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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations (2002)

Chapter: 3 Health Communication Campaigns Exemplar

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Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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3
Health Communication Campaigns Exemplar

INTRODUCTION

This chapter focuses on diversity issues associated with large-scale public health communication campaigns. These campaigns include federal government-supported programs such as the National High Blood Pressure Education Program and the National Youth Anti-Drug Media Campaign; the state-sponsored antitobacco campaigns such as Florida’s Truth Campaign and California’s Anti-Tobacco Campaign; and privately sponsored programs such as the Campaign to Prevent Teen Pregnancy and the Avon Breast Cancer Crusade. This chapter describes how those campaigns have addressed diverse audiences and presents available evidence for their success in reaching and affecting those audiences. This analysis is based largely on the review by our Committee of approximately 18 U.S. health communication campaigns, the majority of which are national in scope and currently ongoing (see Table 3-1).

Nearly all of these campaigns indicate in their public documents that they have given special consideration to diverse audiences. A campaign may have targeted an African-American

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

audience for enhanced levels of exposure to messages by purchasing time on stations with wide African-American listenership; a campaign may have shaped a message strategy for girls, meant to appeal to the particular beliefs that underpin their decisions about smoking; a campaign may have used actors well known to older audiences in advertisements to stimulate mammogram demand by those audiences. Often these special efforts are justified on the grounds that particular audiences are at greater risk, based on the sort of epidemiological evidence reviewed in other chapters in this volume, or more simply because different segments of the population are assumed to be responsive to different communication approaches. Nonetheless, addressing diversity is not accomplished in just one way. Although nearly all programs claim such efforts, the particular approaches they have used vary, and the level of resources applied to such special efforts varies as well. An important task for this chapter is describing the range of approaches that typically have been employed. This will be especially useful for new programs considering how to address the needs of diverse audiences. But descriptions of how programs have tried to “solve” the issue of diversity are not sufficient.

Descriptions provide little grounds for choosing among approaches or for deciding to undertake a special effort altogether. The extra resources required for special efforts to adjust programs to serve diverse audiences can be substantial, including additional research, increased production of materials, and additional purchases of media time, among other incremental costs. The justification for more resources is strongest if it relies on evidence that a particular approach to address diversity works better than programs with no diversity-based targeting approach or better than programs with alternative diversity approaches. This chapter summarizes such evidence where it exists. However, there is relatively little evidence about differential effects of campaigns on diverse audiences overall, and the evidence is even more scarce about the relative utility of the range of diversity approaches that have been used. One of the main recommendations of this volume will be to

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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TABLE 3-1 Campaigns—Intended Populations

National Campaign

Racial/Ethnicity

National Safe Kids Campaign

All ethnicities targetedb

Buckle Up America

All ethnicities targetedb

Child Safety Seat Distribution Program (USNHTSA)

Asian American, Hispanic/Latino, Native American/Alaskan Native

Folic Acid (March of Dimes)

High-risk populations—e.g., Asian American, Hispanic/ Latino, Asian American/Pacific Islander, Native Americanb (including Spanish); now targeting Hispanic/Latino populations

Depression Awareness, Recognition, and Treatment Program

Asian American, Hispanic, (some Asian American/Pacific Islander)

National Air Bag and Seat Belt Safety

Asian American, Hispanic/Latino; (Spanish materials)

National 5 A Day (fruits and vegetables versus cancer, sponsored by the National Cancer Institute)

Asian American, Hispanic/Latino at national level; Asian American, Hispanic/Latino, Native American/AI, Asian American/Pacific Islander at state/local level

Back to Sleep

Focus on Asian American, starting focus on Native American; generic materials for major ethnic populations also include Asian American/Pacific Islanderb

Milk Matters Calcium Education

Native American, Asian American, Hispanic/Latino (populations with lactose intolerance)

National Campaign to Prevent Teen Pregnancy (private nonprofit)

Hispanic/Latino, Asian American

Best Start (Loving Support)

Asian American, Hispanic/Latino, (Asian American/Pacific Islander, Native Americanb)

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Gender

Age

SES/Social Class

Launch Date

Male, Female

≤14 years

Low income

1988

Male, Female (same)

≤14 years, parents, grandparents

General and low-income

1997

Male, Female (same)

(parents)

Low-income

2000a

Female

Child-bearing age

General, low SES, low education

1998

Male, Female (some different)

Older age; teenagers

1985

Male, Female (same)

New (and younger) parents

Low-income, low-education

1996

Male, Female (some different)

adults (25 to 55 years)

Low-income, low-literacy

1991

Male, Female (same)

Older (and general caretakers)

1994

Male, Female (female different)

Children, teenagers, parents

Low-income (outreach mailing—WIC)

1997

Male, Female (different)

Teenagers, parents

Low-income

1996

Female

Special materials for teenagers

Low-income, low-literacy

1997

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

National Campaign

Racial/Ethnicity

National High Blood Pressure Education Program

Asian American, Hispanic/Latino, Asian American/Pacific Islander, Native American/Alaskan Native

Youth Anti-Drug Media Campaign

Asian American, Hispanic/Latino, Native American, Asian American/ Pacific Islander, Alaskan Native, Aleuts; (11 languages)

Florida Pilot Project on Tobacco Control (“truth” campaign)

Asian American, Hispanic/Latino, Asian American/Pacific Islander

National Truth Campaign (tobacco)

Asian American, Hispanic/Latino, Asian American/Pacific Islander

National Cancer Institute Breast Cancer Education Program Mammography (not just once)

Asian American, Hispanic/Latino, Asian American/Pacific Islander

National Breast Cancer Awareness Month

Asian American, Hispanic/Latino, Asian American/Pacific Islander; Spanish materials

National Diabetes Education Program (diabetes)

Asian American, Hispanic/Latino, Asian American/Pacific Islander, Native American

Centers for Disease Control and Prevention Flu

Asian American, Hispanic/Latino; Spanish materials

National Eye Health Education Program

Hispanic/Latino, Asian American

Feet Can Last a Lifetime (diabetes)

Asian American, Hispanic/Latino, Asian American/Pacific Islanderb; Spanish materials.

aEfforts by state and local governments began as early as 1998.

b“Like” (i.e., racial/ethnic) models/photos used.

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Gender

Age

SES/Social Class

Launch Date

Male, Female (some different)

Elderly, teenagers, youth

Low income/ education

1972

Male, Female (female different)

Youth (9 to 18 years); parents

— (rural/urban)

1998

Male, Female (same and different

Middle school students, high school students

1998

Male, Female (same)

Youth, teenagers, young adults

2000

Female

>40 years

Low SES, low education

1997

Female, Male/general public (female different)

All ages; (elderly targeted)

Low-income, (rural), low-access, low-literacy

1985

Male, Female (same)

Seniors

Low SES

1998

Male, Female (same)

25 to 54 years

1998

Male, Female (same)

>60 years (mostly)

Low-literacy/low-education

1991

Male, Female (same)

Low-literacy

1995

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

gather systematic evidence about campaigns’ diversity efforts and effects.

In the following sections, we discuss the definition of a campaign, the various approaches campaigns have used to address diversity, and specific evidence about diversity effects. The concluding section offers recommendations.

WHAT ARE CAMPAIGNS?

