Mass media plays a central role in people’s lives. Its importance is evident in the amount of time people spend watching television, surfing the World Wide Web, listening to music, and reading newspapers and magazines. The delivery of information through mass media is instant and available around the clock. The proliferation of communication technologies— miniature TVs, handheld radios, and personal computer companions such as Blackberry and Palm Pilot—contribute to the omnipresence of the media in daily life. More and more, a growing proportion of “life experience” is mediated through communication technologies instead of being directly experienced or witnessed. The public health community and policy makers often do not appreciate the importance and power of the media in shaping the health of the public. More importantly, media outlets or organizations do not see themselves as a part of, or contributing to the public health system. As this chapter discusses, however, the media plays a number of roles in educating the public about health issues and has a responsibility to report accurate health and science information to the public.
In this chapter, the committee examines the potential role of the media as an actor in the public health system, that is, how it can use its presence and power to lead to the mobilization of societal action that creates the conditions for health. The chapter specifically discusses how the news media can place health issues on the national public agenda and can catalyze action at the national and local levels. The chapter also addresses how advertising media, entertainment media, and the Internet provide health-related information that can reinforce or alter norms and attitudes that
influence individual behavioral and societal changes. The chapter concludes with a brief discussion of the theories that help us understand the impact of the media on behavioral change and on evaluation and research issues, including the difficulties in predicting the outcomes of media campaigns. The committee recommends a number of steps that can be taken to further enhance the role of the media in improving the population’s health.
NEWS MEDIA AND THE NATIONAL PUBLIC AGENDA
The ubiquitous nature of the news media, in particular, makes it a powerful tool for directing attention to specific issues. Generally, Americans look to the news media for coverage of events and to help us understand the world around us. Although the news media does not specifically tell us what to think, it plays an important role in identifying what issues we should think about (McCombs and Shaw, 1972). The more coverage a topic receives in the news, the more likely it is to be a concern of the public. Conversely, issues not mentioned by the media are likely to be ignored or to receive little attention.
The unfolding news coverage of HIV/AIDS provides a good example of how an important health issue may be invisible to the public eye until the media bring it to light. The first publicly documented cases of AIDS were reported in the June 5, 1981, issue of Morbidity and Mortality Weekly Report (MMWR) (CDC, 1981a). The publication provided five case histories of previously healthy, young (ages 29 to 36) homosexual men from the Los Angeles area who developed Pneumocystis carinii pneumonia (PCP), an affliction usually seen in severely immunodepressed patients, and a myriad of other opportunistic infections. A July issue of MMWR (CDC, 1981a) reported Kaposi’s sarcoma in 26 homosexual men and additional cases of PCP in Los Angeles and San Francisco. Physicians were alerted about Kaposi’s sarcoma, PCP, and other opportunistic infections associated with immunosuppression in homosexual men. A subsequent issue of MMWR (CDC, 1982c) reported 70 additional cases of Kaposi’s sarcoma and PCP, and by December 1981, the Centers for Disease Control and Prevention (CDC) had reported more than 150 deaths.
During this time, news media coverage of the illnesses that appeared to be affecting homosexual men was limited. According to an analysis conducted by the Kaiser Family Foundation (1996), it was only in August 1982 that the New York Times brought readers up to date on an emerging and puzzling health crisis in the homosexual community. The article, “A Disease’s Spread Provokes Anxiety,” used the term acquired immune deficiency syndrome, or AIDS, for the first time. Later that year, the Washington Post reported on the death of an infant who had received a transfusion of blood from a donor with AIDS (CDC, 1982b). By 1983, a Newsweek
TABLE 7–1 Media Coverage of AIDS
Death of Rock Hudson, a well-known public figure
Florida family burned out of home; a dramatic case of public anxiety concerning AIDS leading to violence. Arsonists were seeking to keep the family’s AIDS-afflicted hemophiliac sons out of the local school system
Ryan White’s death at age 18. White contracted HIV at age 13 through blood products used to treat his hemophilia. He was the country’s best-known victim of AIDS as a result of nonsexual transmission
Public request by Kimberly Bergalis to test health professionals for AIDS. Kimberly contracted HIV from her dentist. Her dramatic case raised the controversial issue of AIDS testing for health care professionals
Magic Johnson reveals his HIV-positive status. Johnson was the first major public figure not in a higher-risk group to announce his HIV-positive status and to attribute it to heterosexual activity and was the first major professional athlete (he was the National Basketball Association’s most valuable player three times) to leave his sport because of HIV infection
Arthur Ashe dies of AIDS. Ashe, a renowned tennis star, political activist, and social commentator, contracted HIV through a blood transfusion during a surgical procedure
SOURCE: Kaiser Family Foundation (1996).
poll found that 9 in 10 Americans over 18 years of age had heard about AIDS but were generally uninformed or misinformed. Subsequent coverage of AIDS included several newsmaker and public interest stories that further increased the public’s concern about AIDS.
News media coverage during the mid- to late 1980s may have contributed to improved public awareness and knowledge of AIDS. By 1989, Gallup surveys indicated that nearly all adults were aware that HIV, the virus that causes AIDS, can be transmitted by shared needles (98 percent), homosexual intercourse (96 percent), and heterosexual intercourse (95 percent) (Kaiser Family Foundation, 1996). Table 7–1 gives examples of the media coverage of AIDS from 1985 to 1993.
The media also play an important role in gaining the attention of specific opinion leaders, including politicians, governmental regulators, community leaders, and corporate executives, among others. Between 1982
and 1987, several members of the U.S. Congress placed AIDS on the political agenda by holding hearings on the growing numbers of people afflicted by it and research into its causes and prevention. Celebrity activists and spokespersons covered by the media also increased the visibility of AIDS on the political agenda. However, it was not until 1987 that President Ronald Reagan gave his first public speech about AIDS. During that year the Congress also passed legislation that took into account the larger societal implications of the epidemic and that went beyond funding for AIDS prevention, research, and treatment efforts. The AIDS Federal Policy Act of 1987 prevented discrimination against individuals with disabilities—including those with HIV/AIDS.
In 1988, as public recognition of the burgeoning AIDS epidemic increased, the growing need for information was addressed by a booklet sent to all 107 million U.S. households by then-Surgeon General C. Everett Koop. Understanding AIDS: A Message from the Surgeon General was one of the largest educational public health mailings in U.S. history (Koop, 2002).
Political attention to AIDS continued to grow from the late 1980s through 1990. Advocacy groups and celebrities used news media coverage to bring attention to the case of Ryan White, an Indiana teenager who acquired AIDS through blood products used to treat his hemophilia, and to AIDS issues in general (AIDS Project Los Angeles, 2001). In August 1990, the Ryan White Comprehensive AIDS Resources (CARE) Act was enacted, a few months after Ryan’s death. This landmark legislation authorized funds in emergency relief to cities devastated by the AIDS epidemic (P.L. 101–381).
As noted earlier, a high level of media coverage about a topic elicits public attention and concern. In the case of HIV/AIDS, the news media engaged public attention and stimulated policy response. Shuchman (2002) provides several examples of journalism as a catalyst of health care system change.
A New York Times probe of fraudulent practices at the Columbia/HCA Healthcare Corp. chain of hospitals in March of 1997 led to a federal criminal investigation of the company (Gottlieb et al., 1997). A Los Angeles Times series on the U.S. Food and Drug Administration’s system of drug approval in 2000 strengthened the claims of those advocating tighter controls at the agency (Willman, 2000). Extensive coverage by the Washington Post and others of the death of a young patient in a university-based gene therapy experiment resulted in stronger federal protections for patients enrolled in clinical trials (Nelson, 2000). A Boston Globe series on the hazards of placebo-control trials in psychiatry was one of several journalistic investigations that resulted in changes in the way psychiatric patients are enrolled in research protocols (Whitaker and Kong, 1998) (quoted in Shuchman, 2002).
News attention to specific issues, however, may also distort public perceptions and change behavior in adverse ways. Gilliam and colleagues (1995) found that the public’s concern regarding crime increased, despite little actual change in the frequency of criminal activity and national survey statistics indicating a declining population-adjusted rate of crime over the previous two decades. The authors note that although Americans do not experience crime directly, they receive large doses of crime coverage from the media. The authors suggest that such coverage drives Americans to name crime as the most important problem facing the country and shapes public attitudes toward criminals, the death penalty, mandatory jail sentences, and “three strikes” laws. In response to public concerns, policy makers endorse strategies to strengthen law enforcement and the criminal justice system. Dorfman and Thorson (1998) also note that one by-product of media reporting on crime and violence is that readers receive a distorted picture of the world and that people react to reading and hearing news about crime and violence by fearing their world. Dorfman and colleagues (2001) have developed techniques to enable journalists to report on highly unusual crimes without misrepresenting the patterns of violence in their communities and creating misguided fears. Such techniques for reporting on violence integrate a public health perspective and offer readers information to understand the determinants of violence and to develop strategies for reducing violence in the community (Stevens, 1998).
NEWS MEDIA AS A CATALYST TO PROMOTE HEALTH AT THE COMMUNITY LEVEL
The AIDS example illustrates the role of the news media in placing the AIDS epidemic in the public light and on the national political and legislative agendas. The news media can also function as a catalyst for action at the local or community level. The story of “motel families” living across the street from Disneyland in Orange County, California, demonstrates the power of the news media to highlight social issues and stimulate action by local government and community members.
Over a period of 6 months in 1998, Laura Saari, a writer for the Orange County Register, brought to light the sharp social and economic contrast that exists in one of California’s more affluent counties, where one in five children lives in poverty. The article on motel children uses the voices of children to poignantly communicate the impact of poverty on their lives (see Box 7–1).
The story had a significant influence on the community; more that 1,100 people contacted the paper to offer $200,000 in donations, 50 tons of food, 8,000 toys, and thousands of volunteer hours. The media coverage also activated a response by the local government. The Orange County
BOX 7–1 Growing Up in “Toxic Communities” Sunday, August 2, 1998 Copyright ©The Orange County Register By Laura Saari
Five children sit on the lip of the Dumpster and spear cans to get the money for a McDonald’s.
