Promoting Health: Intervention Strategies from Social and Behavioral Research (2000)

Lawrence Wallack, Dr.P.H.^1,2

In the summer of 1999 the East Coast was suffering through a terrible heat wave and deaths were mounting (Barstow, 1999). New York City sagged under the oppressive weight of the heat and city officials were struggling to address the crisis. The apparent cause of death for those who died was the physical effects of the heat. However, the underlying cause simply may have been fear and isolation, in part the consequence of not being connected to a broader community. One news report related the observation of emergency workers who said “an alarming number of city residents without air-conditioning keep their windows shut because they fear becoming victims of crime, and instead became

patients” (New York Times, 1999, p. 1). An earlier heat wave killed more than 700 in Chicago (Semenza et al., 1996). Of course these deaths were not random occurrences; those most likely to die were isolated, disconnected, and likely to live in high homicide areas (Shen et al., 1995). A lower risk of death was associated with “anything that facilitated social contact, even membership in a social club” (Semenza et al., 1996, p. 90).

Heat waves provide a useful reference for thinking about the role of media in public health. It is a seemingly simple matter to reduce personal risk by opening a window or going out to a cooling station. Yet, people's behavior is strongly influenced by the social, economic, and political context of the larger community. Failure to account for the influence of community forces on behavioral choices will lead to narrowly focused media approaches that perilously ignore significant determinants of health.

The media matter in public health. But just how they matter is often a contentious issue. The way media matter is based on how we conceptualize the nature of public health issues and hence their solutions—and this is often controversial. If public health problems are viewed as largely rooted in personal behaviors resulting from a lack of knowledge, then media matter because they can be a delivery mechanism for getting the right information to the right people in the right way at the right time to promote personal change. If, on the other hand, public health problems are viewed as largely rooted in social inequality resulting from the way we use politics and policy to organize our society, then media matter because they can be a vehicle for increasing participation in civic and political life and social capital to promote social change. Of course, media matter in both these ways and other ways as well.

The central argument of this paper is that mass media approaches to improving the public's health need to be rethought in light of recent developments in social epidemiology, political science, sociology, and mass communication. Of particular importance is how these findings relate to social capital and population health. Traditional behavioral-oriented media campaigns, while useful, have been limited in creating significant behavior change and improvements in health status (e.g., McGuire, 1986). While there are many reasons for these modest results, this may be due in part to the failure of these campaigns to adequately integrate fundamental public health values related to social justice, participation, and social change—values made more important by the increasing research on the relationship between social inequality and health inequality.

There is an expanding science base for understanding public health as a product of social and political arrangements rather than of primarily personal behaviors. This is not to say that individual actions and personal responsibility are not important, but only to emphasize that behavior is inextricably linked to a larger social, political, and economic environment. Attempting to address public health problems without attending to the context in which they exist inevitably produces, at best, limited solutions. An important part of that context may be the range of opportunities for people to participate in the life of the community. The importance of involvement in civic life may well be a fundamental characteristic

of socially and economically healthy communities (e.g., Sampson et al., 1997; Gittell and Vidal, 1998). Thus, future media approaches must focus on skill development for participation in the social change process rather than primarily on information for personal change. Civic or public journalism, media advocacy, and photovoice are particularly well suited to this task and are explored in this paper.

This paper provides a framework for understanding the role of media in advancing public health and social goals. It briefly reviews the implications of recent social epidemiological and political science research for developing mass media interventions, the limits of previous public health efforts to use mass communication strategies, and prospects for a new public health media of engagement and participation.

There is a long history establishing the role of social status, measured in various ways, as a strong determinant of health (Haan et al., 1989a,b; Adler et al., 1993; Adler et al., 1994; Marmot and Mustard, 1994; Anderson and Armstead, 1995; Blane, 1995; Kaplan, 1995; Lantz et al., 1998). This extensive body of research indicates that social class differences exist for virtually every type of adverse health outcome and for treatable as well as nontreatable diseases. Rather than this being a rich-poor dichotomy or a factor just of poverty, the distribution of disease follows a gradient. This means that even among those in the upper quadrant of income or education levels in the society, those lower in the quadrant have poorer health. These findings are robust and appear consistent over time and across western industrialized countries. The health differences cannot be explained by traditional risk factors or access to health care. So access to health care is not the defining factor for population health status. The explanation for the social gradient is unclear. A wide range of material (physical resources) and nonmaterial (psychosocial) factors has been suggested.

More recently, this line of research has focused on the specific issue of income inequality as a property of the larger social system. This research suggests that it is not the individual's absolute level of resources that matters as much as one's position relative to everyone else (Smith and Egger, 1992; Wilkinson, 1992, 1996; Duleep, 1995; Kaplan et al., 1996; Kennedy et al., 1996; Navarro, 1997). The central concept is that up to a point the level of absolute income or resources in a society contributes to increasing health status. After that point, however, the way that the resources are distributed has the greatest impact on health: “In the developed world, it is not the richest countries which have the best health, but the most egalitarian ” (Wilkinson, 1996, p. 3).

Social capital appears to be an umbrella concept that includes anything that helps to remove the barriers to collective action in communities. The general

concept is certainly not foreign to the social and community emphasis of public health and is related to various concepts such as collective efficacy, psychological sense of community, neighborhood cohesion, and community competence (Lochner et al., 1999). Specifically, Gittell and Vidal (1997) define social capital as “the resources embedded in social relations among persons and organizations that facilitate cooperation and collaboration in communities” (p. 16). Social capital seems rather like a glue made from various ingredients that holds communities together and allows them to work better together to achieve common goals. It is a component of social cohesion that includes social trust and civic participation (Putnam, 1993). Coleman (1990, p. 302) explains that social capital is defined by its function— what it does rather than what it is:

It is not a single entity, but a variety of different entities having two characteristics in common: They all consist of some aspect of a social structure, and they facilitate certain actions of individuals who are within the structure. Unlike other forms of capital, social capital inheres in the structure of relations between and among persons.

