Strategic Social Marketing Ltd

Jeff.French@strategic-social-marketing.org

MASS MEDIA
BEHAVIOUR CHANGE STRATEGIES

There is clear evidence that targeted, well-executed health mass media campaigns
can impact not only on health knowledge, beliefs, attitudes, and behaviours. Whilst
effect sizes may appear modest compared with the impact of some clinical
interventions on individual patients, these campaign effects can translate into major
public health impact given the wide reach of mass media. Such impact can only be
achieved, however, if principles of effective campaign design are carefully followed.

A meta analysis of campaigns in the United States has been published. Media based
campaigns have been shown to have small measurable effects in the short-term.
Campaign effect sizes vary by the type of behaviour: r=.15 for seat belt use, r=.13 for
oral health, r=.09 for alcohol use reduction, r=.05 for heart disease prevention, r=.05
for smoking, r=.04 for mammography and cervical cancer screening, and r=.04 for
sexual behaviours. Campaigns with an enforcement (regulatory) component are
more effective than those without. (Snyder Et al (2004)

To predict campaign effect sizes for topics other than those listed above, planners
and researchers can take into account whether the behaviour in a cessation
campaign is addictive, and whether the campaign promotes the commencement of a
new behaviour, versus cessation of an old behaviour, or prevention of a new
undesirable behaviour. Given campaign effect sizes in terms of behaviour change,
campaign planners should set realistically modest goals for future campaigns. The
results can also be useful to evaluators as a benchmark for campaign effects and to
help estimate necessary sample size.

The “average” campaign affects the intervention community by about 5 percentage

points, and nutrition campaigns for fruit and vegetable consumption, fat intake, and
breastfeeding, have been slightly more successful on average than for other health
issues.

A review focussing on physical activity campaigns concluded that they should focus
more on influencing short term features such as social norms, to bring about long-
term behaviour change. This should be seen as part of a broader strategy, including
policy and environmental change. Evaluation designs that measure the full range of
variables are preferred to an over-concentration on behaviour alone. Cavill et al
(2004)
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Campaigns that are carefully developed using formative research (both qualitative
and quantitative), pay attention to the specific behavioural goals of the intervention,
target populations, communication activities and channels, message content and
presentation, and techniques for feedback and summative evaluation should be able
to change health behaviours. Cohort (longitudinal) evaluation designs should be
incorporated where possible because of the stronger evidence on cause and effect
relationships they provide.

A Cochrane Systematic review assessing the effects of mass media on the utilisation
of health services concluded that there is evidence that these strategies may have an
important role in influencing the use of health care interventions; they should be
considered as one of the tools that may encourage the use of effective services and
discourage those of unproven effectiveness. Grilli et al (2002)

There is evidence of a dose-response relationship between campaign weight (dose)

and impact (behaviour change). Hylan et al (2006), Craig et al (2006), Schade et al
(2005) , Jorm et al (2005), MMWR (2004)

Components of successful media Campaigns

A number of researchers, both in health promotion and communication have
attempted to identify the conditions under which media are most effective in
promoting health. A detailed analysis of the components of successful and
unsuccessful campaigns has been made by McGuire (1986), who concluded that the
impact of media-even in studies that claim significant effects-may be only slight, but
that the reasons for a null effect are often based on insufficient programming or
analysis.

Douglas Solomon, who has been extensively involved in health media Campaigns,
including the Stanford Heart Disease Prevention Project, analysed good and bad
media campaigns and concluded that campaigns that have been successful owe
much of their success to:

1. the extensive use of formative research regarding audience and message

variables

2. the supplementation of media with interpersonal communication within small

groups that provide social support and modelling of appropriate behaviours
(Solomon 1982; 1984)

Solomon proposes a framework for success consisting of four main factors:

1. Adequate problem analysis including the setting of detailed objectives (ie.

Specific, measurable and reasonable), and audience segmentation.

2. Appropriate media selection and use including formative research to provide

information about media-use patterns.

3. Effective message design determined by specific objective setting, the

generation of alternative message approaches, pre-testing and revision of
campaign messages.
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4. Evaluation including the study of both outcome and process evaluation.