A broken fan, onion peels, a gravy-stained box from a Salisbury steak TV dinner, a can of Hype Morning Rush Energy.
“A toy bucket,” shouts Jeffrey Littlefield, 6. He wiggles a stick to get to the bucket before the other kids. He pulls up a fast-food chicken pail and smiles. Two black teeth.
“I’m fishin’,” he says. “It’s a contest, whoever gets the most cans.”
“Can I help?” asks Anthony Chavez, 3, trying to climb up.
“I see French fries!” says a girl. She jumps in.
The children live at a motel across from Disneyland.
There was a time when tourists checked into motels such as this one, drawn to the U-Dial telephones and color TVs and a balcony view of the Happiest Place on Earth.
Today, the vacancy signs are still up, but their neon tubes have lost their gas. Newer high-rise hotels lure the vacationers.
And so the old rooms-by-the-day have become $140 rooms-by-the-week that soon become rooms-by-the-year, even though everyone always says they’re moving out tomorrow.
For families who can’t find a way into the county’s rental market, the motels are the last stop before the homeless shelter or the street. And it’s not just here. A healthy economy and rising home prices have driven families across the nation into motels.
Often, the buildings are in decay. The ceilings fall, the locks don’t latch, and the roaches don’t wait until dark. Some families live six or more people to a room.
For the hundreds of children living in Orange County motels, violence often is a thin wall away, if that. Drug deals, prostitution, stabbings, assaults, theft, an occasional murder, a fugitive in hiding.
The children are transient. Because of new occupancy limits in some cities, families must move on after 28 days. Social workers who are trying to protect the children often have difficulties just finding them, says Michael Riley, director of Orange County Children and Family Services.
At some schools near motels, a third of the kids who sign up in the fall aren’t there at the end of the year. Head lice are chronic. Nurses have found roaches lodged deep inside children’s ears. “These children are consumed, 24 hours a day, with poverty—and it’s not just financial,” says Linda Dunlap, a nurse whose volunteer group, Project Dignity, works with families in motels. “It’s spiritual and emotional. They didn’t just decide one day they were going to surrender their spirits. They did it to survive.”
The little ones seem too wise for their years, and too angry. Yet they share their last piece of bread with a neighbor. They protect each other fiercely. They try to create order where there is none.
In grade school, many children are still hanging onto their dreams of what their lives could be. By the time they are teenagers, anger often has hardened into resentment, hopelessness, defiance. “I think the general population doesn’t understand what kind of lifestyle is being led in these places,” says Sgt. Joe Vargas of the Anaheim Police Department.
“These are toxic communities. The kids are really starving for stability, and they don’t get it. We’re breeding criminals. We’re breeding kids who are growing up without the life skills necessary to function to their full potential.”
That is the way grown-ups see life in motels. But things look different when you’re a kid.
SOURCE: Saari (1998). Excerpted with permission of the Orange County Register.
Board of Supervisors ordered an audit of services for motel children and directed $1 million in funds to create a housing program to help families move out of motels (Leaman, 1998). A nonprofit agency launched a $5 million capital campaign for a shelter to help motel families with drug abuse problems. The city of Anaheim, where the motels are located, also moved services into the motels so that families would have easier access to parenting classes, job training, and food programs.
Many public health issues are not considered newsworthy. In contrast to the coverage of a frightening infectious disease epidemic such as AIDS or, more recently, the anthrax attacks, the story on motel children illustrates the everyday work of public health that involves struggles with endemic conditions and risk factors that are not considered news. The journalist was able to capture interest in an endemic situation by presenting the story in a novel way, and subsequent advocacy helped to keep the story and the public interest alive.
NEWS MEDIA COVERAGE AND HEALTH INFORMATION
Although news media coverage can help place a specific health issue on the national agenda, tensions exist among news reporters, scientists, and public health professionals as they seek to convey health news and information to the public, especially during a crisis. It is important to understand these tensions if the news media is to be involved in the public health system.
The results of a survey of scientists and journalists are particularly helpful in understanding the attitudes of each toward the other and their
views on transmitting and translating scientific information through the media to the public. Hartz and Chappell (1997) found that scientists complained that reporters do not understand many of the basics of their methods, including the proper interpretation of statistics, probabilities, and risk. Journalists viewed scientists as being too immersed in esoteric jargon and unable to explain their work simply and cogently, whereas scientists said the news media oversimplify complex issues. Reporters also noted that scientists do not understand that “news” is a perishable commodity that must be made relevant to the reader and viewer (see Table 7–2).
These findings allude to many of the tensions between the scientific community (including the public health community) and the journalism community that arise because of differences in defining what is newsworthy, differences in styles of communication (Nelkin, 1996, 1998; Hartz and Chappell, 1997), and differences in perceptions about the role of the media (Nelkin, 1996, 1998).
In identifying newsworthy topics, journalists often seek out stories that are potential attention grabbers. The tenets of newsworthiness include controversy, broad interest, injustice, irony, local “peg,” personal angle, breakthrough, anniversary peg, seasonal peg, celebrity peg, and visuals that can make the story interesting (Wallack et al., 1999).
Scientists and public health professionals believe that journalists, in writing attention-grabbing stories, often violate the traditional norms that guide scientific communication. Nelkin (1996, 1998) notes that media con
TABLE 7–2 Scientists’ and Journalists’ Agreement with Various Negative Statements About the News Media
Scientists’ Agreement (%)
Journalists’ Agreement (%)
Few members of the news media understand the nature of science
News media reporters are ignorant of the process of science
News media reporters cannot interpret results
News media reporters overblow risks
News media reporters rarely get details right
Member of the media seek the sensational
Members of the news media focus on the trendy
News media reporters focus on personalities, not on findings
News media reporters want instant answers
SOURCE: Hartz and Chappell (1997).
straints of time, brevity, and simplicity, for example, impede the careful documentation, nuanced positions, and caveats that scientists believe are necessary to discuss and present their work. Journalists, on the other hand, often see the use of caveats or qualifications as information that can be dismissed to improve the readability of a story. Furthermore, journalistic efforts to enhance audience interest may violate other traditional scientific norms. For example, to create a human interest angle, journalists may look for personal stories and individual cases, although this may distort research findings that have meaning only in a broader statistical context.
Scientific journals may also contribute to the distortion of research findings. Scientific journals often prepare press releases for the news media to assist them in getting the story right. These attempts to translate research into news can be misleading. Woloshin and Schwartz (2002) reviewed the content of journal press releases and interviewed press officers at nine prominent medical journals. The study found that press releases do not routinely highlight study limitations or the role of industry funding. Formats for presenting data were also found to exaggerate the perceived importance of findings.
Fueling these tensions is the fact that scientists, health care professionals, and policy experts rarely receive training in public communication, and reporters are not well trained in science, medicine, and statistics. Both groups are generally untrained in risk communication.
A recent study (Voss, 2002) highlights reporters’ self-perceptions about their own ability to report health news. The study surveyed reporters and newspapers in five Midwestern states. In response to questions about reporting ability, 49.7 percent of respondents reported it was sometimes easy and sometimes difficult to understand key health issues, and 31 percent found it often or nearly always (2.7 percent) difficult to do. Also, 51.3 percent of respondents reported that it was sometimes easy or sometimes difficult to interpret statistical data, whereas 27.4 percent found it often or nearly always (6.2 percent) difficult. More than three-quarters of respondents (83 percent) reported that they had no training to cover health topics. Similarly, a national survey of journalists and news executives found that only 12 percent of reporters covering health care are viewed as “extremely prepared” and 43 percent are viewed as “prepared” to cover health care issues (Foundation for American Communications, 2002).
To help ease these tensions and to improve the quality of the information delivered to the public, scientists and public health officials as well as journalists and editors should seek opportunities for training. The need for media training is acknowledged in the statement of Al Cross, President of the Society of Professional Journalists, who notes that “training is a good way to meet your public responsibilities” (quoted in Kees, 2002) and in the
words of Melinda Voss, executive director of the Association of Health Care Journalists:
It seems to me that it is more important than ever that we as journalists really know how to do our jobs right, because so many critical policy decisions are being made that affect everyone. The ability to properly report medical studies and survey research and the ability to interpret statistics are all a part of doing the job right. We owe it to our audiences. (quoted in Kees, 2002)
In response to the need for better health and science reporting, governmental agencies and foundations have developed programs for journalists that seek to provide them with experiences that will deepen their subject matter knowledge and strengthen their reporting. With funding from the John S. and James L. Knight Foundation, the CDC Foundation sponsors the Knight Journalism Fellowship at CDC (CDC Foundation, 2002). The fellowship provides classroom instruction in epidemiology and biostatistics, public health intervention, public health structure, and health reporting. Fellows are also provided with opportunities to observe investigations of disease outbreaks and participate in research and field practice (http://www.cdcfoundation.org/fellowships/knight/fellowship.html).
The Kaiser Family Foundation (2002b) sponsors three fellowship programs for journalists. The Kaiser Media Fellowships in Health provide print or broadcast journalists and editors interested in health issues with an annual stipend that allows them to pursue individual projects on a wide range of health and social policy issues. The Kaiser Media Internships in Urban Health provide minority journalists interested in urban public health reporting with practical experiences in reporting on the health beat. The Kaiser Media Mini-Fellowships provide travel and research grants to journalists to research and report on health policy and public health issues. Both the Kaiser Family Foundation and the CDC-Knight fellowships, as well as others,1 facilitate a healthy dialogue between health officials and reporters and contribute to the development of a well-trained cadre of health journalists.
Journalist associations also have begun to take a lead in providing opportunities for journalists to improve the quality of information they provide to the public. The Association of Health Care Journalists (AHCJ), for example, is an independent, nonprofit organization dedicated to advancing public understanding of health care issues. Its mission is to improve the quality, accuracy, and visibility of health care reporting, writing, and editing. One of the ways the association works to enhance the understand
Although not dedicated specifically to health issues, the Pew Charitable Trusts sponsors the Fellowships in International Journalism (www.pewfellowships.org), which may cover health issues in other countries.
ing between journalists and health care experts is by offering workshops and training resources on current and emerging issues in health care and reporting skills. With support from the Robert Wood Johnson Foundation, the association recently published Covering the Quality of Health Care—A Resource Guide for Journalists (AHCJ, 2002b).