However, there are specific things that appear to be markers for higher levels of social capital. These include increased social trust, generalized norms of reciprocity, group membership, interdependence, and networks or social organizations through which the cooperation of individuals can be facilitated toward action (Coleman, 1990; Putnam, 1993, 1995a,b). In addition, there is an important prescriptive norm associated with social capital that calls on people to “forego self interests to act in the interests of the collectivity” (Coleman, 1990, p. 311). In sum, social capital is marked by norms, skills, or other individual characteristics, and structures that facilitate groups of people working toward the collective or community good. Civic engagement, when combined with social trust and facilitated by social connectedness, creates social capital (Putnam, 1995b).

Social capital, then, generates new opportunities for communities to participate in civic life. It allows groups to work together toward shared goals that create mutual benefits, and it smoothes the process because high levels of trust and connectedness help to overcome the traditional obstacles to collective action (Putnam 1993, 1995b) —social capital allows groups to achieve ends that otherwise would be beyond their capacity (Coleman, 1990). Importantly, social capital is cumulative and generalizable. It can be created for one purpose and used for other purposes. For example, a group working to increase the responsiveness of a local school board to community concerns might also be effective in mobilizing people to change the way police interact with the neighborhood.

Another important aspect of social capital is that it is not “owned” by any individual. A community with higher levels of social capital creates benefits for all of those in the community whether they helped create the social capital or not. Consider the East Coast heat wave: if communities had stronger social cohesion—marked, perhaps, by neighborhood watch groups—then individuals might be more likely to open their windows or go to a cooling station regardless of whether they participated personally in a neighborhood watch group.

Social capital, of course, can also be used for ends that many might not view as socially desirable. For example, youth gangs might be seen as reservoirs of social capital for young people in certain communities, and hate groups might flourish because of the social capital generated by the trust, norms, and dense quality of group membership. Thus, from a public health perspective, social capital should have a social justice criteria—does it contribute to a fairer, more equitable, and just society (Beauchamp, 1976)?

Drawing on research from political science and sociology (Coleman, 1990; Putnam, 1993, 1995a,b), public health research has now moved beyond identifying the relationship between social inequality and health inequality. It has begun to identify potential explanations for the relationship and implications for the design of public health interventions. The work of Kawachi and colleagues (Kawachi and Kennedy, 1997; Kawachi et al., 1997a,b; Kennedy et al., 1998) and others (Wilkinson, 1996; Lynch and Kaplan, 1997) is especially important in that it has identified lower levels of social capital as a pathway that may channel income inequality into increased mortality. For example, higher overall mortality and rates for most major causes of death were associated with lower measures of social capital as measured by group membership, voting levels, and social trust across 39 states in the United States (Kawachi and Berkman, 1998). Kennedy et al. (1998) reported that the depletion of social capital was strongly associated with homicide and violent crime, even when controlling for poverty and access to firearms. Also, self-reported health status, a strong indicator of actual health (Idler and Benyamini, 1997), is significantly related to the amount of social capital at the state level (Kawachi and Berkman, 1998).

There are various ways that social capital might influence population health. For example, areas with higher levels of social inequality may “systematically underinvest in human, physical, health and social infrastructure” (Lynch and Kaplan, 1997, p. 306). Also, lack of social capital might inhibit the flow of health information through populations, could make it less likely that communities band together for collective action to insure basic health and social services, and might influence psychosocial processes that increase the sense of isolation and low sense of self-efficacy of those living in less cohesive communities (Kawachi and Berkman, 1998).

Social capital appears to be an “elastic” commodity in the economic sense. That is, small increases in various components of this public good can result in significant benefits. For example, a 10% increase in the level of social trust, a marker of social capital, could result in an 8% reduction in overall mortality (Kawachi et al., 1997). Addressing a related concept, Sampson and his colleagues (1997) found that a 2-standard deviation increase in collective efficacy—a community's willingness to intervene in community life that is linked to social trust and solidarity—was associated with an almost 40% reduction in the expected homicide rate.

The mass media are a significant part of the environment in which the pursuit of public health goals occurs. The mass media facilitate the pursuit of public health goals in some ways and obstruct it in other ways. On the one hand, large-scale, mass-mediated educational programs to inform the public about health threats have long been a staple of public health practice (Wallack, 1981). Over the years, these campaigns have become increasingly sophisticated with new standards set for the integration of research, theory, planning, and evaluation by the Stanford Heart Disease Prevention Program in the 1970s (Farquhar et al., 1984, 1990; Flora et al., 1989; Fortmann et al., 1990). Current programs involve much greater levels of resources and a strong focus on high-impact advertising. Nonetheless, current efforts, like previous efforts, have generally been limited in achieving the goals for which they were designed.

On the other hand, the public health community has long been concerned about the mass media as a source of problems. Various types of advertising and the portrayal of health-compromising behaviors and products in the media have been identified as promoting disease rather than health. The potential influence of movies, advertising media, and television programming has been considered in regard to alcohol, tobacco, and other drug use; violence; nutritional behavior; sexual behavior; traffic safety; and various other public health threats (e.g., Gerbner, 1990; Centerwall, 1992; Strasburger and Comstock, 1993; Strasburger, 1995; Singorielli and Staples, 1997; Kilbourne, 1999; Kunkel et al., 1999). Over the years, various interventions have been developed to influence the producers, directors, and writers of television series to change or include specific information on various health topics such as alcohol, tobacco, immunization, drunk driving, emergency contraception, and other topics (e.g., Breed and DeFoe, 1982; Montgomery, 1989; DeJong and Wallack, 1992; Glik et al., 1997; Langlieb, Cooper, and Gielen, 1999).

The research on social capital has significant implications for developing media strategies in public health. It expands our attention to whether the very nature of the structure and organization of the media might build or destroy social capital, might add to or detract from public health. It suggests that broader issues must be addressed—the nature of commercialism rather than advertising about a specific product, the impact of television on social relations rather than on specific behaviors—but public health has not raised these issues in a substantive way. The introduction of social capital as a concept that cuts across many categories of public health threats demands consideration of the broader effect of media on our social fabric rather than just on our specific behaviors.

