public Affairs, Public Health Service, DENS Contract No. 282-81-0082. Washington, D.C., September 14, 1982. 13- Profile: Broadcasting. Washington, D.C: National Association of Broadcasters, 1981. 14. Green D: Exposure to Print and Electronic Media: Women Age 18-34. Report submitted to the Public Bealth Service by Chilton Research Services. Radnor, Pa., January 1982. U. S. . Depar tment of Health and Human Services: The Surgeon General 's Workshop on Maternal and Infant Health. DEWS No. (PHS) 81-50161. Public Health Service. Washington, D.C.: U.S. Government Pr intend Office, January 1981. 16. Bratic E: Healthy Mothers, Healthy Babies Coalition--A joint pr ivate-publ~c initiative. Public Health Rep. 97: 503-509, 1982 .