The importance of effective communication among public health officials, the media, and the public is particularly critical during crises. During such times, the news media play an important role in amplifying or attenuating the public’s perception of risk and serve as a key link in the risk communication process. The media played a key role in reporting the anthrax attacks following the terrorist attacks on September 11, 2001. The events emphasized the need to communicate scientific and medical information in a way that the public can understand and to provide clear information about the concepts of risk and how to apply them.
In November 2001, Dr. Kenneth Shine, president of the Institute of Medicine, advised Congress that communication to the public and to health professionals about the anthrax terrorist attack were found to be insufficient and needed improvement to deal more effectively with future situations that may compromise public health or national security. He stated:
Within the Department of Health and Human Services, there must be a single credible medical/public health expert spokesperson that reports regularly, most likely daily, to the American people in regard to an outbreak with national significance. This is analogous to the situation in local communities where there is a need for such an individual to communicate on behalf of the local health department. Several months before the anthrax outbreak, uninformed statements on local television in a community with two cases of meningococcal meningitis resulted in thousands of individuals taking antibiotics or seeking immunizations that were not indicated. Local stores of antibiotics were depleted and many people were subjected to risk from unnecessary treatment. This episode emphasizes the need for credible medical/public health information during natural events, as well as during those that are produced by terrorism.
In the case of the anthrax episodes, the media responded by interviewing countless number of individuals. Among them was a self-professed pundit who announced he was an expert on the “anthrax virus.” Anthrax is a bacterium, not a virus. In many cases, well-intentioned infectious disease specialists who knew a good deal about the literature on anthrax could provide accurate retrospective information, but when pressed about the current events, they were not privy to the information about the cases that had occurred. They were then forced to either acknowledge their limitations, which the responsible experts did, or in the case of others less responsible, to speculate based on news reports, rumors, and a variety of other kinds of incomplete or false information.
In the case of anthrax, less than 20 cases resulted in thousands of people taking antibiotics that were not indicated. Perhaps 20 percent of these individuals experienced some side effects from these drugs. These antibiotics changed the bacteriological environment and may have rendered some organisms resistant to the antibiotics employed. (Shine, 2001).
In response to Department of Health and Human Services plans to reorganize communication, legislative, and public affairs offices, the Association of Health Care Journalists and the National Association of Science Writers warned that tight control of information by top department managers may be efficient, but it can also increase the risk of communication bottlenecks that can deprive the public of timely and vital health information, and raises questions about how the public’s access to objective information will be protected (AHCJ, 2002a).
Analyzing the communication response to the anthrax attacks may present potentially critical lessons, and a rigorous review of the handling of the incident by the media and public health officials is needed to improve communication strategies for the future. The summary proceedings of a recent conference of media and public health representatives highlighted a number of lessons learned from coverage of public health crises (Joseph, 2002). First, the primary goal of both the press and public health professionals is to serve the public, and the communication of accurate information is a crucial factor in this service. Second, a credible spokesperson or expert must be available to the press to help ensure that information is accurate. This is especially critical during a crisis when there is pressure for both health and nonhealth reporters to cover an incident. Ideally, the spokesperson(s) should have an ongoing dialogue and relationship with reporters as well as editors. Third, public health professionals need to acknowledge the independence of the news media. The press attempts to provide a balanced story for its audience and must be careful not to serve just as a “vehicle” for a specific group’s message. For the press, there is a fine line between cooperation and the risk of losing independence, or cooptation. Furthermore, the audience or public is not a single entity; it can be segmented into different groups with different experiences, social determinants, cultures, and languages. Thus, it is essential to consider different ways of presenting information, especially when dealing with “risks.” Fourth, both public health officials and journalists share a concern that the U.S. public is unaccustomed to uncertainty and that public levels of literacy are low. The continuation of this dialogue is essential; there is much that media and public health professionals can learn from each other that will help both improve their service to the public.
Understanding and appreciating the perspectives and needs of all parties will create a better climate for accurately informing the public. The committee recommends that an ongoing dialogue be maintained between medical and public health officials and editors and journalists at the local
level and their representative associations nationally. Furthermore, foundations and governmental health agencies should provide opportunities to develop and evaluate educational and training programs that provide journalists with experiences that will deepen their knowledge of public health subject matter and provide public health workers with a foundation in communication theory, messaging, and application. Results from these activities would contribute knowledge on how best to structure training and other educational opportunities for health and media specialists so that they are better prepared to bring accurate health information to the public.
MEDIA AND HEALTH COMMUNICATION
Health communication campaigns are interventions intended to generate specific outcomes for a relatively large number of individuals within a specified period of time and through an organized set of communication activities (Rogers and Storey, 1987). Large-scale health communication campaigns seeking to change behaviors were first seen in the United States in the eighteenth century in the form of efforts to educate the public about infectious diseases and the benefits of immunization. In 1721, Reverend Cotton Mather used pamphlets and personal appeals to promote immunization during a smallpox epidemic in Boston (Paisley, 2001). Another illustrative example of a public health campaign was associated with the newly found knowledge that the Mycobacterium tuberculosis bacillus caused tuberculosis (TB) and that TB was communicable and could be prevented. In 1896, the New York City Department of Health, responding to a report on TB developed by D. Hermann Biggs, issued an ordinance that prohibited spitting on sidewalks. The public and civil sectors helped to drive behavioral change at the individual level by placing notices in public areas warning that spitting on the floor spread disease. Hospitals joined the effort by posting signs proclaiming “spit is poison” (Ruggiero, 2000). More recently, health communication campaigns have used a variety of ways to present health messages.
This section discusses the use of specific media to promote health messages. It first addresses public service announcements (PSAs) and then discusses the role of emerging media channels—the entertainment media and the Internet—in conveying health messages. The section concludes with an examination of social marketing and media advocacy, strategies that use media as part of a broader approach to changing individual behavior or promoting social change.
Advertising Media: Public Service Announcements
Broadcasters can help create conditions for improved population health by choosing to donate time for PSAs that convey health-promoting messages. PSAs became a possible conduit for disseminating health-related
messages when the Federal Communications Commission (FCC) required that stations donate a certain amount of airtime to serve the public and the community in exchange for the use of public airways.
The FCC defines PSAs as “any announcement (including network) for which no charge is made and which promotes programs, activities, or services of federal, state, or local governments or the programs, activities, or services of nonprofit organizations and other announcements regarded as serving community interests” (FCC Rules, Section 73.1810 [d]). The requirement, however, does not specify the length of time or the time of day that broadcasters should make PSAs available. In fact, PSAs are only one option for fulfilling the FCC requirement; broadcasters can meet their public interest obligations without running any PSAs at all. Furthermore, new broadcasting venues such as cable networks have no statutory obligation to serve the public interest (Kaiser Family Foundation, 2002a).
The Kaiser Family Foundation recently conducted a study to examine the amount of airtime that television broadcasters donate for PSAs.2 They found that broadcast and cable television networks donate an average of 15 seconds an hour to air PSAs. This represents just under one-half of 1 percent (0.4 percent) of all airtime. Much of this donated airtime (43 percent) is made available between midnight and 6 a.m., and only 9 percent is available during prime time. The major broadcast networks (ABC, CBS, Fox, and NBC) donate an average of 5 seconds an hour to PSAs during prime time. The study also found that health issues are the top priority of PSAs at some networks: 52 percent of all donated airtime on MTV, 35 percent of all donated airtime on Fox, and 33 percent on CBS are devoted to health issues (Kaiser Family Foundation, 2002a).
In addition to donated airtime for PSAs, paid PSAs have become another mode to deliver public service messages. According to the Kaiser Family Foundation study, of all PSAs aired, 36 percent are paid for by sponsors (e.g., governmental agencies such as the Office of National Drug Control Policy and community-based organizations). Sponsors buy an average of 9 seconds an hour of advertising time for paid PSAs per network. Paid PSAs are not only longer (on average, 9 seconds compared to 5 seconds for donated PSAs), but they are better placed. Only 18 percent of paid PSAs are run between midnight and 6 a.m., whereas 43 percent of donated spots run between those hours. Health issues are also a primary focus of paid PSAs—39 percent convey health messages.
The growing use of paid PSAs has raised concerns about the degree to
which networks are meeting their public service obligations. Paid PSAs are regarded by some as an indication that the traditional public service model— relying on donated airtime from broadcasters seeking to fulfill their public service obligations—is no longer working (LaMay, 2002). Some paid PSA sponsors report that before turning to paying for PSAs, they encountered significant difficulties getting messages on the air, especially during prime time (Berger, 2002).
Struggles to get PSAs with health messages on the air can significantly challenge efforts to educate and persuade the public to adopt healthy practices or to avoid behaviors that pose a risk to health. Reviews of the impacts of PSAs have found them to increase public recognition or awareness of a problem and in some cases to motivate action or change behavior. Hu and colleagues (1995), for example, found that California’s paid antismoking media campaign accounted for a 2 to 3 percent lower level of cigarette sales, or an estimated reduction of 232 million packs of cigarettes during the 2-year study period. The $1 million investment in media messages reduced per capita cigarette sales by 7.7 packs. Part of the success of this campaign was that the paid nature of the PSAs allowed greater freedom in their design, which was considered controversial and attracted news media attention (Dorfman and Wallack, 1993). Antismoking media campaigns in Massachusetts and Florida also report significant reductions in smoking behavior. Siegel and Biener (2000) report that among a panel of Massachusetts adolescents (aged 12 to 13 years at the baseline), those who were exposed to television antismoking advertisements were significantly less likely to progress to established smoking 4 years later (odds ratio = 0.49; 95 percent confidence interval = 0.26, 0.93). Similarly, Zucker and colleagues (2001) report a 19 percent decline in smoking among Florida middle school students and an 8 percent decline among Florida high school students exposed to antismoking media campaigns.
The outcomes noted above are well documented. Atkin (2001) notes, however, that “effects may unfold indirectly and gradually as messages increase knowledge, stimulate information seeking, and interpersonal discussion and move individuals through early stages of decision making.”