A communication campaign has been defined as an intervention that “intends to generate specific outcomes or effects, in a relatively large number of individuals, usually within a specified period of time, and through an organized set of communication activities” (Rogers and Storey, 1987). Communication campaigns can be differentiated from focused educational interventions that work entirely through clinical or other in-place institutions as well as those that are delivered individually to people (e.g., in their homes). Our focus is on a subset of campaigns that have large target audiences (for example, the entire population of a state or country). Yet even programs that fit into this category are quite different from one another. Some characteristics that are typical, although not always present, are the following:

  • Communication campaigns intend to provide direct education for those people who are expected to adopt or change to a healthier behavior.

  • Campaigns seek to affect large audiences and bring substantial resources to the task (sometimes monetary, sometimes voluntary, sometimes through collaboration with other institutions).

  • Campaigns often use multiple channels, and may complement mediated (television, radio) channels with personal channels (health professionals, outreach workers).

  • Campaigns attempt to influence adoption of recommended behaviors by influencing what consumers know and believe about the behavior, and/or by influencing actual and/or perceived social

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

norms, and/or by changing actual skills and confidence in skills (self-efficacy), all of which are assumed to influence behavior.

  • Campaigns often are sponsored by the government, sometimes in collaboration with private advocacy or professional organizations, or by national advocacy or professional organizations alone.

  • Campaigns are often a component of broader social marketing programs. Social marketing is the application of commercial marketing ideas to help solve social and health problems (Andreasen, 1995). Social marketing programs complement communication efforts with other intervention components. For example, a social marketing campaign to encourage childhood vaccination might complement a public communication effort to promote vaccination uptake with a subsidy in the price of vaccines and an easier system for obtaining vaccines, or even a change in the rules about what vaccines can be given together.

  • Even more broadly, many campaigns complement efforts to directly influence populations with efforts to affect public policy (taxes, regulation) as well as to change other aspects of the environment and the marketplace, including changes in the ways that other social institutions act. These complementary efforts would be expected to influence populations indirectly. These multilevel social change programs might include grassroots organizing, political and media advocacy, partnerships with private institutions, and the design and offering of new products. They recognize the importance of system and environmental constraints that support or impede the desired behavior changes.

Throughout the 20th century, communication campaigns were developed to address most major public health issues, including a broad array of behavioral outcomes ranging from the initiation and maintenance of preventive health behaviors to the cessation of behaviors that increase the risk of negative health outcomes. For example, health communication campaigns were developed to reduce smoking; promote compliance with high blood pressure treatment and childhood and adult vaccination schedules; promote safer

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

sex practices to prevent HIV/AIDS; reduce illegal drug use; promote use of seatbelts, car seats, and bike helmets; reduce the practice of driving while alcohol impaired; encourage mammography and other disease-screening behavior; and promote healthy dietary choices for the prevention of cancer, cardiovascular diseases, diabetes, and other chronic diseases. Specifically, Congress authorized nearly $1 billion for the National Youth Anti-Drug Media Campaign between 1998 and 2002. California alone spent more than $634 million in its campaign against tobacco use between 1989 and 1999 (San Francisco Examiner, 1999), with 15 to 20 percent of those expenditures going to a continuing mass media campaign (Pierce, Emery, and Gilpin, 2002). Box 3-1 presents the outline of one campaign, the National Cancer Institute’s Once A Year for A Life Time program to encourage mammograms. It incorporates many elements typical of long-lived campaigns.

Various texts provide overviews of the public communication campaign experience (Rice and Atkin, 1989, 2001; Salmon, 1989; Guttman, 2000; Hornik, 2002). We will not try to present or even summarize that literature, except to indicate that there is substantial evidence that some campaigns have affected important health behaviors, although not in every instance. For the purposes of this chapter, the essential point to understand about such projects is that they involve carrying out a series of operational tasks, and each of those tasks is an opportunity to pay more or less attention to the issue of diversity.

The major tasks to be undertaken by a campaign include (1) choosing target audience(s) and particular behavioral objectives; (2) choosing a message strategy and executions; (3) choosing the mix of dissemination channels and settings; and (4) undertaking formative, monitoring, and evaluation research to support the program. Decisions about each of these tasks will vary with the evolution of the campaign and its audience. A campaign is not defined by a specific and static mix of messages, audiences, and channels. Rather, it is defined as a program that makes decisions about these operational details, decisions that will vary over time.

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Authors have broken down these tasks in many ways. Sutton, Balch, and Lefebvre (1995) acknowledge Novelli’s six-step “marketing wheel” for planning a social marketing process (Novelli, 1984) that has been used in many national health education campaigns. They also point to the health communication process practiced at the Centers for Disease Control and Prevention that included a 10-step “wheel” of action (Roper, 1993). Their own system focuses on six steps: (1) defining and understanding the target audience; (2) determining the behavioral objective—that is, what action the audience should take (and not take, if there is a competitive behavior); (3) deciding what reward should be promised in the message for taking the action; (4) establishing what needs to be included to make the promised reward credible; (5) determining what “openings and vehicles” should be used—that is, how to reach audience members when they are receptive; and (6) deciding what “look and feel” or what image of the action should be portrayed in the message.

A full description of the art and science of message development is beyond the scope of this chapter. Details of these steps are not the central issue here. The issue for this chapter is how the fact of diversity has been or might be taken into account as part of the decision process in developing a campaign. We focus on the four broad tasks because they serve to illustrate the argument, while recognizing that a finer differentiation of steps may be required to implement a campaign successfully. Each of these tasks can take special account of concerns about diversity.

THE LOGIC OF SEGMENTATION AND ITS RELATION TO DIVERSITY

Public health campaigns are designed to influence a population to maintain or improve its health status. To accomplish this, campaign developers must understand the link between behavior and health status for the population of interest. Although current reporting systems provide information on the distribution of illness and disease across broad demographic groups and are useful

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

for identifying disproportionate risks and outcomes, this broad level of epidemiological analysis rarely proves useful in identifying the relevant characteristics that best define the audiences for a health campaign. This is because any single group characterized by these broad demographic variables is actually composed of multiple diverse segments with different needs, experiences, attitudes, and behaviors.

To address the heterogeneous nature of populations, health communication programs have applied the marketing concept of segmentation. Segmentation is the process of partitioning a heterogeneous population into subgroups or segments of people with similar needs, experiences, and/or other characteristics. A number of approaches have been developed to help determine optimum audience segmentation. Segmentation assumes that audiences that perceive a message as relevant to their interests, concerns, and problems are more likely to pay attention to the message, to process it deeply, and to remember and act on it, than are audiences that do not perceive the message as personally relevant. An elaboration of these concepts is provided in the following paragraphs.

A sensible communication campaign recognizes heterogeneity in its population. First, all members of the population do not have the same status with regard to a behavior. For a youth tobacco prevention campaign, some youth are already heavy smokers, some smoke irregularly, some have smoked in the past but have quit, and some have never smoked but are intrigued and at higher risk of beginning to smoke, while others have never smoked and, regardless of a campaign, are very unlikely to become smokers. Each of these segments of the youth population may require different interventions. The behavioral objective for the heavy smokers may be enrollment in a cessation intervention; for the casual smokers, it may be stopping all smoking; for the prior quitters, it may be developing skills to resist cigarettes in situations that signal smoking temptation; for the intrigued nonsmokers, it may be resisting offers of cigarettes from peers; and for the committed nonsmokers, it may be reinforcing their existing preference. One campaign might choose only one of these audience segments as its target, or at least

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

begin with one of these audiences. For example, the National Youth Anti-Drug Media Campaign (1998) chose to focus on prevention of trial use of drugs among prior nonusers, and prevention of regular use of drugs among prior occasional users. It did not address current regular users, suspecting that this audience might not be responsive to its efforts.