The above attempts by McGuire(1986) and Solomon (1982;1984) and a perusal of

other research (Medehlson 1973; National Institute of Health 1982; Rogers & Storey
1987; Elliot 1988) suggest a number of practical proposals for designing a successful
campaign. These include the following:

1. Carry out formative research. Intuition is not sufficient for devising

campaigns. Materials should be developed from skilled formative research
(ie. focus groups, surveys), pre-tested, and evaluated during exposure
2. Fully understand the topic being communicated. Some topics are difficult and
complex to teach (e.g. the nature of drugs and their effects), while others may
be easily communicated (e.g. hygiene). Similarly, certain well-established
behaviours are difficult to change (e.g.smoking), while others require only a
minor effort (e.g.not littering).
3. Use skilled creative personnel. Determining a message is simple. Executing
that message in a way that is optimally received and acted upon by a target
audience is a highly skilled process
4. Understand the audience. The extent to which a message is attended to,
comprehended and used by an audience is largely determined by the extent
to which the messenger understands the audience. Detailed profiles of an
audience need to be established as a preliminary to media development if a
message is to be optimally received
5. Target the message. Different sub-groups have different needs, interests,
beliefs and attitudes. Hence, different messages – or at least different
message executions – should be tailored for different groups
6. Take account of interpersonal and peer influences. Campaigns should
attempt to stimulate interpersonal contact such as the promotion of group and
community activities, and the activation of interpersonal communication
networks
7. Maximise contact with the message. This does not mean total bombardment.
Research indicates that concentrated bursts of spot messages often work
better then the same quantity of messages strung out over a long period.
Maximising contact also means optimising media within the constraints of a
limited
8. Set a realistic duration for the study. Many campaigns have not matched the
duration of the study with the desired outcome. Longer campaigns are
required to achieve behavioural change, whereas shorter campaigns may be
sufficient for changes in awareness. Also, ongoing campaigns are necessary
to maintain awareness and to reinforce attitude behaviour change
9. Use multiple channels. Multiple communication channels (ie. different media
and media vehicles plus various non-media channels) tend to have a
synergistic effect, and can carry different types of information
10. Use a credible source or spokesperson. Source credibility is a major factor
affecting message acceptance. Spokespersons are selected on the
assumption that they will be credible to the target audience. For example, the
use of celebrities and sport stars in anti-drug promotions to youth is common
practice. Yet research suggests that youth only identify with certain aspects
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of an idealised role model, such as his or her ability to play music or sport. If
other aspects (e.g. his/her attitude to drugs) conflict with overwhelming peer
pressure, the model will be discarded rather then the anti-social habit . Pre-
testing for credibility is essential in the message pre-testing.
11. Do not confuse logic and emotion. A basic distinction can be drawn between
rational and emotional messages in health. The former are less stimulating,
better for intelligent audiences and are best represented in long copy print.
The latter suited for the electronic media. In common parlance, the difference
is between a message with ‘light’ versus a message with ‘heat’
12. Set realistic goals. Major shifts in behaviour are not common in large
populations over short periods. Hence it is important that intermediate goals,
for example, knowledge and attitudinal goals, are set rather than behavioural
goals. Furthermore, many campaigns set large, unrealistic changes as their
criteria for success (e.g. reducing alcoholism), rather than more realistic
immediate changes (e.g. reducing the incidence of driving while drunk).
Small changes (knowledge, attitudes and behaviour) in large groups are often
more possible and can result in a greater degree of success throughout the
population than can be achieved by large changes in small groups.
13. Provide environmental supports for change. Research has shown
consistently that most media campaigns require ‘on-the-ground’ back-up
support for optimum effect. To accomplish this, media should be
accompanied by strategies associated with community organisation.
14. Confirm that a mass media campaign is really justifiable. Although listed last,
whether a mass media campaign is both viable and justifiable should be
determined early on following the formative research phase. Mass media
should be looked at in terms of costs and benefits and these should be
compared with other strategies. If an alternative strategy is projected to be
slightly less successful but at much less cost, the goals of a campaign may
need to be re-examined. Often, a subsidiary aim of a campaign is to increase
public awareness, or get more acceptance from funding bodies. In these
cases a decision may still be taken to use the less cost-effective media
approach.