In addition to specific behavioral change, Balbach and Glantz (1998) emphasize that public service advertising can also have an effect on public discourse and can create pressure for changes in policy and regulations:
The media, both paid advertising and free media, are important vehicles for putting pressure on public agencies. By running their own advertisements, program advocates can create a forum in which they are able to frame issues publicly in a way that reflects their viewpoint. This is a particularly powerful strategys if other forums, such as legislatures or oversight bodies, have not been responsive. Such advertisements reach deci-
sion makers, the public, and reporters, and call attention to the fact that there are problems with the program. (Balbach and Glantz, 1998:407)
The results noted are compelling; however, researchers and health communicators increasingly understand that PSAs play a significant but limited role in promoting health messages and should be considered part of a broader health communication strategy.
A question often debated when discussing PSAs is: Why should broadcasters be motivated to donate public service announcements, especially if there are monetary implications for them? There are at least three responses to the question; first, the FCC, through its licensing agreements, imposes on broadcasters a commitment to serve the public interest. Second, when broadcasters do so, it creates good will among their audiences, and as evidenced earlier, studies demonstrate that PSAs contribute to improving the health of the public who consume the broadcasters’ media. Third, when broadcasters comply freely, calls for tighter and more specific regulatory actions to ensure broadcasters’ commitment to the public interest are less likely to be made.
As noted earlier, not all broadcasters are averse to donating time for PSAs, and some have made significant contributions of time and effort to promote the health of the public. Viacom, a global media company with leading positions in broadcast and cable television, radio, outdoor advertising, and online, recently announced (October 2002) that it has partnered with the Kaiser Family Foundation to create an unprecedented, public information campaign to eradicate ignorance about HIV/AIDS. The campaign capitalizes on Viacom’s global brand power and strong audience relationships to reach the public at large and those most affected by the disease. The Kaiser Family Foundation brings to the partnership its expertise in HIV/AIDS and public education. The campaign includes domestic and international public messaging, television and radio programming, and outdoor, print, and online content and employee education. The $120 million campaign will be launched in January 2003 (www.viacom.com; www.kff.org). This partnership demonstrates strong corporate responsibility and the role that the public health sector can play to engage media gatekeepers in the task of promoting the public’s health.
In light of the important opportunity that PSAs provide as a vehicle for the dissemination of messages to educate and persuade the public to adopt healthy practices or avoid behaviors that pose a risk to health and of the limited amount of time donated to PSAs throughout the broadcasting schedule, the committee recommends that television networks, television stations, and cable providers increase the amount of time they donate to PSAs as a partial fulfillment of the public service requirement in their FCC licensing agreements. In doing so, the public would benefit from more opportuni-
ties to obtain health messages, the media would be seen as demonstrating greater corporate and civic responsibility, and the need for tighter regulation to ensure that licensing agreement requirements are being met would be diminished.
Historically, as mentioned above, the FCC has required that broadcast networks allot a certain amount of time to “the public interest.” Networks complied but often aired PSAs late at night, when few viewers were watching. This was, of course, the least valuable time that the networks had, and because the networks competed with one another, using late night television for nonpaid advertisements was sensible. A critical opportunity, however, was missed as corporations advertised their products, and the public interest was not served. The FCC should review the regulations governing broadcast and broadband media with an eye toward finding ways in which media institutions can serve the public’s interest in accurate health information without being unfairly burdened in the process.
Better placement of PSAs would benefit the public as well as the media, which will be seen as fully contributing to the public good. The committee recommends that the FCC review its regulations for PSA broadcasting on television and radio to ensure a more balanced broadcasting schedule that will reach a greater proportion of the viewing and listening audiences. This will benefit the public as well as the media’s image as a vital contributor to the public good.
Policy makers may ask if PSAs are more effective in reducing cigarette consumption than other measures, such as tobacco taxation. Hu and colleagues (1995) examined the relative effects of taxation versus an antismoking media campaign in California, as noted earlier. The study results indicate that both taxation and antismoking media campaigns are effective means of reducing cigarette consumption. The authors note, however, that the strength of the effects is related to the magnitude of the taxes and the amount of resources expended on the media campaign.
Corporations spend billions of dollars on paid advertising to promote their products. In 2001 (Ad Age, 2001), the 100 leading national advertisers spent well over $40 billion on advertising. The federal government is among these advertisers, with just over $1 billion spent on advertising-related activities. Competition between state government spending on health promotion and prevention activities (which may include advertising) and corporate marketing activities for products that undermine health is also in tremendous imbalance. The public is negatively influenced by corporate advertisers of unhealthy behaviors and products, with little counteradvertising that promotes positive health behaviors. For example, in 2000, state spending on tobacco use prevention was $768.4 million, whereas tobacco companies spent $9.7 billion on marketing across the states (National Center for Tobacco Free Kids, 2002). To deal with such an imbalance in
advertising, researchers have proposed that a federal tax be levied on tobacco advertising and promotion (Bayer et al., 2002). The impact of a 10-cent tax would generate about $2.1 billion a year, which would substantially increase the funds currently available for antitobacco advertising. The U.S. Supreme Court has not yet tested the constitutionality of a content-based tax on commercial speech. More discussion and research are needed to identify and develop support for strategies that can improve the balance between advertising that promotes health and advertising for products that harm the health of the public.
Entertainment Media: Television
Television is one of society’s most common and constant learning environments. Television entertainment programs and commercials, with potential positive and negative health messages embedded in them, reach tens of millions of viewers each day. Often, these messages reach viewers who may not otherwise expose themselves to such information and do not fully realize that these messages may influence their thoughts and actions (Signorielli, 1990). However, concerted efforts to develop strong partnerships between the entertainment media and health communicators are increasingly contributing to more accurate and timely health information in entertainment programming.
American television producers have a history of working with health promotion experts to address public health issues. A few examples are alcoholism on Hill Street Blues and Cagney and Lacey; AIDS on St. Elsewhere, Designing Women, and LA Law; birth control on Valerie (Wallack, 1990); and the Jeanie Boulet storyline on AIDS on ER.
A more concerted effort to partner with entertainment media to disseminate health messages was undertaken by researchers at the Harvard School of Public Health Center for Health Communication. In 1988, the Harvard Alcohol Project partnered with the three largest television networks—ABC, CBS, and NBC—to demonstrate that a new social concept, the “designated driver” for avoiding driving after drinking, could be diffused rapidly through American society via mass communication techniques. As part of the project, television writers agreed to insert drunk driving prevention messages and references to designated drivers into the scripts of top-rated television programs. The networks also aired frequent PSAs during prime time that encouraged the use of designated drivers (www.hsph.harvard.edu/chc/alcohol). Evaluations of the campaign’s impact documented a rapid, widespread acceptance and the strong popularity of the designated driver concept. Before the campaign, 62 percent of Gallup poll respondents said that they and their families used a designated driver all or most of the time. By mid-1989, the percentage had risen to 72 percent, a
statistically significant increase in the numbers of individuals using designated drivers. Surveys sponsored by the National Highway Traffic Safety Administration in 1993 and 1995 found that about three-quarters of those surveyed responded that people should not be allowed to drive if they have been drinking any alcohol at all. These results indicate a wide acceptance of the social norm that the driver should not drink (Winsten and DeJong, 2001).
The designated driver concept and the strategy to emphasize it, however, were extremely controversial. Some alcohol control advocates argued that they may have done more harm than good by encouraging excessive drinking by passengers and deflecting attention away from the social determinants that influence alcohol consumption (DeJong and Wallack, 1992).
In a more recent partnership, researchers at the Kaiser Family Foundation, together with a writer and producer of ER, NBC’s medical drama, collaborated to test the effect of health information communicated through an ongoing television drama. They learned that a short mention of an important health issue in an entertainment television show can make millions of Americans aware of that issue. The experiment included preshow, postshow, and follow-up surveys of ER viewers. The surveys assessed viewers’ knowledge gain, their retention of health information, and their interest in health-related stories and actions taken based on the storylines.
Study results indicate that viewer knowledge increased as a result of the ER episodes. For example, after an episode with a 1-minute story line on emergency contraception, the percentage of viewers who were aware of emergency contraception increased from 50 to 67 percent, and 20 percent of viewers noted that they had learned about the issue from ER. This effect, however, decreased to baseline levels 2 months later. Similar knowledge gains occurred after a short vignette focused on a sexually transmitted disease (STD) caused by human papilloma virus (HPV). HPV is the most common cause of STDs in the country, and it has been linked to more than 95 percent of all cases of cervical cancer. The proportion of ER viewers who had heard of HPV increased from 24 to 47 percent, and 32 percent who had heard of HPV noted that they had learned about it from ER. One month later this effect had decreased but remained above preshow levels; 38 percent of those surveyed reported having heard of HPV, and 16 percent could give a correct description of HPV. Furthermore, the study found that slightly more than half (51 percent) of the regular viewers surveyed were prompted to discuss health issues presented on the show with friends and family, and one in five viewers reported turning to other sources for more information about a health issue presented on ER (Brodie et al., 2001).
Among their conclusions, the researchers noted that although entertainment television is a powerful medium for reaching a diverse and large audience on a regular basis, fictional depiction for the sake of dramatic-
effect could give viewers inaccurate information or lead them to misperceptions about health issues. This observation confirms the need for a present and competent public health partner to ensure that health information is accurate or to counteract misleading storylines.
As noted above, the increase in knowledge of emergency contraception and HPV decreased over time. This suggests that media initiatives that introduce health messages into entertainment programming should be conceived as ongoing projects because the effects may be short-lived. The example described in the next section shows how ER storylines are leveraged to continue health information dissemination and discussion at the local level.
Following ER: The Audience Is Still Watching
Another unique effort to disseminate health messages using television leveraged health-related storylines on ER and linked them to health segments that were broadcast on local news stations after ER. The Following ER health news series initiative aimed to educate and motivate viewers to take action on health issues. The series was sponsored by the Kaiser Family Foundation and implemented by the Johns Hopkins Health Institutions. News staff from NBC affiliate WBAL in Baltimore provided the news reporting. News segments included a 90-second news broadcast that instructed viewers on how to prevent the type of disease or injury depicted in ER’s weekly episode. The segments also provided viewers with information about the resources of national organizations or health experts in the form of toll-free numbers or Internet addresses. Following ER ran for 4 years and reached an average weekly viewership of 1.7 million.