Thus, the audience can be broken down by current behavior and the behavioral objective that campaign planners might seek for each group. However, within each of these behavioral subgroups, there is still more heterogeneity. Assume the antitobacco campaign chose to focus efforts on the intrigued nonsmokers. Some of those intrigued nonsmokers are young teenagers and some are older teenagers; some are girls and some are boys; some are surrounded by peers who smoke and others may have few friends who smoke. Some report frequent contact with prosmoking promotion by the tobacco industry that puts them at risk (Pierce and Giplin, 1995), while others do not have such frequent contact. Some may view smoking as a desirable personal symbol of rebellion against authority, while others may be more influenced by knowledge of the negative effects of smoking on athletic endurance. A single message (e.g., smoking harms your health) might affect all of these portions of the audience similarly, but much experience in undertaking these campaigns suggests otherwise. Rather, many campaigns assume that if there is heterogeneity in the causes of audience behaviors and in what influences behavior change, then there is a need for heterogeneity in message strategies as well.

Populations are heterogeneous in their behavior, and in the correlates and causes of their behavior, but they are also heterogeneous in the ways they can be reached. Some youth are devotees of MTV or hip-hop music radio stations, while others watch widely popular sitcoms or dramas, and some can be found in the audience of the teen-focused WB network. Others are regular viewers of religious television broadcasts, while still others are religiously watching rebroadcasts of the Simpsons after school. Some can be reached in school settings, while others have dropped out; some

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

are frequent visitors to malls, while others attend rock concerts. There are many settings and channels through which intrigued nonsmokers may be reached, and different subgroups are likely to be accessible through each setting and channel. Based on an understanding of the target audience, campaign planners must seek to find the best times, places, and opportunities where the audience will be exposed and open to receiving the message.

Finally, just as heterogeneous subgroups can differ in their behaviors, in the causes of behavior, and channels and settings through which they can be reached, they can also vary in the executions of the messages that will appeal to them. The values they hold, the social groups with whom they identify, and the social activities in which they participate also will influence what messages appeal to them, and thus these factors influence campaign design. One group of youth may be accustomed to quick cuts and intense music and will pay little attention to talking heads in an advertisement. Another group will attend to slower paced ads, but pay close attention to the quality of the argument. Others are persuaded by the source: Some may be enamored of celebrities, and others by those with evident expertise.

Marketers, in recognizing this heterogeneity in the audience, attempt to define addressable segments of the audience, people who share behavioral status and a common cause of the behavior, along with other associated experiences, cultural identity, or other characteristics. Those will help define segment-specific message strategy, channel choices, and message execution choices. Health communication campaigns have selected and defined their intended audiences in very different ways. Although some campaigns divide the prospective audience into groups according to characteristics of social diversity such as age, race, income, gender, or education, this is often because only limited information is available about the potential target audiences.

The key to the effectiveness of audience segmentation for health campaigns is how well the segmentation approach identifies and separates homogeneous audience segments for which a particular message is personally relevant and motivating from those

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

for whom it is not. The goal is to target segments of people who will respond in a similar way so that a health message can be designed to maximize its relevancy. Segmentation is now considered a necessary step in the process of design and development of communication campaigns (Atkin and Freimuth, 1989; Grunig, 1989; Rogers and Storey, 1987; Slater et al., 1996). Health campaign planners require quantitative evidence to define or identify potential audience segments and both quantitative and qualitative evidence to understand those segments well.

The idea of a heterogeneous audience is a core assumption of most current health communication programs. However, only some of that heterogeneity for a particular health behavior will correspond to the diversity categories that are the focus of this volume: race, ethnicity, gender, age, economic status and social class, education, and sexual orientation. For example, regarding marijuana use, although age matters a great deal, the genders are similar. Sexual orientation clearly is related to risk of sexually transmitted disease, but may not be a core issue for planning a campaign to encourage diabetes screening. For some behaviors and for some audiences, other factors may be much more useful for segmenting audiences than any of the focus diversity categories. For example, developers of antidrug campaigns for youth know that risk of drug use initiation is predicted by prior smoking and alcohol use and by a personality variable—sensation seeking—none of which are closely related to the traditional demographic categories used for monitoring attention to diversity (except for age). However, even in these circumstances, when the traditional diversity variables may not predict behavioral status or even the causes of behavior, these diversity categories may be relevant to the channel choices and the message executions. Thus antidrug messages may address the same behavioral target and assume the same motivations for drug use for all current nonusing youth, but use different celebrities (’N Sync for young white teens and Mary J. Blige for young African-American teens) as sources for antidrug messages or buy media time on different channels (an afternoon soap opera for girls and a football game for boys).

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

These strategies will be helpful insofar as the selected diversity characteristics enhance the persuasiveness of executions and access to channels and thus improve total exposure to and credibility of the antidrug messages.

Good health communication segmentation may match the diversity categories that are the focus of this volume, but there is no assurance that this will be the case. There may be a strong and legitimate political impulse to focus on groups defined by demographic or racial/ethnic categories, particularly if those groups are unequal with regard to epidemiological risk of bad health outcomes. However, the implicit assumption of targeting is that such groups are homogeneous with regard to their likely responsiveness to campaign strategies. This assumption simply may be wrong or may be a poor predictor of differences in responsiveness, which can lead to inefficiencies in campaign execution.

This discussion presents the logic and a few examples of how programs use segmentation to organize their audiences. In that context, we can review a broader set of examples, and how they have brought the focus diversity categories to bear on their choices of audiences, behaviors, assumed motivations for behavior, channels, and message executions.

Choosing Among Potential Audience Segments

The argument that audiences are heterogeneous is strong, and thus the logic of choosing to consider segmentation is strong. However, which segments deserve priority is not resolved on the basis of the division into segments. Programs use a variety of criteria for choosing among potential audience segments, including:

  • Audience need. Higher epidemiological risk of a targeted segment based on disease morbidity and mortality, and/or prevalence of behaviors related to these health outcomes, can suggest a campaign focus.

  • Segment size. With limited resources, communication cam-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

paigns often seek to reach the largest possible number of people who could benefit from the message.

  • Impact. Audience segments often vary according to their potential to benefit from health messages. This may be related to their readiness to accept the message or to their likelihood of being influenced by a communication intervention. Campaign planners may give a higher priority to audiences who will take less work to change so they get the highest return on their investment. Alternately, some campaign planners will see their mission as getting the hard cases to adopt healthier behaviors, and focus their attention on the least ready. The COMMIT Program, sponsored by the Canadian Ministry of Health and carried out in Brant County, Ontario, focused on getting heavy smokers to quit but was not able to show any success. However, when the project developers refocused their analysis on moderate smokers, a secondary audience, they discovered that their intervention had a worthwhile success.

  • Accessibility. Whether an audience segment can be reached effectively also can influence the selection of audience segments. Although a segment may be at risk for a negative health outcome, the inability to develop dissemination strategies that reach it at a reasonable cost may preclude it from the selection as an audience segment.

  • Political considerations. The realities of the system under which many health communication campaigns are developed mean that political and legislative (or regulatory) mandates can determine the characteristics of audience segments. Representatives and advocates from particular population groups can exert considerable influence on the process of selection of topics and audiences for communication campaigns.

These are competing criteria for choosing among segments. Once they are understood, the choice among segments is not only a technical decision, but also a political/social/ethical decision. The decision thus may not belong solely in the hands of the project planners, but is appropriately negotiated among the constituencies

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

who have an interest in the outcome. Two factors are of particular importance for these decisions: (1) the desires of the intended populations and community leaders, and (2) the projected costs and benefits associated with intervening or not intervening for a particular group.