The rugged individualism inherent in American society is one of the major barriers to collective action and a cornerstone of a market system that generates excess public health casualties (Beauchamp, 1976, 1981, 1988; Bellah et al., 1986). Technological trends will likely increase individualism and further undercut the foundation for the type of social cohesion necessary for a civil society

(Putnam, 1995a; McChesney, 1999). Hypercommercialism, the commodification and marketing of virtually everything, cuts across all media and into all aspects of everyday living. Hypercommercialism may well increase a sense of hyperindividualism and contribute to a focus on increasing personal accumulation rather than enhancing social participation. This has serious implications for social capital and creates urgency for innovative media approaches to build social capital.

There are various ways that mass media may inhibit the formation of, or reduce, the stock of social capital in the society. If the concept of social capital and civic engagement is broadened to political participation, its potential effects can expand considerably. From a public health perspective, increasing engagement in community health issues is likely to lead to increased participation in the political process. Those working to prevent alcohol problems, limit availability of handguns, prevent tobacco use, improve nutrition in schools, or prevent unsafe sexual activity quickly find themselves moving from simply working with others to confronting political institutions and interest groups on policy issues.

If social capital is the glue that helps communities work effectively on collective issues, then it is important that the media do not dissolve the bonding capacity of the glue. Unfortunately, television, and mass media in general, may function to reduce rather than reinforce or nurture social capital. Putnam (1995a) asserts that there has been a significant decline of social capital in the United States and attributes a substantial part of the blame to television. Both of these claims have been disputed, with Ladd (1999) arguing that social capital, far from declining, is being generated at levels beyond anything in the past, and others questioning the focus on television as a significant variable (Schudson, 1996). However, for purposes of this paper, my concern is whether social capital is related to indicators of public health and whether mass media might influence the level of civic participation from a public health perspective.

Television viewing contributes to lower levels of group membership and civic trust—two key components of social capital (Putnam, 1995a). This occurs because the time spent watching television displaces time that might be allocated to other activities related to civic life. Further, increased television viewing may lead to higher levels of pessimism and cynicism about the world.

George Gerbner and his colleagues (1994a) have argued that television cultivates a very distorted perception of the world in heavier viewers. For example, these heavy viewers score low on social trust and are less accepting of norms of reciprocity. When compared with lighter viewers, heavier viewers are more likely to believe that most people “cannot be trusted” and are “just looking out for themselves” (p. 30). Further, compared with lighter viewers, they are more likely to overestimate their chances of being victimized by crime or violence, believe that their neighborhood is unsafe, and assume crime is rising regardless of the actual facts. Television “facts ” become the basis for making judgments

about the real world. Not surprisingly, heavier viewers are more likely to express “gloom and alienation….[and] express a heightened sense of living in a mean world of danger, mistrust, and alienation” (Gerbner et al., 1994b, p.9). So, not only do people have less time to participate in civic activities, but their level of fear, mistrust, and alienation would hardly make such participation inviting.

Another issue raised by Putnam is that of the passivity-inducing role of television. Indeed, Postman (1985) argues that television, and the media in general, provide an information glut that trivializes public discourse, distracts people from substantive issues, and renders the population passive. The issue of passivity draws us to the broader issue of the structure and function of the mass media. Writing before the diffusion of television, Lazarsfeld and Merton (1948) worried that the mass media inhibited social change and suggested that they might contribute to a population that was “politically apathetic and inert” (p. 501). Similar to Postman who followed, they were concerned that the flood of information from a mass media motivated primarily by profit rather than public interest would “narcotize rather than energize the average reader or listener” (p. 502). Schiller (1973) picks up this theme and argues that it is, in fact, the aim of the mass media to lessen rather than raise concern about social issues.

The primary source of news for people is local television, though newspaper reading is more strongly associated with voting (Stempel and Hargrove, 1996). Journalism, in general, has been severely criticized for its contribution to the trivialization of public discourse and the alienation of the public from the political process (e.g., Fallows, 1997; McChesney, 1999). Part of the reason for this is the way that the news fragments issues and thus obscures the connections among them (Schiller, 1973). Iyengar (1991) argues that television news overwhelmingly frames social issues episodically in concrete, individual, personal stories that communicate personal responsibility rather than social accountability. The result is that viewers are more likely to “blame the victim” for the cause and solution of the problem rather than hold public officials or institutions accountable. He explains, “Because television news generally fails to activate (and may indeed depress) societal attributions of responsibility,…it tends to obscure the connections between social problems and the actions or inactions of political leaders. By attenuating these connections, episodic framing impedes electoral accountability” (Iyengar, 1991, pp. 141–142).

Most recently, McChesney (1997, 1999) has argued that the very nature of the media system in the United States “undermines all three of the meaningful criteria for self-government” (1997, p. 7). These criteria are lack of significant disparities in wealth, a sense of community and acceptance of the idea that one's well-being is linked to the larger well-being, and an effective system of political communication that engages citizens. He argues that the mass media through corporate concentration, conglomeration, and hypercommercialism create a depoliticized, passive citizenry who are largely cynical and apathetic.

In sum, the mass media may adversely affect the development or maintenance of social capital in the United States. A fundamental question is whether the media relate to people as consumers or citizens (Burns, 1989). If they are val-

ued only as demographics that are more or less likely to consume various types of products, then media will offer little to efforts to build social capital. If, on the other hand, the media relate to people as citizens who are valued for their potential participation, then media may well offer much support for building social capital. An equally important issue is how people relate to the media.

If you ask a group of public health practitioners whether improvements in health status will come about primarily as a result of people getting more information about their personal health habits or of people getting more power to change the social and environmental conditions in which they live, they will inevitably voice the latter belief. Because many people enter the public health profession motivated by the opportunity for contributing to social change, and because practitioners are closely connected to people with the problems, they either bring or quickly develop an understanding of social causation of disease. However, when asked where most of their work effort is focused, they explain that they spend most of their time trying to change personal health behaviors, not social factors.³ The practice of public health, and certainly conventional health education, has, to a great extent, been the practice of building human capital—providing people with the tools for good health, in this case health information.