The use of entertainment media as a strategy for providing health information is well founded. In 1999, the case for presenting health information through entertainment was strengthened by a CDC study of the Healthstyles Survey Database. Healthstyles is a proprietary database developed by Porter Novelli, a social marketing and public relations firm. The database contains responses to the Healthstyles survey. The sample for the survey is drawn from the DDB Needham Lifestyles Survey, which bases its sampling on seven characteristics of the Bureau of the Census, considered by most market research experts to create a sample that best represents the U.S. population (CDC, 2000).
Results of the CDC analysis indicate that viewers of soap operas report that television is a major source of health information. Viewers report that they learn about health topics from soap operas and take positive action as a result. Women and African Americans, who are among the groups with the largest representation among regular soap opera viewers, report the highest rates of learning and action as a result of soap opera viewing (see
BOX 7–2 Selected Findings from the 1999 Healthstyles Survey
Regular viewers report that they learned something about a disease or how to prevent it from the following television entertainment shows in the past year:
More than one-third (34 percent) of regular viewers took one or more actions after hearing something about a health issue or disease on a soap opera in the past year:
Regular viewers seek out and attend to health information more than nonviewers. They:
SOURCE: CDC (2000).
Box 7–2). Many people report that the information that they receive in the media has an important influence, often indirectly or directly affecting their behavior. Public health officials, however, are typically trained primarily in the sciences and not in using media channels to promote health or convey health information. This disconnect can give rise to confusion and less than optimal utilization of the media to promote public health goals. Consequently, the committee recommends that public health officials and local and national entertainment media work together to facilitate the communication of accurate information about disease and about medical and health issues in the entertainment media.
Recognizing the powerful impact of the entertainment media in conveying health information and messages, a number of health agencies and other groups are working to acknowledge the efforts of the Hollywood community. CDC, for example, established the Sentinel for Health Award
for Daytime Drama (CDC, 2002b) to recognize exemplary achievements of daytime dramas that inform, educate, and motivate viewers to make choices for healthier and safer lives. CDC also funds the Hollywood, Health, and Society program at the University of Southern California Annenberg Norman Lear Center (University of Southern California, 2002). The program seeks to combine public health expertise with entertainment industry knowledge and outreach. Similarly, The Media Project, operated jointly by the Kaiser Family Foundation and Advocates for Youth, has worked for years to promote accurate descriptions of reproductive health issues in television shows and also administers an awards program. The SHINE Awards (Sexual Health IN Entertainment) honor those in the entertainment industry who do an exemplary job of incorporating accurate and honest portrayals of sexuality into their television, film, and music video programming (The Media Project, 2002). The Entertainment Industries Council, Inc., in partnership with the Robert Wood Johnson Foundation and the National Institute on Drug Abuse of the National Institutes of Health, sponsors the PRISM Awards (www.eiconline.org). These awards honor the correct depiction of drug, alcohol, and tobacco use in television and feature films, music, and comic books. The committee applauds efforts to recognize and highlight the contributions of the entertainment media in conveying accurate health information and messages as part of their programming activities.
Strong partnerships between the health community and the entertainment media are also important because they provide not only an opportunity to promote positive health messages but also an opportunity to educate the entertainment media about the impact of negative health messages on viewers, especially children. According to a 1998 Nielsen report on television viewing, the average child or adolescent watches an average of nearly 3 hours of television per day. Coupled with children’s general vulnerability, this makes them especially susceptible to the messages conveyed through television.
A growing body of evidence associating the portrayal of violence in the entertainment media with increased aggression in young people, for example, has led a number of governmental and nongovernmental bodies to express concern regarding the amount of violence in the entertainment media. Those voicing concerns include the U.S. Surgeon General (1972), the National Institute of Mental Health (1982), the American Psychological Association (1993), and the American Academy of Pediatrics (2001). Concerns have also been expressed about the entertainment media’s depictions of cigarettes, alcohol, and illicit drug use, sexual behavior, and body concepts because of their potentially negative impacts on children (Roberts, 2000).
Given the important influence of the entertainment media on children and adults, the committee joins the voices of concern raised by other gov-
ernmental and nongovernmental bodies and encourages entertainment television writers to refrain from glamorizing tobacco, alcohol, and drug use or violence and to incorporate appropriate contextual elements in such programming whenever possible.
The Internet is rapidly and radically transforming many aspects of society, including reshaping how information is accessed and shared (NRC, 2000). In the health arena, interactive health communication, or the interaction of an individual—consumer, patient, caregiver, or professional— with an electronic device or communication technology to access or transmit health information or receive guidance and support on a health-related issue, is growing at a rapid pace (Robinson et al., 1998). Consumer health in particular is one area that is being reshaped by interactive health communication. Consumer health refers to a set of activities aimed at empowering consumers in their own health and health care. Activities in this area include the provision of health information, the development of tools for self-assessment of health risks and management of chronic diseases, and home-based monitoring of health status and delivery of care (NRC, 2000).
A recent study of interactive health communication applications conducted by the Science Panel on Interactive Communication and Health, convened by the Office of Disease Prevention and Health Promotion of the Department of Health and Human Services, examined the current status of interactive health communication and its potential to promote health. In its consensus statement, the panel identified 12 potential advantages of using the Internet for health communication (Robinson et al., 1998). These potential advantages are listed in Box 7–3.
The panel also identified six specific functions of interactive health communication, which are listed in Box 7–4. These functions of interactive health communication have been noted by consumers as well as public- and private-sector organizations. According to a recent Harris Poll, an estimated 101 million U.S. web users have sought health care information online in the past year, up from 97 million in 2001 (Harris Poll, 2002). Web users also turn to the Internet to find social support (Bly, 1999). Foote and Etheredge (2002), in a study conducted to identify strategies to improve consumer health information services, found that insurers, provider organizations, consumer groups, foundations, and public-sector agencies are now sponsoring initiatives to strengthen these services. They note as an example that some insurers and provider organizations offer consumer-focused websites, preventive care and disease management outreach programs, and peer support programs for patients and caregivers. Some of the new peer support programs include meetings in person or online, introducing pa-
BOX 7–3 Benefits of Interactive Health Communication
SOURCE: Robinson et al. (1998).
BOX 7–4 Functions of Interactive Health Communication
tients to “buddies” who have similar medical experiences, chat rooms, bulletin boards, customized websites with online tutorials, links to other relevant websites, referral information to local resources, e-mail access to experts and peers, and computerized management support tools.
Although the potential benefits of interactive health communication applications are many, the growing volume and use of these applications also raise several concerns. This section briefly highlights three areas of concern: (1) the quality of information, (2) the digital divide, and (3) the privacy and confidentiality of personal health information.
A recent National Research Council (NRC) committee charged with studying the Internet and health applications noted the need for tools to help consumers find information of interest and evaluate its quality (NRC, 2000). The sheer volume of health information on the Internet, the NRC committee noted, can be overwhelming. For example, a simple web search for “diabetes mellitus” returned more than 40,000 web pages, and some 61,000 websites contain information on breast cancer (Boodman, 1999). The committee emphasized that consumers need effective searching and filtering tools that can help identify and rank information according to their needs and capabilities and present it in a form they can understand, regardless of educational or cultural background. Consumers also need a way to judge the quality, authoritativeness, and origin of the information. Because the Internet allows anyone to publish information, filtering and credentialing become extremely important. The Scientific Panel on Interactive Health Communication, for example, has called for disclosure statements on websites to make it easier for consumers to evaluate the source and authority of information resources. Other efforts to help consumers evaluate health-related websites focus on systems for classifying information according to characteristics such as accuracy, timeliness, completeness, and clarity (NRC, 2000). Mitretek Systems’ Information Quality Tool, a tool that helps educate consumers by evaluating a website’s strengths and weaknesses, is an example of such an effort (Mitretek Systems, 2002).
The digital divide is another area of concern that must be addressed if disparities in access to interactive health communication are to be overcome. The digital divide refers to the experiences of two groups of people: one group has access to information technology and relevant training to use that technology; the other group, for a variety of reasons, does not have access to such technology and is not trained to use it. The difference between these two groups of people is what has been called the “digital divide” (NTIA, 2002). A recent Pew Internet Project study reported that the digital divide is narrowing. Internet use is becoming more available to women and minorities. The African-American population online grew 8 percent during the first half of 2000. A large portion of the increase came from African-American women: 45 percent of African-American women had Internet access in November and December, whereas 34 percent had Internet access at midyear (May to June). Access to the Internet also increased for African-American men and access by the Hispanic population increased by 7 percentage points (Fox, 2001).
Even if access to information services were to improve for all groups, disparities could continue to exist because many individuals have low levels of literacy or problems with the English language. Developers of web-based information sites and interactive health applications need to consider that approximately one of five Americans is functionally illiterate and unable to comprehend written materials. One study (Berland et al., 2001) found that the average reading level of English-language websites was collegiate and ranged from 10th grade to graduate school level. Similarly, website developers and those using the Internet to provide health information and applications should consider the growing diversity of the U.S. population and globalization. In response to this problem, federal efforts are under way to develop agency-related non-English-language websites that are accessible to all persons who, as a result of national origin, are not proficient in English or are limited in their ability to communicate in the English language (White House, 2000). Illustrative of the response to the Executive Order is the Department of Health and Human Services’ Spanish-language Healthfinder, a guide to health information, and the Food and Drug Administration’s efforts to provide food and cosmetic information in 17 languages.
Protection of the privacy and confidentiality of personal health information is a challenge for Internet health communication activities. According to consumer surveys, individuals feel very strongly about keeping their health concerns private. They must have confidence that information that is collected, stored, and made available online is protected. If the information is shared, it should be shared only with a health professional with the capacity and commitment to maintain complete confidentiality (Patrick et al., 1999). Policy making at the federal and other levels is under way to develop steps that will ensure the secure, private, and confidential transmission of information.