Consideration of the desires of intended populations requires the involvement of potential audiences in the design of health communication efforts. Campaign planners and implementers must have some measure of understanding, dialogue, and mutually accepted and shared practices with intended audiences (Gbadegesin, 1998) to ensure that the communication campaign addresses shared values and goals (rather than those imposed by implementers). Challenges in identifying relevant and representative group members and social authorities, as well as in determining the degree of consent required from a group prior to the initiation of health communication interventions, are explored in our discussion about the ethics of health communication in Chapter 7.

Audience Selection: Findings from Review

The majority of health communication campaigns reviewed by this committee selected intended target populations based on need. Need was generally identified through available epidemiological and public health data sources, which characterize audiences by demographic variables (e.g., ethnicity, gender, age, educational attainment, socioeconomic status). In some cases, campaigns relied on other quantitative data for the selection of audience segments, such as survey research assessing knowledge or attitudinal, psychological, psychosocial, or behavioral characteristics of audiences, in addition to the demographic and epidemiological data available from public health sources (see, e.g., Grelen, 2001).

For example, the National Air Bag and Seatbelt Safety Campaign used available data to identify its primary audiences based on populations at highest risk for morbidity and mortality associated with traffic accidents (i.e., first-time parents, young parents, new drivers, new vehicle buyers, and ethnic minorities). Similarly,

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

the Depression Awareness, Recognition, and Treatment (D/ART) campaign commissioned scholarly papers and literature reviews, conducted focus groups with physicians and diverse members of the public, and used available demographic data (e.g., National Institute for Mental Health Epidemiologic Catchment Area study) to determine focus areas and populations of need (see, e.g., Murray and Lopez, 1996; Davidoff, 1998; Leo et al., 1999).

In other cases, intended audiences and specific health behaviors and health outcomes were chosen because of their priority status on the nation’s health agenda, as defined by Healthy People 2010 (U.S. Department of Health and Human Services, 2000) and the Initiative to Eliminate Health Disparities (Geronimus et al., 1996). Such was the case for the National Diabetes Education Program, for example, which targets ethnically diverse audiences, who are disproportionately affected by diabetes and its complications (see Chapter 5 of this volume).

Some campaigns address needs of smaller population segments, then broaden their efforts. For example, the Folic Acid Campaign first focused on women of childbearing age who were contemplating pregnancy, then broadened its audience segments in phases. Eventually, the campaign conducted communication efforts for all women of childbearing age, with a particular focus on high-risk populations (Centers for Disease Control and Prevention, 1999). On the other hand, the National 5 A Day Campaign began broadly, with all adults not meeting the guidelines for fruit and vegetable consumption. As more was learned by developers about the population, the campaign became more targeted, focusing primarily on audiences who were already trying to eat more fruits and vegetables daily and felt guilty about their poor eating habits, but believed they could not change. The campaign became even more targeted when communication strategies began to target specific socially and ethnically diverse populations, in recognition of the need to address cultural and income differences in dietary habits. This targeting generally was done on a regional rather than a national basis (Van Duyn, 2000).

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Such campaigns chose to make the tradeoff between size of audience and need, starting with broadly targeted campaigns, then later focusing more on targeted groups in greater need only after more resources became available to develop and disseminate subgroup-specific materials. The Back to Sleep Campaign, which at first targeted the full population, only later developed a targeted communication campaign for Native American/Alaskan Native populations, although this subgroup has had the highest rate of sudden infant death syndrome (SIDS) (National Center for Cultural Competence, 2000). Similarly, the Campaign to Prevent Teen Pregnancy began to complement its general audience campaign with a special campaign for Hispanic populations, who have the highest rates of teen pregnancy (Brown and Nightingale, 2000; DeJong and Winsten, 1998). Another example is the Milk Matters Campaign, which began with a general audience focus, and later focused on Hispanic audiences and those who are lactose intolerant, once it had the resources and capacity to do so (Adler, 1999).

Political advocacy groups and federal health goals (and funding allocations) also guided the selection of campaign topics and audiences. For example, the Best Start Loving Support Campaign began as a cooperative agreement between Best Start Social Marketing and various federal agencies such as Women, Infants and Children (WIC), a program conducted by the U.S. Department of Agriculture, and the Maternal and Child Health Program, sponsored by an association of state and local health officials. These agencies were supported by congressionally allocated funds to promote breastfeeding among participants in the Women, Infants and Child Health programs (see, e.g., Maryland Community and Public Health Administration, 2000). The National Anti-Drug Media Campaign was launched by the Office of National Drug Control Policy in response to the Treasury-Postal Appropriations Act of 1998, in which Congress approved funding for a national media campaign to reduce and prevent drug use among young Americans. The funding included a strong expectation that specific work would be done with ethnically diverse audiences, and that has been

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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a hallmark of the campaign (Office of National Drug Control Policy, 2000; Johnston, O’Malley, and Bachman, 2001).

Antitobacco campaigns have had a strong mandate from their funders to focus on youth. The Florida Tobacco Pilot Program originated from the $200 million initially allocated from Florida’s $11.3 billion settlement with the tobacco industry. These funds supported design and implementation of a state-run program to prevent and reduce youth tobacco use (Florida “truth” campaign). Similarly, the National Truth Campaign was launched as a result of the Master Settlement Agreement among 46 states, 5 U.S. territories, and the tobacco industry, which established the Legacy Foundation and a Public Education Fund to support the campaign. Although intended audiences were predetermined by the sponsor or funding source, most of the campaigns mentioned conducted their own public relations and marketing research to identify communication strategies to most effectively reach subgroups within the diverse audience segments selected (Massari, 2000).

Campaigns often include plans to shift or expand intended audiences over time as part of their communication objectives. For example, the Folic Acid Campaign uses a stage-market segmentation plan, whereby it broadens its audience segments in progressive phases, gradually including all women of childbearing age and focusing on those who are at highest risk.

Communication campaigns often redefine their intended audiences over time, as they learn more about their audiences. In several cases, campaign implementers identified audiences who were not responding to the general campaign communication strategies, and created separate or specialized campaigns for those audiences. This was made possible by good quantitative research before and during intervention implementation, which allowed for the diagnosis of disparities in effects. Two such campaigns include the Back to Sleep Campaign and the National High Blood Pressure Education Program, both of which used continuous tracking and evaluation to identify gaps in audience knowledge and behavior and to readjust campaign strategies. Throughout the course of implementation, the National High Blood Pressure Education Pro-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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gram gradually targeted new and expanded audiences, such as African-Americans, women, and specific age and income groups, among others (Roccella, 2002).

Selecting particular audiences for emphasis or recognizing that the audience for a campaign is heterogeneous is a first step. However, having recognized that heterogeneity, there are many ways that a campaign can adapt to the presence of differing groups in the audience. The process of adaptation is the focus of the next section.

ADAPTATION OF HEALTH COMMUNICATION CAMPAIGNS FOR DIVERSE AUDIENCES

A campaign is made up of many components. Each opens separate avenues for adaptation to segments of an audience. There are generally three broad approaches to adaptation.