James Coleman (1990) distinguishes between human and social capital, a distinction that is fundamental to understanding the role of public health media campaigns to improve health. He explains, “…[H]uman capital is created by changing persons so as to give them skills and capabilities that make them able to act in new ways. Social capital, in turn, is created when the relations among persons change in ways that facilitate action” (p. 304). The history of media campaigns shows that they try to increase human capital, not promote collective action. These campaigns provide individuals with knowledge about risks such as alcohol, tobacco, sedentary life-styles, diet, unsafe sex, and the like in the hope that they will change the way they act. Sometimes such campaigns might attempt to link people, such as the recent $2 billion antidrug campaign that tries to get parents to talk to their children about drugs, but for the most part they simply provide people with health information (DeJong and Wallack, 1999). These campaigns are governed by the idea that people need more and better personal information to navigate a hazardous health environment rather than that people need skills to better participate in the public policy process to make the environment less hazardous.

Mass-mediated health communication efforts generally flow from a pragmatic logic that assumes an information gap in individuals—if people just knew and understood that certain behaviors were bad for them and others good, then these people would change to the behaviors that benefited their health. Filling the information gap becomes the purpose of the campaign; if enough people changed their behavior, then this would lead to a healthier society. The problem is operationally defined as people just not knowing any better. The goal, then, is to warn and inform people so they can change. In order to make this happen, campaigns focus on developing the right message to deliver to the largest number of people through the mass media. Finding the right message is central to the campaign and extremely important. The message, however, is always about personal change rather than social change or collective action.

Better health communication campaigns are characterized by at least three important factors. First, these campaigns are more likely to use mass communication and behavior change theory as a basis for campaign design. This means using a variety of mass communication channels, making sure the audience is exposed to the message, and providing a clear and specific action for the individual to take. Second, they are more likely to use formative research such as focus groups in order to develop messages and inform campaign strategy. Many better-designed interventions also include various social marketing strategies such as market segmentation, channel analysis, and message pretesting (Lefebvre and Flora, 1988). Third, they are more likely to link media strategies with community programs, thus reinforcing the media message and providing local support for desired behavior changes (Wallack and DeJong, 1995).

While there are many ways that a well-designed campaign can increase the potential for success, meaningful success itself has been elusive. In a comprehensive review of communication campaigns Rogers and Storey (1987) noted, “The literature of campaign research is filled with failures, along with qualified successes—evidence that campaigns can be effective under certain conditions” (italics in original, p. 817). This review, more optimistic than some and slightly more pessimistic than others, generally echoed previous reviews (Wallack, 1981, 1984; Alcalay, 1983; Atkin, 1983; McGuire, 1986) and anticipated later reviews (Salmon, 1989; Brown and Walsh-Childers, 1994; Wallack and DeJong, 1995; DeJong and Winsten, 1998).

Overreliance on public education campaigns constitutes a barrier to the accomplishment of public health goals. First, such an emphasis conflicts with the social justice ethic of public health, which calls for a fair sharing of the burden for prevention (Beauchamp, 1976). At worst, such campaigns may contribute to the problem they seek to address. This happens when the narrow behavioral focus of the campaign deflects our attention away from social and structural determinants of health by focusing exclusively on the behavior of individuals —in effect blaming the victim for the problem and placing the sole burden for change on him or her (Ryan, 1976; Wallack, 1989, 1990; Dorfman and Wallack, 1993).

Second, participation in civic life is generally not advanced by most of these campaigns since they tend to focus on personal behaviors that individuals can

take on their own behalf in order to improve their health. Public policy or social action is seldom, if ever, a focus of public health media campaigns because these campaigns are usually supported with public money that makes advocacy for specific policies problematic. Also, many media outlets will not accept public service announcements or even paid advertisements that are considered controversial—and policy issues that inevitably confront corporate interests are inherently controversial.

Third, such actions may be necessary or desirable but do not appear to be sufficient for improving the health of populations. Lomas (1998) argues that individual risk factor modification, an approach at the core of most mass media campaigns, has been “spectacularly unsuccessful ” (p. 1183).

Finally, it is not possible to define a problem at the community or societal level and then focus primarily on solutions at the personal or individual level. There are many definitions of public health but one clear thread running through these is the fundamental idea that the primary focus must be on the health and well-being of communities or populations, not individuals (Rose, 1985, 1992; Mann, 1997). It does not follow then that applying primarily individual-level solutions can effectively address public health problems.

The Institute of Medicine suggests a broad vision of the mission of public health, explaining that it requires creating the conditions in which people can be healthy. It goes on to say, “Clearly, public health is ‘public' because it involves organized community effort” (Institute of Medicine, 1988, p. 39). Social capital is a fundamental fuel for generating the kind of collective action that is required for public health to adequately pursues its mission. The crucial issue, then, is what kinds of media approaches can increase the capacity of groups, and broader communities, to act on matters related to public health that potentially benefit the entire society.

Developing media strategies to build social capital has two significant public health implications. First, in general, by increasing the level of social capital in the community, there may be benefits to the public's health in the form of lower overall mortality rates. Second, by increasing the level of social capital, groups may become more effective in advancing policies that may help to build a more egalitarian society and protect health (e.g., early childhood education). In addition, the skills and social structures associated with social capital can be put to use for other issues that might appear less central to health but nonetheless are still central to strong communities.

There are at least three promising media approaches that have the potential to build social capital and thus contribute to public health. These approaches are civic or public journalism, media advocacy, and photovoice.

Public health and journalism at their best hold an important value in common: attention to and concern for the well-being of the public. The former seeks to create the conditions in which people can be healthy (Institute of Medicine, 1988), and the latter seeks to create the conditions in which people can be good citizens (Merritt, 1995). It is now clear that these “conditions” are inextricably linked through the concept of social capital.