Findings Concerning media use in health promotion

A precise of a number of research studies and implications for mass media use in
drug and alchol area (Miller & Ware 1989) suggests that:

• Media may stimulate learning and generate often dramatic changes in

behaviour where a level of pre-motivation exists. In many cases, however,
mass media alone are insufficient for behaviour change and the mass media
should be combined with personalised health education.
• The ‘agenda setting’ role of the media produces its most pervasive impact.
• In the short term the influence of the mass media on its own tends to e in the
direction of reinforcing existing beliefs and opinions and helping crystallise
attitudes, rather than changing them.
• Mass media bestows ‘prestige’; interpersonal communication bestows ‘faith’;
when both are combined, the chances of action are increased.
• Community development and interpersonal contact will be important
components reinforcing, and being reinforced by, rigorously developed mass
media messages and supporting printed materials.
• Through repetition, the mass media may produce long-term benefits by
creating a climate of opinion or setting the agenda for public discussion.
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• The simple persuasive model of mass media influences has now been
replaced by a more socially oriented approach, in which the mass media are
viewed as one of many possible sources of information in society. Mass
media sources cannot be discussed in isolation from personal information
sources – families, friends and so on – which may support or contradict their
messages.
• The impact of a media message can no longer be determined by its content
alone. Members of the audience are now regarded as active participants in
the communication process and pr-existing beliefs, attitudes, experiences and
knowledge affect attending to, interpretation and acceptance of messages.

Changes in public acceptance

Health promotion can have similarities to fashion design. Public acceptance is
changeable and what may be acceptable (and effective) at one time may not be so at
another.

Summing up: When to use the media

In conclusion, it is apparent that the media can be an effective tool in health
promotion, given the appropriate circumstances and conditions. Some of the
situations in which media have been found to be most appropriate are:

1. When wide exposure is desired. Mass media offer the widest possible
exposure, although this may be at some cost. Cost-benefit considerations
therefore are at the core of media selection.

2. When the time frame is urgent. Mass media offer the best opportunity for
reaching either large numbers of people or specific target groups within a
short time frame.

3. When public discussion is likely to facilitate the educational process. Media

messages can be emotional and thought provoking. Because of the possible
breadth of coverage, intrusion can occur at many different levels, stimulating
discussion and thereby expanding the impct of a message.

4. When awareness is a main goal. By their very nature, the media are
awareness- creating tools. Where awareness of a health issue is important
tot eh resolution of that issue, the mass media can increase awareness
quickly and effectively.

5. When media authorities are ‘on-side’. Where journalists, editors and

programmers are ‘on-side’ with a particular health issue, this often guarantees
greater support in terms of space and editorial content.

6. When accompanying on-the-ground back-up can be provided. Regardless of

whether media alone are sufficient to influence health behaviour, it is clear
that the success of media is improved with the support o back-up programs
and services.

7. When long term follow up is possible. Most health behaviour changes require
constant reinforcement. Media programs are most effective where the
opportunity exists for long-term follow up. This can take the form of short
bursts of media activity over an extended period, or follow up activities
unrelated to media.
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8. When a sufficient budget exists. Paid advertising, especially via television,

can be very expensive. Even limited reach media such as pamphlets and
posters can be expensive, depending quality and quantity. For media to be
considered as a strategy in health promotion, careful consideration of costs
and benefits needs to be undertaken.

9. When the behavioural goal is simple. Although complex behaviour change

such as smoking cessation or exercise adoption may be initiated through
media programs, the nature of media is such that simple behaviour changes
such as immunisation or cholesterol testing are more easily stimulated
through the media. In general, the more complex the behaviour change, the
more non media back up is required to supplement a media health program.

10. When the ‘agenda’ includes public relations. Whether we acknowledge it or

not, many, if not most health promotion programs have an ‘agenda’ which is
not always explicit. Such an agenda may be to gain public support or
acknowledgement, to solicit political favour or to get funds for further
programs. Where public relations are either an explicit or implicit goal of a
program, mass media are effective because of their wide-ranging exposure.

References

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Craig, C. L., Cragg, S. E.,Tudor-Locke, C. Bauman, A. 2006 Proximal impact of Canada on the Move: the
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Schade, C. P., McCombs, M. 2005. Do mass media affect Medicare beneficiaries' use of diabetes services? Am J
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 Strategic Social Marketing Ltd
Jeff.French@strategic-social-marketing.org

Snyder, L. B., Hamilton, M. A., Mitchell, E. W., Kiwanuka-Tondo, J., Fleming-Milici, F., Proctor, D. 2004. A meta-
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Solomon, D.S. 1984, ‘Social marketing and community health promotion: the Stanford heart disease prevention
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