This section has focused primarily on the Internet as a medium for personal health care information. The Internet also provides access to a number of data resources that focus on population health. CDC WONDER serves as a single point of access to a variety of CDC public health information that can be valuable in public health research, decision making, priority setting, program evaluation, and resource allocation and for informing the public at large (http://wonder.cdc.gov). Similarly, the Department of Health and Human Services, in collaboration with the Association of State and Territorial Health Officials, National Association of County and City Health Officials, and the Public Health Foundation, manages a website that provides access to community health status indicators (NACCHO, 2002). The Community Health Status Indicators Project was developed in response to community-based requests for data to assess health, plan programs, and develop data-based health policy. Individuals and community
groups can access the site for health-related and other data for each of the 3,082 U.S. counties.
More recently, the Internet has become an important tool for providing real-time access to critical information. CDC, for example, webcasts critical briefings on bioterrorism through the site www.bt.cdc.gov. In late September 2002, the site provided a full copy of the revised Smallpox Response Plan and Guidelines (CDC, 2002a), an online telebriefing that discusses the plan and that provides a transcript of the briefing and a press release. Another Internet-based initiative is the University of North Carolina School of Public Health’s Public Health Grand Rounds, sponsored by CDC (University of North Carolina, 2002) . Grand Rounds covers a variety of public health topics including bioterrorism preparedness. Webcasts are available for simultaneous downlink to a personal computer anywhere in the world. Part of the show allows viewers to call in or e-mail questions. Moreover, webcasts are followed up for 3 weeks with a postshow web forum so that viewers can continue to ask questions and receive answers, share best practices, and network with other participants. These activities can be conducted individually or in groups.
Strategies That Use Media Tools to Promote Population Health
Thus far, this chapter has discussed the use of specific media channels to promote health and has shown how certain media programs have influenced health-related behaviors. Given the prominence of media communication in people’s lives, some scholars have argued that the public’s health is best served by focusing public health resources on media strategies. These strategies place at the center of their activities the use of media communication to shape public opinion and promote health. By using media communication, the health of the public can be promoted in cost-effective and sustainable ways. Two of the most prominent of these strategies are social marketing and media advocacy.
Social marketing is an approach that attempts to apply advertising and marketing principles to “sell” positive health behaviors (Kotler and Zaltman, 1971; Kotler and Roberto, 1989; Kotler et al., 2002). Social marketing combines marketing concepts with social influence theories to motivate individuals to change their behavior. Drawing from variables used to plan traditional marketing strategies, social marketing has reinterpreted them for use in planning how to “sell” health objectives (Wallack, 1990).
In commercial business, marketing is about getting the right product
(what you sell), at the right price (what the consumer pays), in the right place (where it is sold), at the right time, and in such a way as to successfully satisfy the needs of the consumer (what you do to attract the buyer) (Cannon, 1986; Hastings and Haywood, 1991; NCI, 2002). Marketing techniques use the consumer or target audience as the central focus to plan and conduct a marketing program. In social marketing for improved health outcomes, these marketing variables (the “four P’s”) take on the following definitions:
“Product” might be defined as the behavior that the program is trying to change within the target audience; more specifically, it could be safer sex or nonsmoking.
“Price” represents what the consumer must give up to accept the health promoter’s offering. Price might include the monetary, time, psychological, or physical costs to the consumer.
“Place” concerns the distribution channels used to reach the consumer; these could be the mass media, the community, or interpersonal channels of communication.
“Promotion” is the means (e.g., media outreach and testimonials) by which the health promoter communicates the product to the consumer (Leathar et al., 1986; NCI, 2002) and the benefits of adopting this new product (e.g., practicing safe sex or not smoking).
These variables in an AIDS initiative, for example, could translate into condoms as the product, a free price, health centers, clinics, or schools as the place, and advertising and personal selling for promotion (Leathar et al., 1986).
Key to the social marketing approach is rigorous up-front planning and research, with engineering-style decision making found in traditional marketing processes. At a minimum, the problem and objectives must be clearly defined and stated, the consumer must be heard, and the product must be responsive to consumer needs (Walsh et al., 1993).
Formative research is an important tool used throughout the social marketing process to ensure that consumers are heard and that the product is responsive to their needs. Formative research, for example, can provide consumer input early in the design of a program to better define the nature of the problem to be tackled and to specify the goals. It can also be used to conduct an analysis of the audience for segmentation—the process of partitioning a heterogeneous population into groups or segments of people with similar needs, experiences, or other characteristics. Formative research can also be used to measure the media-viewing habits of the target population so that messages can be placed in the right media, to assess preexisting knowledge and attitudes for specific segments of the population, and to test
possible campaign slogans for cultural sensitivity. Lastly, formative research can provide feedback throughout the entire process through surveys, interviews, and focus groups that lead to improvements in the marketing of positive health behaviors or objectives. Evaluation is a critical component of social marketing that assesses whether the product was successfully marketed to the target audience at the right price and place and through the most effective promotion strategies to result in improved health outcomes. As a result, formative research allows the consumer to guide the entire social marketing process (Leathar et al., 1986; Wallack, 1990; Walsh et al., 1993).
In addition to the four P’s described above, social marketing adds three more “P’s” to influence health behaviors that benefit the target audience and the public at large. These include partnership, policy, and politics:
“Partnership” involves the identification and interaction of multiple organizations and agencies that share similar goals and that can work together to reach the target audience more effectively. Promoting and sustaining healthy behaviors, such as physical activity among children, requires the participation of all interested parties, including health care providers and clinics, schools, communities, faith-based organizations, and others.
“Policy” recognizes the need for social and environmental changes to support individual behavioral change. Without supportive policies, social marketing campaigns cannot be sustained. Making convenience stores accountable to the laws regarding the selling of cigarettes to minors is an example of how policy supports a campaign to decrease underage smoking in a particular community.
“Politics” involves the recognition and strategies incorporated to gain political support for a campaign or ensure political diplomacy within the targeted community and across interested parties. Social marketing programs often target complex and controversial issues, such as gun safety initiatives, that require understanding, involvement, and support from outside organizations or parties who may limit or hinder the program’s reach if they are not identified and approached early (Weinreich, 1999).
When a social marketing campaign is being developed, the planning process follows the same steps identified above for general health communication strategies. The needs and perceptions of the consumer remain the primary focus in developing a campaign or program. The process starts with (1) planning and strategy selection, followed by (2) the selection of channels and materials, (3) the development of materials and pretesting, (4) implementation, (5) assessment of effectiveness, and (6) feedback to refine the program. The process is circular, with the last stage feeding back into
the first one so that the campaign or program is constantly learning and improving on the basis of past experiences, successes, and failures (Valente and Schuster, 2002).
One example of a social marketing approach is the ABC Immunization Calendar program developed by the Health Communication Research Laboratory at St. Louis University in Missouri. In response to the fact that less than half of children ages 2 and younger are fully immunized in most major U.S. cities, the ABC Immunization Calendar program was developed to raise immunization rates among children from families in lower socioeconomic groups—the targeted audience (Zell et al., 1994). Based on evidence that more patient-oriented approaches by providers have been recommended and that computer-generated educational materials that are tailored to individuals are more likely to be read, remembered, saved, and discussed and to lead to changes in behavior, especially among poor and underserved populations, the program provides computer-made immunization promotion calendars tailored to each child (National Vaccine Advisory Committee, 1992; Skinner et al., 1994; Brug et al., 1996; Bull et al., 1999). The calendar includes the child’s name, picture, height, and weight as well as room to track his or her growth, family birth dates, helpful hints, interesting facts about the child’s living environment (e.g., use of car seats, limiting exposure to smokers, and the presence of smoke detectors in the house), the most recent and next immunization appointment, and appointments for future well-baby checkups.
The calendars were developed on the basis of interviews and focus group meetings with mothers of young children from communities of lower socioeconomic status who strongly supported the inclusion of a color photo of their child on the calendar. Because many families could not afford to have professional pictures taken of their child, the calendar fulfilled this need and was seen as a valuable and prized addition to the home. The calendars were printed on brightly colored paper and laminated for durability. Mothers would receive calendars for each of the months leading up to their children’s next immunization appointment. When the child was vaccinated, new calendars were generated for the next appointment. As a result, the calendars provided an incentive for the family to keep appointments, come to the clinic, and have the child immunized.
To monitor the program’s effectiveness, mothers who were given calendars, as well as the providers at participating health clinics, were asked about the perceived value and utility of the calendars, enrollment in the program, adherence to the immunization schedule in terms of keeping appointments, and overall immunization behavior. In the clinics and communities where the ABC Immunization Calendar program has been implemented, great strides have been made in increasing the number of immunized children. Multiple strategies at the state, clinic, and family or
community levels, however, are needed to more effectively increase the rate of childhood immunization among families in lower socioeconomic groups. An immunization tracking database at the state level can help health care providers identify children who are not yet immunized, whereas clinics can offer immunizations during the evenings and weekends or at facilities in the community, such as a house of worship or community center, so that more parents have opportunities to have their children vaccinated. Coupled with these two components, the ABC Immunization Calendar program uses the focus and strategies of social marketing to more effectively engage parents and ensure higher rates of childhood immunization among low-income and underserved families.
The national Turning Point Initiative3 understood the potential impact that social marketing initiatives can have on improving population health and formed a collaborative of partners to review and widely disseminate social marketing information to improve community health. A resource guide on social marketing is available from the Turning Point (2002) website.
A clear tension exists between social marketing and corporate marketing, especially when corporate advertising messages result in audience confusion. Corporation-sponsored ads that are health promoting can undermine public health media campaigns. Farrelly and colleagues (2002) found that corporation-sponsored “don’t smoke” campaigns that target youth were associated with an increase in the intention to smoke in the next year. Landman and colleagues (2002) also concluded that tobacco industry programs that target youth do more harm than good for tobacco control. In Florida, tobacco program evaluators noted that Philip Morris ads confused youth viewers and interfered with the state-sponsored antismoking campaign.
Since its commercials, which are preachy and poorly done, run in the same demographic buy as the “truth” commercials, which have already been established as irreverent and effective, Philip Morris’ efforts have proven problematic. Many teens assume the Philip Morris ads are “truth” ads and have asked why the campaign has “gone lame.” (Florida Department of Health, 1999)
As a result of such findings, antismoking associations such as the America Legacy Foundation (www.americanlegacy.org) have called for the removal of tobacco industry-supported “don’t smoke” campaigns.