In the late 1980s and early 1990s, journalism was in crisis. There was great concern about the loss of public civility and the decline of public life. The 1988 presidential campaign had the lowest voter turnout since 1924 and journalism was being blamed for citizen apathy and cynicism. In 1994, a Times Mirror Poll reported that 71% of national respondents agreed that “the news media gets in the way of society solving its problems” (Merritt, 1995). The public was alienated from the political process; there was a sense that public life, politics, and journalism all seemed to be caught in a downward spiral (Clark, 1993; Merritt, 1995; Fallows, 1997).

Journalism in general, and newspapers in particular, began a process of soul searching about whether they might do a better job in serving the democratic process. What evolved in the early 1990s was the controversial concept of public journalism (Rosen, 1991, 1993; Merritt, 1995), and soon the term “civic journalism” was being used interchangeably (Rosen, 1994). ⁴ It was not long before interesting collaborations among local newspapers, television stations, and radio stations were developing around the country.

Civic journalism projects seek to engage the community in the process of civic life by providing information and other forms of support to increase community debate and public participation in problem solving. Jay Rosen, an academic, and Davis Merritt, a long-time print journalist, are among the best-known architects of civic journalism. They argue that civic journalism represents a fundamental shift in thinking by the journalist. This shift requires the journalist to be attached to community life rather than maintain the traditional pose of detachment (Rosen, 1994). They argue that journalists have a greater responsibility than just reporting the news. They have a responsibility to help the community work better. The purpose of civic journalism is to create a process by which citi-

zens can participate in the life of the community through public discussion, deliberation, collective problem solving, and ongoing involvement. By the end of the century, there were approximately 300 civic journalism projects in cities of varying sizes around the country (Friedland et al., 1998). These projects have addressed a diverse set of issues, including race relations, crime and violence, juvenile delinquency, alcohol, land use planning, domestic violence, economic development, community leadership, and voting participation.

Civic journalism projects are themselves quite diverse, employing a wide range of approaches. Generally, these projects are initiated by newspapers and involve television and radio stations as partners. They generally are based on three broad activities undertaken by civic journalists:

1. There is an extensive information development and data-gathering process. This can take the form of in-depth coverage of an issue where teams of reporters rather than just one or two are put on the story. In addition, in an effort to develop more insight into the community, special polls, focus groups, interviews, and other techniques are used (Wiley, 1998). Reports for various neighborhoods might be produced based on polling data, follow-up interviews by journalists with poll respondents, dialogues at town meetings, and detailed analysis of crime data.

2. There is far more extensive news coverage of the issue than is commonly seen, and the coverage is coordinated with other media outlets. This serves to increase the visibility, legitimacy, and urgency of the issue and set the public and policy agenda.

3. There are structures developed to insure that information and community concern are translated into action. Substantial efforts are often made to insure community participation and are facilitated through various means. In some cases a person is hired by the newspaper to coordinate the process. The Poverty Among Us project in St. Paul, Minnesota, provided money for child care and translators to remove barriers to participation in community discussions.

Civic journalism is still at an early stage, and the evaluation of projects is moving from case studies to more sophisticated survey research and statistical modeling analyses. Case studies provide an impressionistic view of problems, processes, challenges, and successes. For the most part the news is encouraging (Pew Center for Civic Journalism, 1997; Ford, 1998). High levels of media coverage of significant local problems are being generated, and participation in the projects seems extensive. In Charlotte, the Observer ran a front-page story on crime and violence that was augmented with four inside pages. The following month, the Observer provided almost seven pages to exploring life in the community. A local television station and two radio stations followed up with roundtables and call-in shows focused on solutions to the crime and violence problem (Taking Back Our Neighborhoods, 1995). Subsequently, more than 700 groups and individuals volunteered to work on various community needs. The city responded by razing dilapidated buildings, clearing overgrown lots, and

opening parks and recreation facilities. Local law firms got involved by providing pro bono services to close crack houses.

In Peoria, Illinois (“Leadership Challenge”), several hundred people met to develop a citywide action plan. New leaders emerged and the shape of city government changed when a person who had been influenced by the project ran for mayor and won. In Springfield, Missouri, the News-Leader's “Good Community” program focused on juvenile crime. One event attracted 700 people who pledged 13,000 hours to community service. After three years the project is continuing and “crime is down in Springfield and public involvement is up” (Ford, 1998, p. 15).

In Binghamton, New York, the Press and Sun Bulletin (“Facing Our Future”) convened a town meeting and devised 10 action teams on topics important for economic development. In addition to hiring a former city official to find discussion leaders for the teams, the newspaper provided special group process training for the team leaders. More than 100 meetings were held and more than 300 people participated in the team meetings. The media partners in the project covered recommendations of the teams. In this particular project, “Facing Our Future” continued on to become “Building Our Future” (Ford, 1998). More rigorous evidence is now available to support these anecdotal claims of effectiveness.

The most extensive evaluations of civic journalism have examined five projects in four cites. The first project, “Taking Back Our Neighborhoods,” addressed crime and violence in parts of Charlotte, North Carolina. The second and third projects, “We the People,” focused on land use issues and juvenile delinquency in Madison, Wisconsin. The fourth project, “Voice of the Voter,” tried to increase the vote among low-turnout groups in a mayoral election in San Francisco, California, and the final project, “Facing Our Future,” in Binghamton, New York, sought to stimulate citizen involvement in finding solutions to economic decline.

A series of evaluation studies provides encouraging findings on the effects of the civic journalism efforts (Chaffee et al., 1997; Ognianova et al., 1997; Thorson et al., 1997; Denton and Thorson, 1998). In general, the survey evaluations focused on outcomes as well as theoretical pathways and found promising results for the hypothesis that the news media can enhance the democratic process by increasing involvement (Denton and Thorson, 1998). It was fairly clear that interest in and discussion of civic issues could be attributed to the civic journalism projects (Madison). More importantly, the projects were associated with increased participation in neighborhood problem solving (Charlotte, Madison, San Francisco) and increased voting in groups with usually low turnout (San Francisco) (Chaffee et al., 1997). Chaffee and his colleagues were encouraged by their findings and concluded that “[civic journalism] programs appear from our evidence to be effective ” (p. 26).

