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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
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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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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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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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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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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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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.
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Warner RE and Murt HA: Impact of the antismoking campaign on
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Hinman AR, Brandling-8ennett AD, and Nieburg PI: The opportunity
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4. Pap smear controversy pits cancer society vs. ob-gyns. Hosp.
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Flay BR, D~Tecco D, and Schlegel RP: Mass media in health
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model. Health EduC. Q. 7:127-147, 1980.
6.
using an extended information processing
Siano JJ: Consistency is key in building brand identity.
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15.
12. Juarez and Associates, Inc: Healthy Mothers Market Research: How
to Reach Black and Mexican American Women. Final report submitted
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Representative terms from entire chapter:
low birthweight