  1. Create a single campaign intended to affect most audiences by focusing on what is held in common across audiences. The common approach assumes that apparently heterogeneous audiences differ in some ways, but may share enough characteristics with regard to what influences their behavior, what media they can access, and what message executions will appeal to them so that a single campaign (with its lower costs) will be effective. (An example for an antitobacco campaign, much like the Truth campaign: Focus on not smoking so as to resist tobacco industry promotion of smoking; provide messages that suggest a multiethnic, united youth movement fighting against industry manipulation; use mainstream television channels and programs watched to some extent by most youth; use multiethnic actors and language broadly used by youth in all advertising.)

  2. Create a common campaign with regard to behavioral targets and essential messages, but adapt it for different audiences by varying the primary diffusion channels and specific executions of messages. (For the antitobacco campaign, purchase extra exposures in media more heavily used by African-American or Hispanic

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

youth; develop ad executions that feature actors of those backgrounds, and use language particularly recognized in those communities.)

  1. Create largely distinct campaigns for different subgroups, varying the behavioral focus, the essential message strategies, the channel choices, and the message executions. These campaigns make the opposite assumption from the first type—that groups are so heterogeneous that if they are to be affected by a campaign, it has to be adapted closely to their unique characteristics. (For the antitobacco campaign: If it were true that resistance to authority appeals to 14- to 16-year-old teens, and reluctance to violate parental expectations appeals to those of age 11 to 13, create distinct campaigns for the two groups with different message strategies focusing on resisting manipulation and avoiding parental disappointment, purchase media time on programs particularly appealing to each group, and use different actors and settings for the advertisements.)

Specific campaigns may not fit precisely within one of these categories. If they do fit in one of them early on, they may move from one category to another as they evolve. There is no a priori assumption that following one of these approaches is better than another. It is logical to assume that per person reached, campaigns in the first category are the least expensive, campaigns in the last category have the potential to be most effective. If there is a common theme that is influential for a wide spectrum of audiences and if funds are limited, it will be quite attractive to work on a common campaign. If audiences are much more distinct and resources are plentiful, discrete campaigns make sense. The decision on how to adapt should be made in the context of available resources, behavioral focus, and the degree of actual heterogeneity with regard to influences on behavior, access to channels, and projected responsiveness to different message executions.

All three of these models contrast with tailored communication programs that are adapted to reach individuals rather than groups. To tailor a message, a sample of the members of the in-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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tended audience completes an assessment. Based on their answers, individuals then receive a particular form of the message (Kreuter et al., 2000b). In principle, tailoring should produce messages that are superior to group messages, because variations in behaviors and beliefs within each diverse group would be reflected in the tailored messages, as would other individual differences. However, in the context of large-scale communication campaigns, particularly those that can achieve broad reach only with the use of mass media channels, tailoring is unlikely; in that circumstance, tailoring might be used as one aspect of a targeted communication campaign, such as for a small, very high-risk segment. Thus, a mass media campaign could be used to motivate people to call a toll-free number for help in quitting smoking. At that point, they would be sent individually tailored materials to deal with their smoking patterns and quitting experiences (Kreuter et al., 1999).

There is a strong logic to attending to segmentation and, as much as possible, developing a campaign that is responsive to such heterogeneity using any of the approaches just described. However, before we look at examples, a different perspective is worth considering. Much ongoing campaign theory argues for attention to segments. In the abstract, it is easy to see the advantage, but in practice, segmentation assumes it will be possible to sort through, in fairly precise ways, which approaches will work with what audiences, and to devise channel and message strategies that will fulfill those preferred approaches. In fact, turning segmentation arguments into practice may result in any of the following three problems.

  1. Resources may not stretch to cover multiple targeted subcampaigns, even if using them is the best approach. The only viable heterogeneity strategy for some campaigns may be the common-denominator version.

  2. Even if resources are sufficient to pay for some targeting, it is difficult to estimate how much of an advantage there is to a particular targeting approach, for message strategy, for channels purchase, or for message execution. Often, in practice, the re-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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search base for making such decisions is limited. Adaptations may focus on channel strategies (given widely available media access information) or more superficial elements of message execution targeting (e.g., employing actors of the same race in advertising). Diversity-based differentiation of message strategies is rare because these strategies are more difficult to develop and justify (due to a lack of strong evidence).

  1. The logic of making micro decisions about message strategies, channels, and message executions assumes that the major path to a campaign’s effect runs through individual exposure to campaign messages. However, as outlined in Chapter 2 on theory, the paths to effect of some campaigns may reflect a different path of influence as well. To achieve sustained population behavior change, successful campaigns may require supportive environments and social norms. Their effects may reflect not just individual persuasion, but shifts in social norms. An ad that may be less personally persuasive to an individual may be more likely to generate public discussion about an issue. If people across diverse subgroups share reception of messages, there may be effects that are not merely the sum of the individual effects of personal exposure. Also, communication campaigns can target secondary and tertiary audiences in an attempt to create social, institutional, and policy changes that support health behavior.

Most communication campaigns address multifaceted health problems resulting from individual, social, environmental, economic, and political factors. Increasingly, campaigns are recognizing the need to intervene across multiple levels of influence in order to have a significant impact on the relevant health behavior and to sustain it at a national level. Multilevel campaigns implement strategies to address the multiple facets of the same health problem by targeting primary audiences (for individual behavior change), secondary audiences (such as health professionals who may, in turn, reach or influence primary audiences), and tertiary audiences (to modify broader sociopolitical systems that ultimately influence individual behaviors). Such campaigns might include communica-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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tion efforts that focus on social influences (peers, families), public policy and environmental influences (policy makers, legislators, enforcement agencies), organizations (employers, labor unions), institutions (schools, religious affiliations, popular media), community elements (social, cultural, and community leaders), and the health care system (health professionals). The majority of campaigns reviewed for this volume focused on health professionals, not only as sources through which to disseminate health messages to the public and diverse subgroups, but also as targets for behavioral change to support modifications in the health care environment and health care delivery system.

Furthermore, many communication campaigns advocate changes and improvements to public policies by developing communication strategies intended for policy makers at the federal, state, or local levels. Various campaigns have collaborated with corporate leaders and employers to improve worksite environments. Efforts also have been implemented to promote campaign goals by targeting faith and community leaders as a strategy to indirectly affect culturally diverse populations.

Other campaigns have employed initiatives to change the popular media or to influence news coverage in attempts to influence social norms. Campaigns have sought to achieve these goals by promoting the dissemination of campaign messages (content placement) in popular media programming, ensuring accurate and factual depictions of the targeted health issue in the media through the provision of information and technical assistance, and using popular celebrities as campaign spokespersons. Additionally, some campaigns use media advocacy activities to change how the popular and news media address particular health issues in order to influence public policy.

These approaches can be consistent with a diversity-focused approach to campaign development; many campaigns focus on reaching out to policy communities with central concerns about diversity. However, the model of effect for these campaigns reflects a complex interaction of individual persuasion, social norm changes, and institutional shifts. The tradeoff for obtaining sub-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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stantial attention from external institutions may mean some loss of control of messages. If Oprah Winfrey and Peter Jennings are to address an important health issue, they will not permit campaign planners to write their scripts. Great sensitivity to diversity in campaign planning may be feasible with regard to messages diffused directly by a campaign. In contrast, when social mobilization around an issue is the goal, and it requires working indirectly through other institutions, the goals and working routines of those other institutions may determine the outcome. Scarce campaign resources may be best spent on efforts to encourage institutional actors, including mass media, to focus on an issue. Resources spent on meticulous calibration of messages may prove less relevant to such social and institutional mobilization.