While finding evidence of success, Chaffee and his colleagues were concerned that selective exposure might explain their findings. This would mean that people already interested in the issues and perhaps predisposed to civic participation sought the programs rather than being stimulated by the programs. In

a related study that also included the Binghamton site, Ognianova and her colleagues (1997) tested whether the civic journalism project leads to increased concern about issues and civic involvement (media stimulation of involvement) or whether existing involvement leads people to be aware of the civic journalism project (selective exposure). Their conclusion was that awareness of the project led to concern, knowledge, and subsequent involvement: “Analyses of the two alternative models with data from four different cities in the United States showed clear and consistent support for the media stimulation model ” (Ognianova et al., 1997, p. 21). Other work on all four cities (Thorson et al., 1997) explored the potential of a two-step model of civic journalism where awareness of projects helps to shift attitudes and leads to subsequent increases in civic involvement. This research concluded that indeed civic journalism was an effective means for reconnecting citizens to public life.

Media advocacy is the strategic use of mass media in combination with community organizing to advance healthy public policies. The primary focus is on the role of news media, with secondary attention to the use of paid advertising (USDHHS, 1988; Wallack and Sciandra, 1990–1991; Wallack, et al., 1993, 1999; Wallack, 1994; Wallack and Dorfman, 1996; Winett and Wallack, 1996). Media advocacy seeks to raise the volume of voices for social change and shape the sound so that it resonates with the social justice values that are the presumed basis of public health (Beauchamp, 1976; Mann, 1997). It has been used by a wide range of grass roots community groups, public health leadership groups, public health and social advocates, and public health researchers (Wallack et al., 1993, 1999).

The practical origins of media advocacy can be traced to the late 1980s. It grew from a collaboration of public health groups working on tobacco and alcohol issues with public interest and consumer groups also working on these or similar issues. The public interest and consumer groups brought a new array of strategies and tactics that were more familiar to a political campaign than a public health effort. The public health people provided a clearer understanding of the substantive scientific issues and the importance of theory in creating change. The result has been an approach that blends science, politics, and advocacy to advance public health goals.

From a theoretical perspective, media advocacy borrows from mass communication, political science, sociology, and political psychology to develop strategy. Central to media advocacy are the concepts of agenda setting (McCombs and Shaw, 1972; Deering and Rogers, 1997) and framing (Gamson, 1989; Iyengar, 1991; Ryan, 1991). From a practical perspective, media advocacy borrows from community organizing, key elements of formative research (i.e., focus groups and polling), and political campaign strategy (e.g., application of selective pressure on key groups or individuals) (Wallack et al., 1993). Blending

theory with practice provides an overall framework for advocacy and social change.

Media advocacy differs in many ways from traditional public health campaigns. It is most marked by an emphasis on:

• 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. One of the fundamental rules of media advocacy is that it is not possible to have a media strategy without an overall strategy. Media advocacy is part of the overall plan, but is not the plan, for achieving policy change. For example, a group in Oakland, California, effectively used media advocacy to advance a city ordinance to place a tax on liquor stores and institute a moratorium on new licenses in the city (Seevak, 1997). The effort took 4 years to implement, starting at the local zoning commission and ending up in the California State Supreme Court. Over that period, the group used media advocacy to provide legitimacy to the issue, to increase the credibility of its position and add urgency to the problem, and to let politicians know that the community was very involved in the issue and would be following all votes. To achieve this, the group used a variety of tactics to generate news coverage and discussion on the editorial pages. This increased the effectiveness of the grass roots coalition advancing the policy but would have made little difference if the coalition did not have strong community support (resulting in large turnouts at key meetings and hearings, and visits and calls to politicians), a clear and reasonable policy, and research to back up its claims. The group might have failed, lacking any one of the ingredients for change: a reasonable policy goal that could make a difference, an issue that the community supported and was willing to work for, and a media strategy to advance the policy and support community organizing.

Media advocacy focuses on four primary activities in support of community organizing, policy development, and advancing policy:

1. Overall Strategy Development: Media advocacy uses 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 (for example, in the Oakland illustration above, various elements of the community were organized to apply pressure on the zoning commission, mayor's office, city council, and state legislature, which were all targets at various points in the campaign). Finally, various messages for the different targets of the campaign are developed.

2. Setting the Agenda: Getting an issue in the media can help set the agenda and provide legitimacy and credibility to the issue and group. Media advocacy involves understanding how journalism works in order to increase access to the news media. This includes maintaining a media list, monitoring the news media, understanding the elements of newsworthiness, pitching stories, holding news events, and developing editorial page strategies for reaching key opinion leaders.

3. Shaping the Debate: The news media generally focus on the plight of the victim, while policy advocates emphasize social conditions that create victims. Media 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 who 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 of 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.

4. Advancing the Policy: Policy battles are often long and contentious, and it is important to make effective use of the media to keep the issue on the media agenda. The Oakland effort took 4 years and now must focus media attention to ensure that the policy is implemented properly. Thus, 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 key anniversaries of relevant dates, publication of new reports, significant meetings or hearings, and linking the policy solution to breaking news.

Media advocacy has been applied to a number of public health and social issues including affirmative action, child care, alcohol, tobacco, childhood lead poisoning, health promotion, violence, handgun control, and suicide prevention, as well as others. To date, most evaluations of media advocacy have been case studies (Wallack et al., 1993, 1999; DeJong, 1996; Jernigan and Wright, 1996; Wallack and Dorfman, 1996; Woodruff, 1996). These case studies have shown that community groups trained in media advocacy can effectively gain access to the news media and enhance their participation in the process of public policy making. In California, for example, media advocacy training, follow-up, and support were provided to hundreds of community activists, researchers, service providers, and others working on violence prevention. These skills were used in

the process of passing substantial numbers of local ordinances limiting the availability of firearms and ultimately passing statewide legislation banning the manufacture and sale of Saturday night specials or junk guns (Wallack, 1997, 1999). Nonetheless, media advocacy can be controversial, and there are risks to the organizations that use it as part of their strategy (DeJong, 1996).