As discussed in Chapter 2, an increasing science base links social determinants to the health status of populations. Health behavior, in particular, has been shown to be linked to the larger social, political, and economic environments (Smedley and Syme, 2000). Media advocacy is a developing strategy that seeks to change social determinants of health, primarily public policy, rather than personal habits or behaviors. Specifically, media advocacy is defined as the strategic use of mass media and its tools, in combination with community organizing, to advance healthy public policies. The primary focus is on the role of the news media, with secondary attention to the use of paid advertising (DHHS, 1989; Wallack and Sciandra, 1990, 1991; Wallack et al., 1993; Chapman, 1994; Wallack, 1994; Wallack and Dorfman, 1996; Winett and Wallack, 1996). Media advocacy seeks to create a loud voice for social change and shape the message so that it resonates with social justice values that are the presumed basis of public health (Beauchamp, 1976; Mann, 1977). A wide range of grassroots community groups, public health leadership groups, public health and social advocates, and public health researchers have used media tools to effect social change that would influence health (Wallack et al., 1993, 1999; Woodruff, 1996).
Media advocacy differs in many ways from traditional public health campaigns. In particular, it emphasizes the following: 4
Linking public health and social problems to inequities in social arrangements rather than to flaws in the individual;
Changing public policy rather than personal health behavior;
Focusing primarily on reaching opinion leaders and policy makers rather than on those who have the problem (the traditional audience of public health communication campaigns);
Working with groups to increase participation and amplify their voices rather than providing health behavior change messages; and
Having a primary goal of reducing the power gap rather than just filling the information gap.
Media advocacy is generally seen as a part of a broader strategy rather than as a strategy per se and focuses on four primary activities in support of community organizing, policy development, and advancing policy:
Developing an overall strategy: Media advocacy relies on critical thinking to understand and respond to problems as social issues rather than personal problems. Following problem definition, the focus is on elaborating policy options; identifying the person, group, or organization that has the power to create the necessary change; and identifying organizations that can apply pressure to advance the policy and create change. Finally, various messages for the different targets of the campaign are developed.
Setting the agenda: Getting an issue in the media can help set the agenda and provide legitimacy and credibility to the issue and the group. Media advocacy involves understanding how journalism works to increase access to the news media. This includes maintaining a media list, monitoring the news media, understanding the elements of newsworthiness, pitching stories and holding news events, and developing editorial strategies for reaching key opinion leaders.
Shaping the debate: The news media generally focuses on the plight of the victim, whereas policy advocates emphasize the social conditions that create victims. Health advocates frame policy issues using public health values that resonate with broad audiences. Some of the steps include “translat[ing] personal problems into public issues” (Mills, 1959); emphasizing social accountability as well as personal responsibility; identifying individuals and organizations that must assume a greater burden for addressing the problem; presenting a clear and concise policy solution; and packaging the story by combining key elements such as visuals, expert voices, authentic voices (those with experience with the problem), media bites, social math (creating a context for large numbers that is interesting to the press and understandable to the public), research summaries, fact sheets, policy papers, and so forth.
Advancing the policy: Policy battles are often long and contentious, and it is important to develop strategies to maintain the media spotlight on the policy issue on a continuing basis. This means identifying opportunities to reintroduce the issue to the media, such as on key anniversaries of relevant dates, upon publication of new reports, by providing notice of significant meetings or hearings, and by linking the policy solution to breaking news (Wallack, 2000; Dorfman and Woodruff, 2002).
To demonstrate when media advocacy is an appropriate strategy, Wallack and Dorfman (2000) provide the example given in Box 7–5. This example emphasizes that economic conditions had to change before individual behaviors could be expected to change.
The Coalition on Alcohol Outlet Issues (CAOI) in Oakland, California, is one group that has used media tools to secure passage and implementation of legislation designed to reduce crime around liquor stores (Seevak, 1997). Formed in 1993, the citywide coalition included a broad range of
BOX 7–5 Wallack and Dorfman’s Example
5-a-Day campaigns have as their goal improving health status by increasing consumption of fruit and vegetables. This worthy goal will remain unattainable, despite the most persuasive communications campaign, if fruit and vegetables are not easily available and affordable. One local group in California wanted to initiate a local 5-a-Day campaign to improve the outcomes of teen pregnancies. When they sought our advice on administering a 5-a-Day campaign, we asked, “Where will the young women get the fruit and vegetables?” The major supermarkets have abandoned the inner-city neighborhoods that were home to the teens they wanted to reach, leaving nothing but corner liquor stores that stocked old and expensive fruit and vegetables, if they stocked them at all. We suggested they frame this from an economic development perspective and involve the teens in a campaign to demand the return of the grocers, to initiate a community garden, or other effort to create an environment in which they could make healthy choices for themselves and their families. In this example, a 5-a-Day social marketing campaign would make sense only after a campaign had been carried out to ensure the local availability of fruits and vegetables.
SOURCE: Wallack and Dorfman (2000).
community-based organizations and residents whose goals were to educate the community about alcohol outlet issues and to organize and generate support for Ordinance 11625. This ordinance would require liquor stores to pay an annual fee of $600 to cover the cost of an education, monitoring, and enforcement program to reduce problems associated with alcohol outlets such as violence, drug dealing, gambling, prostitution, vandalism, and other public health and safety problems. Ultimately, this ordinance would give the city authority to revoke the business permits of noncompliant liquor stores.
CAOI’s membership included all racial and ethnic groups and mirrored the population mix of the city, especially the “flatland” areas with the lowest median household income; the largest number of public housing projects; the fewest grocery stores, community centers, and job opportunities; and three to five times as many liquor stores as the wealthier parts of the city. From the beginning, CAOI committed itself to keeping its members engaged in a well-organized and clear strategy to secure passage of the ordinance. The strategy also called for reaching out to the community and building support among members who would actively participate in CAOI’s initiatives. The coalition used media tools to educate community members about the ordinance, demonstrate unity of opinion to policy makers, and
identify “holes” in the arguments of the opposing side (i.e., the liquor industry’s desire for profits over social and environmental improvements in the city). CAOI’s strategy included meeting with public officials, testifying at hearings, providing well-prepared spokespersons, and holding demonstrations and rallies to which the media was always invited.
The coalition developed close relationships with journalists and other media outlets by providing newsworthy information, storylines, and testimonials. CAOI also prepared media or press kits for all journalists and easy access to coalition contacts. As a result, dozens of print, television, and radio stories were generated that secured the attention of policy makers and helped frame the issue as one of public safety and local control.
CAOI incorporated media tools with each step of the political process, including drafting the ordinance, securing passage by the City Council, and implementing the legislation. The coalition also helped fight off the legal and legislative tactics employed by the liquor industry, which sought to derail the ordinance by arguing that the city had overstepped its authority and had no legal right to pass such requirements on alcohol outlets. In the end, the California Supreme Court upheld the ordinance and ensured that cities and counties across California had tools to better regulate alcohol availability.
HEALTH COMMUNICATION CAMPAIGNS: THEORY, EVALUATION, AND RESEARCH NEEDS
In the twentieth century, large-scale health communication campaigns focused on the promotion of hygiene behaviors, safety and accident prevention, substance abuse prevention, adoption of healthy lifestyles and eating habits, family planning and contraceptive use, and many other topics (Valente and Schuster, 2002). Through mass media campaigns, health promoters try to accelerate behavioral change by informing the public (increasing knowledge), changing attitudes, and directly encouraging individuals to adopt healthy behaviors.
Theories Used to Understand Media Impact
Behavioral change theory plays an important role in the promotion of health by use of communication strategies (Valente, 2002). Theory indicates the types of messages that will more likely be successful by specifying how behavioral change occurs. For example, if theory indicates that adolescents smoke because they incorrectly perceive smoking to be popular, then successful programs will have to change these norms. In short, theory guides program and message design. Theory is also used to estimate how much impact can be expected from a health communication program. Estimates
of impact are important for determining the sample size needed to conduct an appropriate evaluation to assess whether the program worked. Finally, theory can help determine why and how a health promotion program did or did not work (Valente, 2002). A short synopsis of relevant behavioral change and media impact theories follows.
Social Influence, Social Comparison, and Convergence Theories
Social influence, social comparison, and convergence theories proposed by social scientists specify that one’s perception and behavior are influenced by the perceptions and behaviors of the members of groups to which one belongs. Peer group influences and social influences such as those presented through television and radio can affect the process of change and eventual conversion of behavior (Johns Hopkins University, 2003).
Health Belief Model
The health belief model is one of the oldest models developed to understand health-related behavioral change (Becker, 1974). It reflects a conscious decision-making process (Peterson and DiClemente, 2000). The model posits that two major factors influence the likelihood that a person will adopt a recommended health-protective behavior. First, the person must feel susceptible or threatened by the disease or condition, and a high level of severity must characterize the condition. Second, the person must believe that the benefits of taking the recommended action outweigh the perceived barriers (or costs) to performing the preventive action (IOM, 2002). The health belief model is believed to have been used more than any other health-related behavioral change model over the past decade (Peterson and DiClemente, 2000).
Diffusion of Innovation Theory
The diffusion of innovation theory describes the process by which an innovation, new ideas, opinions, attitudes, and behaviors are communicated through certain channels over time and spread among the members of a social system or community (Ryan and Gross, 1943; Katz et al., 1963; Rogers and Kincaid, 1981; Valente, 1993, 1995; Rogers, 1995; Valente and Rogers, 1995). Diffusion theory has been used to examine the spread of new computer technology, educational curricula, farming practices, family planning methods, medical technology, and many other innovations. Diffusion theory has five major assumptions: (1) adoption takes time; (2) people pass through various stages in the adoption process; (3) they can modify the innovation and sometimes discontinue its use; (4) the perceived characteris
BOX 7–6 Critical Steps in Persuasion
tics of the innovation influence its adoption; and (5) individual characteristics influence its adoption (Valente and Schuster, 2002). Rogers (1995) suggests that the mass media are quick, effective routes for introducing new information, especially in the early stages and with audiences that are predisposed to accepting new ideas.