One example of the tradeoffs between diversity-focused versus generalized campaigns comes from the history of HIV/AIDS campaigns. It was an epidemiological fact that some behaviors put people at greatest risk of HIV infection. These behaviors were more common in some identifiable subgroups of the population, particularly men who have sex with men. There could have been an argument that the majority of campaign efforts should have focused on communities where many individuals’ personal behavior put them at risk. Indeed, many efforts focused on gay men. However, in most countries, this was only one component of a more broadly focused HIV campaign, one that declared all members of society as at risk. This strategy may have reduced infection incidence, but whether it would have done so more effectively than a campaign that focused on those at highest risk is still a question. Nonetheless, it seems clear that framing risk as broadly present in society, rather than only belonging to certain marginalized subgroups, was associated with a broadened policy concern: more health research dollars, more legislation outlawing discrimination based on HIV status, and perhaps lessened stigmatization of people living with HIV. Indeed, absent the broad policy concern, resources for an alternative focused campaign might have been missing entirely.

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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We continue our discussion of diversity and addressing heterogeneous audiences by presenting examples of how various campaigns have worked to reach the audiences. In doing so, we leave behind this alternative perspective on how campaigns have effects, and its somewhat chastening view about limits on how far one can and should go in implementing segmentation, or at least how helpful a research base will be in informing the right choices.

Heterogeneity in Behaviors Addressed

Health campaigns can be refined for diverse audiences by adapting behavior change goals so that they are relevant, appropriate, and appealing to diverse audiences. A variety of campaigns reviewed for this volume capitalized on communication efforts by promoting different behavioral goals among audience segments that differed with respect to their relation to the targeted behavior or health condition.

Recognizing that an individual’s relationship and exposure to a specific health risk behavior is likely to change with lifecycle stage, many communication campaigns promote different behavioral goals based on the various age groups in the intended audience. For example, the Florida Tobacco Pilot Program promotes different antismoking-related messages to youth, depending on their age and smoking status. The focus of messages ranges from the prevention of smoking initiation among younger teens and currently nonsmoking older youth to the discussion of smoking cessation techniques and strategies to maintain cessation among current smokers and older teens.

Furthermore, because individual, familial, and societal roles change with age, some campaigns promote different behaviors to adults and youth. In effect, the campaigns develop unique interventions that focus on different aspects of the same health problem. For the prevention of drug use, the National Youth Anti-Drug Media Campaign promotes messages about the rejection of drug use to youth and also promotes messages to adult role models, such as parents and teachers, about the need to monitor youth

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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behavior. Similarly, the National Campaign to Prevent Teen Pregnancy communicates messages about sexual responsibility and advocates use of safer sexual behaviors to teens. In contrast, messages intended for parents stress the importance of having open discussions with their children about issues related to sex, including prevention of pregnancy and sexually transmitted diseases.

Heterogeneity in Causes and Correlates of Behavior (and Thus in Message Strategies)

Because perceived benefits and barriers to behavior change may differ across audience segments, effective communication campaigns for diverse audiences should be adapted to appropriately frame messages to address the audience’s perceived risks, costs, benefits, and social pressures related to the desired behavior change. Several examples of campaigns from this review promote the same behavioral goal through different strategies for diverse populations, including the Folic Acid Campaign. This campaign has developed different communication materials for women, focusing on the more immediate benefits to infants among women contemplating pregnancy, and the longer term benefits for those not contemplating pregnancy. Similarly, the Campaign to Prevent Teen Pregnancy has different communication strategies and materials for teenage boys and girls, emphasizing gender-specific rewards and barriers.

The National Diabetes Education Program is adapted to address the major ethnic groups in the United States. Messages promote identified cultural values that encourage diabetes self-care (cultural incentives) and challenge cultural traditions that inhibit diabetes care-related behaviors (cultural barriers). For example, messages for Hispanics to control diabetes were developed to counter the fatalistic belief that diabetes complications are inevitable, and messages for Native American/Alaskan Native populations emphasize the importance of growing older to “be around” for younger generations and to pass on traditions (Centers for Disease Control and Prevention, 1999).

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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On the other hand, some campaigns use information about identified audience rewards and barriers to develop general communication strategies that will be effective across all intended populations, based on similarities across diverse groups. The Best Start Loving Support Campaign developed strategies to overcome common barriers to breastfeeding identified by the mothers in their audience (regardless of age and ethnicity), including embarrassment at breastfeeding in public; competing demands of work, school, and/or social life; and lack of social support. Furthermore, campaign messages promoted identified facilitators to breastfeeding behavior change, such as the close bond between mother and baby, relaxation, empowerment, and pride.

Heterogeneity in Channels and Settings for Diffusion of Messages

Channels include all the means for communicating with the audience, such as media, interpersonal sources, and settings and promotional events. The times, places, and states of mind in which different audience segments will be receptive to messages can vary dramatically. For example, churches and other religious organizations may be appropriate openings for target audiences who attend church regularly, but they would have no influence on those segments uninvolved in organized religion.

Because the most influential channels of communication may vary with the content of the health issue and characteristics of the intended audience, formative research typically is conducted to identify the most effective communication channels. Campaigns often choose to reach particular diverse groups through different channels. For electronic media, it is possible to change the timing and placement of messages to coincide with preferred programs, listening times, or Web-surfing activities. Campaigns attempting to reach Spanish-speaking audiences commonly translate materials for communication and dissemination through Spanish-language media. Similarly, campaigns targeted at Chinese, Japanese, and Korean Americans often use ethnic radio and newspapers, which

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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appear to be available in many geographic areas of the country where high concentrations of these populations reside (National Heart, Lung, and Blood Institute, 2000).

Different age, gender, and income groups also tend to favor different media, so it is prudent when targeting by these characteristics to investigate which media are best for each group. For example, a smoking campaign in Vermont selectively placed television spots on one or another program based on formative research the developers conducted separately with each target group (e.g., young girls and young boys) (Worden et al., 1996). Similarly, a communication campaign may use billboards and store displays to reach low-income, inner-city dwellers, and newspapers to reach suburban households. Efforts to reach gay, lesbian, and bisexual populations often supplement mainstream media with publications geared to those groups.

The Internet now offers an additional channel of communication to promote campaign messages and goals in settings that are accessible to some consumers (home, library, cafes) during times that are convenient for them. Whereas national programs traditionally have used toll-free telephone lines to offer resources and publications, support or advice, information, program and policy updates, and, in some cases, referrals, communication campaigns now can offer these information services 24 hours a day, 7 days a week through the Internet. All ongoing campaigns in the current review have developed their own Web sites, most of which offer not only campaign information and resources, but provide links to other sources of information and related sites. Some campaigns offer sites in multiple languages. Issues of access, knowledge, skills, and use related to Internet health communications across diverse income, education, age, and ethnic groups are further explored in Chapter 6 of this volume.

The Internet has also afforded campaigns the opportunity to tailor communications1 to individuals through regular e-mail up-

1  

Tailored messages are used most often in print channels, but also can be applied to CD-ROMs, the Internet, telephone counseling, and video kiosks (Kreuter et al., 2000b).

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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dates to Web site visitors (e.g., Folic Acid Campaign), tailored e-mails to campaign members or volunteers through electronic mailing lists (e.g., National Truth Campaign), and personalized reminders to promote the desired health behavior (e.g., annual mammogram reminders by the National Alliance of Breast Cancer Organizations). Some campaigns have developed Web sites that are responsive to the unique needs of diverse audience segments, such as the National Youth Anti-Drug Media Campaign, which offers content-based Web sites for parents (http://www.theantidrug.com), teens and “tweens” (http://www.freevibe.com), teachers (http://www.teachersguide.org), student journalists (http://www.StraightScoop.org), and other audience segments.