In a more systematic evaluation of the role of media advocacy in a controlled study designed to advance community policies to reduce drinking and driving, Holder and Treno (1997) concluded that media advocacy was effective in several areas and “an important tool for community prevention” (p. S198). For example, local people trained in media advocacy were able to increase local news coverage in television and newspapers and presumably frame it around policy issues. They suggest that results of the media advocacy component of the intervention “can focus public and leader attention on specific issues and approaches to local policies of relevance to reducing alcohol-involved injuries ” (p. S198). Another evaluation looked at the effects of media advocacy in the Stanford Five City Heart Disease Prevention Project (Schooler et al., 1996). Dependent variables included coverage of the issue, prominence of the article, framing of the article (e.g., prevention versus treatment), and impact on the media agenda (i.e., ratio of locally generated articles on heart disease to those on other health issues). The study concluded that “media advocacy efforts can be successful” (p. 361) but found that maintenance of the effects was weak. In both of these evaluation studies (particularly Schooler et al., 1996) it was unclear whether there was a focus on advancing public policies or whether, like many media efforts, the focus was more related to increasing awareness. Also, it was unclear whether a comprehensive media advocacy approach was implemented as was found in the case studies on limiting alcohol outlets in Oakland or banning junk guns in California.

Photovoice, a relatively new concept, is the use of photography for social change by marginalized and traditionally powerless groups. It has deep roots in documentary photography, feminist theory, empowerment theory, and participatory research (Wang and Burris, 1994, 1997; Wang et al., 1996a, 1996b, 1998, 1999; Wang and Pies, 1999). Photovoice is “designed to enable people to create and discuss photographs as a means of catalyzing personal and community change” (Wang et al., 1999, p. 4). Much health education and health promotion have at their core a great passion for community participation and social change (e.g., Minkler, 1997), and photovoice is a media approach designed to increase the likelihood of this occurring by “engaging the community to act on its own behalf” (Wang and Burris, 1994, p. 182).

Photovoice focuses on grass roots involvement and attempts to increase the participation of marginalized groups in the policy process. Various projects have been implemented with women in rural China (Wang and Burris, 1994; Wang, et al., 1996a,b, 1998; Wang and Burris, 1997), homeless men and women in

Ann Arbor, Michigan (Wang et al., 1999), and people recruited from public health and social service sites in Contra Costa County, California (Wang and Pies, 1999). The goals of these projects are quite similar and clearly reflect the theory and values of the approach:

1. To understand local issues and concerns through the perspective of specific groups of people. This means seeing health, work, and community issues through the eyes of the participants and those most affected by the problems rather than just the usual experts.

2. To promote knowledge and critical discussion about significant community issues. This involves group discussion among participants regarding their photographs.

3. To reach policy makers and others who can be mobilized to create change. This means finding ways to translate and make visible the “data” in the photographs so that others can be enlisted in the social change process.

The photovoice process has been documented in a series of articles by Wang and her colleagues. Once a project is defined, a target audience of policy makers or community leaders is identified and participates in the planning process. Its primary role is to serve as a group with the political will to put participants' ideas and recommendations into practice (Wang et al., 1999). At the same time, facilitators are trained. This involves grounding in the process of photovoice, including ethical issues such as privacy and power, which might arise in the process of taking pictures. Technical knowledge about cameras and photography is provided as are basic group process skills for leading discussion.

Trainers or facilitators then recruit participants through a variety of means depending on the project. (For example, in the “Language of Light,” homeless project participants were recruited through shelters and provided with cameras and small stipends.) Participants, in turn, attend a series of workshops to learn about the methods of photovoice, the technical aspects of using and caring for a camera, and the safety and privacy issues that might arise from using a camera in public or social service settings. After the first workshop, the meetings are used for group discussion and feedback on the pictures. Participants who wish to write about their photographs may follow a series of “root-cause questions” similar to those used in discussion.

In the final stage of the project, facilitators and participants select pictures to share with journalists and policy makers in order to move the documentation process to the action process. Each of the projects achieved some success in reaching broader audiences and policy makers. In China, project facilitators organized a slide show that attracted some of the most powerful policy makers in the province. Three policy decisions regarding day care for toddlers, training programs for midwives, and educational scholarships for girls were enacted as a result of facilitators' and participants' advocacy using the photovoice process. The participating Chinese village women highlighted each of these issues through their photographs and stories (Wang et al., 1996a).

In Ann Arbor, the “Language of Light” project provided pictures and captions for a series of articles in local newspapers, a gallery exhibition, and a major public forum. These activities communicated concerns of the homeless to a broader population and also put a human face on the issue. The public forum was attended by several hundred people and allowed the project to provide input to policy makers on a proposal to build a new homeless shelter that would have resulted in major disadvantages to the homeless population (Wang et al., 1999).

The “Picture This” project in Contra Costa County held exhibitions of its pictures at the County Office of Maternal and Child Health and the state capitol during a statewide meeting. In addition, more than a full page in the local newspaper was provided to show pictures and report on the project. Several stories of change came out of the project, including one resulting from a picture of a closed hospital with a caption complaining about inadequate health services for low-income people: “The picture and other complaints prompted the county to improve care at its Pittsburgh [California] clinic” (Spears, 1999).

Photovoice, though a new concept that has not been subject to rigorous evaluation, appears to have promise for increasing community involvement. The use of pictures in addition to words may well increase the power of local groups to effectively press their case for social change. Perhaps most important is that this approach may be a particularly useful tool for those who find the usual means of participation in community discussion to be a foreign and unfriendly process that seems to uphold the views of those who already make the decisions.

The Internet promises to provide people with unprecedented access to information about the kinds of factors that affect their health and affords health educators the opportunity to use this medium to design interventions to change health behavior (e.g., Cassell et al., 1998). An estimated 33.5 million adults seek out medical information on the Internet (Davis and Miller, 1999), and many others use the Internet to find social support (Bly, 1999) Also, Cart (1997) has discussed the potential of the Internet for local communities to organize, gain immediate access to critical facts, and increase their power as citizens to effectively participate in policy debates. She also suggests that on-line networks “[have] the potential to bring back ‘communities that disappeared with front porches'” (Cart, 1997, p. 328).