Input–Output Persuasion Model
Formulated by William McGuire in 1969, the input–output persuasion model identifies five steps that are critical to how successful persuasion attempts will be in effecting change (see Box 7–6). The theory also considers how various aspects of communication such as the message design, source, and channel, as well as receiver characteristics, affect the behavioral outcome of communication (McGuire, 1969, 1981).
Theory of Reasoned Action
Proposed by Fishbein and Azjen in 1975, the theory of reasoned action specifies that the adoption of a behavior is a function of a person’s intention to perform that behavior. The intention to perform a given behavior is, in turn, a function of a person’s attitude toward performing the behavior (belief that performing the behavior will lead to certain outcomes and the expected value of the outcome) and of perceived social norms (belief that a specific individual or groups thinks that one should or should not perform the behavior in question) and motivations to comply (the degree to which, in general, one wants to do what the referent thinks one should do) (IOM, 2002).
Social Learning (Cognitive) Theory
According to the social learning (cognitive) theory model, four components are critical if behavioral change is to occur. First, an information
component is needed to increase awareness and knowledge and to convince people that they have the ability to change behavior. Second, a motivational component is needed to develop social and self-regulatory skills to practice the new behavior. A third component enhances the development of social and self-regulatory skills (through the promotion of self-efficacy), and a fourth component develops or engages social supports for the individual making the change. Applied to communication through the mass media, the message gives audiences an opportunity to identify with characters who demonstrate (different or new) behaviors and allows them to engage the emotions and mentally rehearse and model the new behavior (Bandura, 1977, 1986; Peterson and DiClemente, 2000; IOM, 2002).
Theories of Emotional Response
As described by Zajonc, emotional response is believed to precede and condition cognitive and attitudinal effects. For communication strategies, this means that highly emotional messages would be more readily accepted by audience members and would more likely lead to behavioral change than messages that are low in emotional content.
The stages-of-change theory posits that several psychological stages can be observed in individuals who are making a behavioral change (Prochaska et al., 1992). Changes in behavior are believed to result when the psyche moves through several iterations of a spiral process. This process begins with precontemplation (not really considering making the change); continues with contemplation of making the change, preparation (intention to make the change), and action (making the change); and finally, ends with maintenance of the new behavior.
Cultivation Theory of Mass Media
George Gerbner proposed the cultivation theory of mass media in 1973. The theory proposes that repeated and intense exposure to definitions of “reality” in television and other mass media messages can lead to the perception of that reality as normal. The social legitimization of the reality presented can thus affect behavior (Gerbner, 1973, 1977; Gerbner et al., 1980).
The agenda-setting theory was made prominent by McCombs and Shaw (1972) and, more recently, by Dearing and Rogers (1996). The theory
provides a framework for understanding how media influences the salience of an issue in the minds of audiences. The theory suggests that the pervasiveness of mass media and the passivity of audiences allow the media to shape opinions. Furthermore, the theory allows consideration of how media attention to specific issues (e.g., violent crime) that is disproportionate to objective measures (e.g., statistics on violence) can influence what an audience thinks.
Drawing from the political and social sciences, framing theory suggests that the way in which information is framed can have a significant impact on the way that people process information and on their subsequent actions. As explained by Kinder and Berinsky (1999), “frames” are verbal, visual, or image devices used to focus and define a topic or issue in a particular way.
In the context of health communication, framing theory is used to develop strategies that will result in individual behavioral change or changes in public policy. For example, framing genetically linked cancers as a family issue as opposed to an individual issue could increase the impact of screening not only for the individual but also for the individual’s blood relatives, allowing a “family-centered approach” to cancer screening (Sheila Murphy, Annenberg School of Communication, University of Southern California, personal communication, 2002). Similarly, different public policy options are required if violent actions are framed as isolated, random incidents or as a public health problem that takes into consideration population-based violence statistics in the context of other community indicators, such as the availability of firearms and alcohol and the degree of unemployment.
The theories reviewed here are the most common ones used in the health and medical fields (Glanz et al., 1997), and most of them acknowledge that the media can play some role in influencing human behavior. These theories can be used to understand how health information in the media affects the public’s health, whether the information is received from deliberate media programming or from day-to-day behavior (IOM, 2002).
Evaluation and Research
Regardless of the media channels used to promote health, all health communication and promotion programs should be accompanied by evaluation and research activities designed to determine the impacts of the health promotion messages. This section provides a discussion of evaluation and research issues.
Evaluations of health communication and promotion programs should be systematic and participatory and should be designed to provide information that is useful for understanding whether the program worked, for whom, and to what degree and to provide information useful for deciding the appropriate next steps.
Evaluation frameworks such as Green and Kreuter (1991) and Valente (2002) can be used to plan evaluation activities. These frameworks generally call for needs assessment, formative research, monitoring, and summative research. The evaluation can be both qualitative and quantitative, but most importantly, it should be tailored so that it is appropriate to the intervention being evaluated. The tailoring requires that the evaluation be integrated into the design and implementation of the health communication activities.
Media-led interventions pose certain challenges for evaluation. First, for example, media communication cannot usually be restricted in its dissemination; thus, creating control groups can be challenging. Community-level evaluations have been conducted, but these often suffer from low statistical power. A second challenge is that media communication is often designed for specific audiences (e.g., teens, African Americans, or Hispanics) and so often cannot be replicated for other audiences or settings. A third challenge is to have the research and implementation teams integrated enough so that the evaluation team can respond to creative changes that occur in the intervention. McKenna and Williams (1993), for example, found that a CDC counteradvertising strategy based on subtle portrayal of the tobacco industry as manipulating teens to smoke did not communicate the message clearly to young teens. About 38 percent of those who viewed a campaign television spot believed that the main message promoted smoking. In conclusion, CDC researchers learned that it is important to obtain input from the target audience throughout the creative process and that more research is needed to better execute messages to target audiences.
Naturally, many other challenges face evaluators as they try to determine what works in the deliberate and not-so-deliberate communication of health information to the public (Valente, 2002). Behavioral change theory is useful for setting program goals and objectives, as these theories attempt to explain the motivations for human behavior. These objectives are then used to determine the study sample sizes needed to demonstrate program effectiveness. Selecting an appropriate study design (experimental versus quasiexperimental, community versus individual level) is a challenge and is often dictated by the planned intervention. For example, a program that uses billboards to communicate its message is delivered at the community level; thus, it is not possible to assign individuals randomly to the intervention.
The difficulty in health promotion program evaluation lies in the fact that every evaluation presents its own demands in terms of the trade-off between rigor and cost. Although randomized control trials are the “gold standard” for evaluating the impact of an intervention, they are rarely feasible for community- or population-based programs. Trade-offs between rigor and feasibility are inevitable and are best addressed by informed researchers who can control relevant threats to validity. Thus, there is a need not only to evaluate health promotion interventions but also to develop an evidence base for what works, among whom, and to what degree.
Research on the effectiveness of media promotions for changing health-related behavior has been conducted for some time. The most commonly researched topics have been tobacco use, alcohol abuse, screening for cancer and other diseases, seat belt use, and the promotion of contraceptives and methods to prevent STDs. These studies have shown that the media can be used to increase knowledge about appropriate behaviors, create more positive attitudes toward the health behaviors, and lead to behavioral change among audience members. This triad of outcomes, knowledge (K), attitudes (A), and practices (P), has provided a convenient shorthand for guiding research on the effectiveness of media-driven health promotions. The degree of evidence for KAP models of behavioral change, however, is limited (Valente et al., 1998). Further research is needed to determine whether the KAP model is a useful one for understanding the impacts of media communication and what other models can or should be developed to understand media-generated behavioral change.
Regardless of the steps that precede behavioral change, media communication has been found to influence behavioral change. In a series of meta-analyses, Snyder (2001) has discovered that media communication about health have been shown to create about an 8-percentage-point change in behavior. Media communication creates more change when it promotes the adoption of new behavior (condom promotion) than when it attempts to get people to quit addictive behaviors (tobacco use). Research by Flynn and colleagues (1992, 1994) also suggests that media campaigns combined with other strategies such as school smoking prevention programs are effective in changing behavior. Thus, although the mechanisms for their effectiveness are not entirely understood, the media play a vital role in assuring the health of the public in the twenty-first century.
The top priority for the research agenda on the effect of media communication on health behavior is to conduct basic research on how the media influence individual health decisions as well as the public’s health (Logan et al., 1999). This research would attempt to understand how media commu-
nications affect health-related behavior by understanding the steps to behavioral change and comparing different theories of behavioral change within a media intervention framework.
A second priority is to determine which media vehicles should be used for which purposes to determine the most effective way to communicate health information to the public. Most research has been conducted with the understanding that the mass media is useful for raising awareness and driving the public agenda, but behavioral decisions are also influenced by interpersonal communication. The interaction between interpersonal communication and media messages, however, is not well understood (Valente and Saba, 1998, 2001). For example, do the media prompt interpersonal discussions that then set in motion a series of behavioral change steps?
A third priority is to develop the evidence base for how health communication can better influence public policy. Research is needed particularly on the overall strategies of media advocacy and social marketing for effecting policy changes, in particular changes that may shape the social determinants of health. Research that can tease out the effects of media communication from community organizing and policy advocacy is also needed. Furthermore, a deeper understanding of which strategies are most appropriate and suited to which goals would be useful to public health practitioners. The committee recommends that public health and communication researchers develop an evidence base on media influences on health knowledge and behavior, as well as on the promotion of healthy public policy.
In this age of information, there is good reason to acknowledge the potential of the mass media in assuring population health. Print and broadcast news media outlets, entertainment television, and the Internet constitute immensely influential channels through which people gather their information, accurate or not, about health. Given the speed and diversity of media outlets, they cannot be considered mere commentators in dialogues on popular culture about health, health risk, and health behaviors. They can foster and participate in informal interfaces (e.g., professional connections and contact points) and formal interfaces (e.g., fellowships and other cross-training for media and public health professionals) with academia. Also, the media and governmental public health agencies can enhance their understanding of each other’s methods and perspectives (e.g., through communication between health officials and journalists or reporters). It is time that media outlets acknowledge their role in the public health system, the strength of their influence, and their potential for assuring the public’s health.
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