Heterogeneity in Message Executions

Message executions involve many specific decisions. Two important ones include the basis offered for the credibility of a promised reward and the image projected by a campaign. One important basis of credibility is the source or person(s) communicating the message. Different audience subgroups may find different sources of information to be persuasive. For example, scientific findings from an expert source may be the most important and credible evidence to one audience segment, while information on social norms from a peer may increase perceived self-efficacy and offer better support to another audience segment.

The source and support for messages may reflect the health issue or topic of communication as it is seen by a particular audience. Some issues may be naturally “medicalized” for a particular audience and thus there is a reliance on sources that offer immedi-

   

Most applications of tailored messages to date appear to use criteria other than diver-sity—broad demographic categories (Kreuter et al., 2000b). The types of criteria used most often are based on behaviors and beliefs derived from psychological theories of behavior change and may therefore meet criteria for attending to relevant aspects of cultural process.

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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ate expertise. Examples for some people might include having regular mammograms, increasing folic acid intake, improving diabetes self-care behaviors, and encouraging parents to place babies on their backs when sleeping. In contrast, the promotion of health behaviors that are for some people largely mediated by social influences and norms, such as teen pregnancy, tobacco and substance use, and breastfeeding, may be more credibly communicated through peer groups, family or community members, celebrity role models, or religious leaders. Finally, messages that attempt to achieve change in environmental issues or politically mediated public health problems, such as traffic safety or the sale of alcohol and cigarettes to minors, may be communicated most effectively through authority figures and representatives of law enforcement agencies.

Most of the health communication campaigns included in this review used multiple sources of support to most effectively reach the diverse segments of their intended audiences. As an example, the National Safe Kids “Get Into the Game” Campaign relies on relevant celebrities and spokespersons to enhance the impact of messages. Different sources are chosen to reach different age and gender groups. For example, to reach adult audiences, the Surgeon General, injury experts, and Al and Tipper Gore (when he was Vice President) were used as sources of support for campaign messages, while injured children and famous athletes were used to convey messages about safety to children (Cruz and Mickalide, 2000; National Safe Kids, 2000). Similarly, the National Campaign to Prevent Teen Pregnancy reaches a wide range of audiences through credible religious leaders, political leaders, health and research experts, popular and news media, and celebrities selected to be appropriate for populations of different ethnic, gender, and age groups.

The image projected by a health communication campaign is another important element that can be modified for diverse audiences. A health campaign’s image often is referred to as its tone or personality. It can be developed through the type of format, style, music, characters, and so on that are used in the creative execution

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

of messages. The tone of a message should “speak the language” of intended audiences. For example, a serious message using spokespersons in their late sixties more likely would be perceived as talking to an older target segment than would a trendy or hip message using today’s rap stars. Even when the underlying message is the same, the way it is communicated may differ among audience segments.

Executions can vary their slogans, visuals, actors, language, and music, among other things. Perhaps the most common means of altering the image of a communication campaign to appeal to diverse audiences is to alter the language, terminology, or slang used in communications. This is easiest to accomplish with print materials (such as newspapers, magazines, and flyers) and televised public service announcements using a voice-over. For example, materials can be produced in Spanish, standard English, and innercity slang.

Another option is to use the actors or models who look like members of the intended audience. Print materials for different ethnic groups, genders, and age groups frequently convey the intended audience by use of pictures. For example, the Best Start Social Marketing Service (a nonprofit organization working under a contract with the Centers for Disease Control and Prevention, or CDC) and the Loving Support Campaign (a CDC effort to promote breastfeeding) created billboards, posters, pamphlets, and mail inserts that featured photographs of people of different ethnic groups. The National Cancer Institute’s Once A Year for A Life Time mammography campaigns combined graphics featuring women similar in appearance to the ethnic and age groups of intended audiences. Although the creation of television public service announcements is costly, a few campaigns have produced parallel executions for television aimed at different groups, such as the National Truth Campaign and the National Youth Anti-Drug Media Campaign, which produced separate advertising for African-American and Hispanic audiences.

Certainly, a wide range of creative efforts has been employed by communication campaigns to project appropriate images that

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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are credible, attractive, and appropriate for intended audiences. Some campaigns have conducted extensive research to develop a consistent, carefully designed “signature” image or symbol (known as “product branding” in social marketing), which speaks the language and conveys the culture of the audiences of interest. Although these campaigns are in the minority, they have made exemplary efforts to portray trendy images that “speak the language” of their intended audiences, using creative products, interactive technologies, celebrity role models, high technology, and sometimes controversial advertisements to attract their attention. Examples include the National Truth Campaign, and its predecessor, the Florida Tobacco Pilot Program. The campaigns represent images of hip, empowered youth making healthy decisions for themselves. The cool, controversial, and rebellious images of the Florida and National Truth campaigns are further promoted through products (e.g., “Truth gear”), innovative events (e.g., “Rip It Out,” teen truth tours, the “reel truth” advocacy campaign), and the Tobacco Memorial erected in Washington, D.C.

EVIDENCE THAT DIFFERENT APPROACHES TO DIVERSITY IN CAMPAIGNS HAVE DIFFERENTIAL SUCCESS

In the previous sections, we described the logic of addressing audience heterogeneity and provided a range of examples of how this has been done in practice. The logic of segmentation often makes sense. Now we ask: Have the particular ways that programs have addressed segmentation in practice proved productive? Is there evidence that paying attention to heterogeneity matters empirically, particularly with regard to the diversity categories featured in this volume?

This section begins with a discussion of what types of evidence would be telling in this regard. Next, it presents the evidence that is available. There will be a large gap between the type of evidence that would be telling and the published evidence base. As a result,

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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we conclude the section by presenting an agenda for such diversity-related research, rather than a summary of what is known.

Good evidence exists that the periods of operation of some national campaigns have been associated with periods of improving overall levels of problematic health behaviors and health outcomes. The operation of the National High Blood Pressure Education Program (Roccella, 2002), National Cholesterol Education Program (2001), Back to Sleep Campaign (Willinger et al., 2000), the CDC AIDS campaign, several European AIDS campaigns (Wellings, 2002; Dubois-Arber et al., 1997), the urban vaccination campaign in the Philippines (Zimicki et al., 1994), and the California (Pierce, Emery, and Gilpin, 2002), Florida (Sly et al., 2001), and Massachusetts (Siegel and Biener, 2000) antitobacco campaigns all are associated with periods of sharp change in their target behaviors. Although simple association of trends over time with campaign initiation is not sufficient grounds for claiming a causal effect, many of the evaluations have additional reasons for attributing the observed change to their efforts. These include reports of high exposure to their messages, evidence for change in intermediate process variables that were the direct targets of the campaigns, and evidence that those reporting more exposure to the campaigns were particularly likely to change (Hornik, 2002).

However, evidence that some campaigns are associated with good outcomes is not evidence that their particular strategies for dealing with diversity were effective, particularly when compared with alternative approaches. What sort of evidence would be relevant to the diversity issue? We outline a variety of levels of evidence that might bear on this issue.

Evidence About Effects on Outcomes

Evidence That a Campaign Had Differential Outcomes for Subgroups of Its Target Audience

This evidence would require examination of the trajectories of the subgroups over the period of campaign operation. Presum-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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ably, this examination would focus on comparison between groups known for disparities at the start. The analysis would evaluate whether target groups differed in their rates of change, and if so which group was favored. This sort of analysis would provide useful information for an operating campaign because it would indicate whether what it was doing was affecting a known gap between groups. However, it would not indicate whether an alternative diversity strategy would be better or worse for this purpose.