The Internet has the potential to supplement and possibly increase the value of any media approach used. Mass media campaigns that can direct people to the Internet for more detailed and personalized information, as well as social support, will no doubt increase their potential to help people. Civic journalism projects that use the Internet will make it easier for people to participate in a more informed way. For the media advocate, the Internet allows fast and easy access to policy information that was simply unavailable in the past as well as specialized information and strategic help from colleagues on the other side of the world as easily as from those down the street. This will help increase the poten-

tial contribution of media advocacy and other activist approaches because it will build social capital by providing one of the basic elements for effective collective action—easy, fast, and direct communication.

McChesney (1999), however, raises an important question about the Internet: “In fact, cannot the ability of people to create their own ‘community' in cyberspace have the effect of terminating a community in the general sense?” (p. 146). Just as the Internet will speed many desirable aspects of our society along, so will it likely accelerate the path to hyperindividualism and hypercommercialism that McChesney warns about. From a social capital perspective this would not be a welcome direction because of the potential adverse effects of the corporate dominance of media technologies on citizen activism (McChesney, 1997, 1999).

Another important Internet issue is the amount and quality of information. While more people have access to unprecedented amounts of information, the quality of such information is uneven. Those seeking cancer information, for example, could easily end up in sites that might offer information that was potentially damaging to one's health. The flood of health and medical advice without some added ability to critically assess accuracy could have significant unintended consequences for consumers of health information.

Finally, access to the Internet is very much influenced by economic status. Efforts to promote universal access have largely faltered, raising the possibility of the information “haves” and “have nots” and further increasing the effects of income inequality.

Recent research points to the urgency of rethinking the role of mass media to advance the public's health. Research strongly suggests that media approaches should focus on increasing the reservoir of social capital by engaging people and increasing their involvement and participation in community life. This, per se, may have a positive generalized effect on the population's health. In addition, because public health seeks to “create the conditions in which people can be healthy” (Institute of Medicine, 1988), mass media strategies should also provide citizens with the skills to better participate in the policy process to create these conditions. Furthermore, it is crucial that social capital be seen not as a substitute for the kinds of policies that are important to reduce social inequality but as a foundation that makes policy change possible. Social capital then is a prerequisite for policy change and a consequence of the process of generating that change (Putnam, 1993).

In the new century, sophisticated versions of the classic mass-mediated public health campaigns will play a role in increasing awareness, providing knowledge, and shifting attitudes. However, these campaigns have not had a significant impact on the health of populations and should be a relatively small part of a comprehensive strategy. Public health should not be seduced by a primarily information-based approach that focuses on the individual and ignores

more potentially effective, but controversial, approaches emphasizing policy or political participation.

Civic journalism, media advocacy, and photovoice have been presented as promising approaches, but this is not the same as suggesting that these are successful approaches. Early evaluations are indeed promising, but more important is the set of values underlying these approaches. The goal of these approaches is to engage people in the process of improving their communities through deliberation about problems, discussions about solutions, and participation in the processes that lead to social or political change. They seek to give people a voice rather than leave them with a message, and they point people to solutions that benefit the entire community, not just the individual. Their goal is nothing short of making democracy work better and by doing so affecting the public's health on the most global level.

As a society, we exalt the person that can “beat the odds” and succeed against adversity (Schorr, 1988). This “triumphant individual” story is, in fact, one of the dominant parables that guide political thought, rhetoric, and policy development in our society (Reich, 1988). Public health is a profession that should work to reduce the odds so that more people can succeed, not a profession that simply provides information, services, and encouragement to people so they might be among the few lucky ones to beat the odds (Beauchamp, 1981).

In considering media approaches we must select the kinds of strategies that have the long-range potential to change the odds. The income gap between the rich and the poor has more than doubled in the past 20 years. Currently, 20% of the population earns more than one-half of all the income in America. The 20% with the lowest income earns only 4.2% of all the income (Johnston, 1999). This inequality gap is bad for society overall, not just those on the bottom rungs, and the public health body count will be one tragic indicator of this. Building social capital is not a panacea, but it can make an important contribution to changing the odds.

Developing media approaches that can enhance social capital and level the playing field is important for the future of public health. There are a number of questions that must be addressed in considering the selection of media strategies:

1. Does the approach increase the capacity of individuals or small groups articipate in collective action by to participate in collective action by

• providing participatory skills, and

• creating a structure or network through which individuals, groups, and organizations can act?

2. Does the approach connect the problems or issues to broader social forces?

3. Does the approach increase the community's capacity to collaborate and cooperate by strengthening existing groups (create bonding capital) and connecting various groups (create bridging capital)?

4. Does the approach reflect a social justice orientation—the idea that “each member of the community owes something to all the rest, and the community owes something to each of its members” (Etzioni, 1993, p. 263)?

The greater the degree to which a media approach can respond affirmatively to these questions, the more likely it is to build social capital. The public health profession should support such approaches even though in some cases the link to public health might seem tenuous.

The research on the effects of these approaches on public health outcomes is limited, and more comprehensive and systematic evaluations are necessary. One of the problems in determining effects is that these approaches must be seen as supporting and advancing larger interventions for policy change. Civic journalism, media advocacy, and photovoice are likely means to increase social capital and enhance the capacity of communities to act. This should, if the social epidemiological research is on the right track, lead to improved health across a number of areas. Isolating and linking the contribution of specific media approaches to this kind of social and policy change will be very difficult. Nonetheless, increased participation at the local school board may well result in less activity at the local hospital.

Public health is, at its core, a political process, and one of our best strategies is to use the democratic process to advance public health goals and objectives. Social and political participation is important, and it is necessary that we develop media strategies that foster community participation rather than just inform personal behavior. The safe and familiar path of mass media campaigns has not been sufficient for change. It is time to travel a new path—even if its terrain is not well mapped and its specific direction must still be clearly marked.

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