Evidence That Different Diversity Strategies Produce Differences in Effect

Four strategies can be used to compare evidence, as described in the following paragraphs:

  1. Comparison across periods of the same campaign, when, for example, the campaign moved from a unified campaign strategy to one of multiple diversity-based substrategies. The focus comparison would be whether the relative trajectories on outcomes were more favorable to the disadvantaged subgroup during one period than in the other. Such comparisons over time would be compelling if there were no other changes across the time periods. A particular concern would be that those who were slower to change are those who were the leftover targets for later time periods. This would happen if those individuals who were ready to change were shown to have been positively affected in the first campaign periods.

  2. Comparison across distinct campaigns with the same behavioral objective and broad target audience, but with different diversity strategies. For example, if one state youth antitobacco campaign followed one diversity strategy and another followed a different one, how would the relative trajectories of the target subgroups vary? Again, this comparison would be telling if the comparison units (e.g., states) could be assumed to be otherwise similar.

  3. Comparison of distinct campaigns with the same behavioral objectives, but different diversity strategies, to examine

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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whether they produce differential rates of change for the disadvantaged population. For example, a focused campaign to reach Native American populations to stimulate active care seeking for diabetes might begin operating soon after a national campaign with the same objective. Is there evidence that the focused campaign produces higher rates of care seeking among Native Americans than the national campaign, particularly in the context of relative costs per person reached?

  1. Comparison across campaigns that differ in diversity strategy, but also differ in other important aspects, such as in their behavioral foci (tobacco versus drugs; blood pressure versus cholesterol). This evidence would be useful, but would depend on offering a credible argument that the other differences between the comparison campaigns were not so large as to confound the diversity differences. The credibility of claims based on this evidence would be greater if it was based on multiple comparisons rather than on just one comparison.

Evidence About Differential Effects on Process Variables

Evidence That Diverse Subgroups Respond Differentially to Message Strategies

The discussion about theory (Chapter 2) describes the basis for justifying the use of different message strategies for different subgroups. It argues that different strategies were justified when there was evidence that for specified groups, different sets of beliefs were predictive of their behavior. For example, for the youth antitobacco campaign, one subgroup’s discussion about beginning to smoke might be related to its belief that a person’s athletic endurance would be damaged by smoking. Another group might exhibit a stronger association of concerns about parental disapproval of their child starting to smoke. A campaign might develop messages that embodied each of those ideas, then they might be tested with members of both subgroups. The test could be done in a constrained way: asking subgroup members to evaluate the ads and

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

their arguments, with an expectation that subgroups will identify the arguments in their ad to be more important and more likely to be persuasive. The test also could be done in a more elaborate way, relying on a pilot study with three arms: one of which used both ads, one of which used the preferred ad for each subgroup, and one of which used the not-preferred ad for each subgroup. The outcomes would be belief change with regard to the argument made and movement on intention to initiate smoking. The expectation would be that the “correctly targeted” strategy would be the best, and the “incorrectly targeted” strategy the worst, for all groups. However, any advantage of the “correctly targeted” strategy would have to be evaluated in the context of the possible additional costs associated with double production of materials and extra delivery resources required (e.g., broadcast time).

Evidence That Diversity-Based Targeting Produces Improved Campaign Exposure

Is there evidence that target groups reported more frequent exposure to messages when the channel strategy was targeted to maximize their exposure than when it was not? At some level this is not a controversial issue. In general, if campaigns use conventional channels, publicly available data (such as Nielsen ratings for television programs) can provide reasonable projections of exposure by important subgroups. Evaluations of alternative diversity strategies for channel selection are more interesting when:

  • The issue has to do with the cost-efficiency of purchases— that is, whether the additional reach associated with targeted purchases justifies the additional expense of such purchases.

  • The diversity strategy involves subgroups whose access to media is not available from publicly available data sources, such as groups who differ in sexual orientation.

  • The channels being considered are not conventional ones, for example, if there were to be consideration of the tradeoff between relying on conventional media channels and institutional

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

channels (churches, community groups) to reach out to the African-American community.

Examination of this evidence might begin with simple crossgroup comparisons with regard to achieved reach overall and for each of the specific channels used. Comparison would begin with evidence about differential access to channels, but would include evidence of recall of messages transmitted over each channel, and perhaps reports that the exposure to the message produced subsequent conversation. As the first test described under the approaches to evaluating outcome effects of programs, this approach would provide useful information about what exposure was being achieved across diversity subgroups for a particular campaign. However, in isolation it would not indicate whether a different diversity channel strategy would improve relative exposure among groups.

Comparisons of diversity strategies might rely on the more elaborate comparison tests parallel to those described for the outcome analyses. They would be used with a focus on recalled exposure rather than effects on outcomes.

Evidence About Diversity Effects for Message Executions

There is an easy argument that subgroups will respond differently to messages with varying sources or with varying styles or images, even if the message strategy does not vary. On the other hand, every new execution adds to the cost of the campaign, and if it is meant to complement a differential channel purchase strategy, those additional costs can be substantial. The issue is not whether such varied executions would be helpful, but rather how much of such executional variation should be done, and the extent to which the advantage counterweighs the cost. What evidence might be useful to support targeting execution strategies rather than using a common-denominator execution strategy (e.g., having ads that feature boys and ads that feature girls versus ads that feature both)? Logically, the same sort of evidence that will be persuasive for

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

message strategy variation also will be persuasive for message execution variation. At the simplest level, assessment of alternative executions across target subgroups will provide some picture of whether something can be gained. At the next level, systematic testing of alternative executions, on the model of the three-armed strategy test described earlier with belief change as the outcome, would provide a more credible and more expensive exploration of adapting to diversity in message executions.

These are the forms of evidence that would support decisions about how much and how to adapt communication campaigns to maximize effectiveness across diverse subgroups. For each of these types of evidence, what is the extent of the evidence base? Our review of the available documents suggests that the evidence base is quite limited. Most of the evidence that was found that bears directly on the diversity issue is evidence about differential effectiveness of existing campaigns across subgroups, responding to the question just asked. In addition, there is little evidence about differential reach of projects across important subgroups. We uncovered no evidence that systematically compared effectiveness across diversity strategies.

Evidence About Differential Effectiveness

Florida Tobacco Pilot Program

The ongoing Florida Tobacco Pilot Program (currently known as the National Truth Campaign) aims to reduce teen smoking through a wide variety of activities, including media promotion, in-school education, contests, and enforcement. Initial results are positive for both middle and high school youth. Rigorous tracking and ongoing outcome evaluations of the program have revealed that knowledge of tobacco possession laws increased for all grades and ethnic groups and both genders, while the number of middle and high school students who bought cigarettes decreased in the first 2 years of implementation. Importantly, current cigarette use declined significantly in both the first and second years of the cam-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

paign among middle and high school students, boys and girls, and non-Hispanic white, non-Hispanic Black, and Hispanic students (other ethnic groups not reported) (Florida Department of Health, 2000a). The overall rates of decline in Florida’s teen smoking occurred at a significantly faster pace than that of the national average. Between 1998 and 2000, current cigarette use in Florida declined 54 percent among middle school students and 24 percent among high school students, though rates of decline varied by age, stage of smoking, ethnicity, gender, and geographic region. For example, there were greater reductions in cigarette use among high school girls (6.2 percent) than among high school boys (3.3 percent) (Florida Department of Health, 2000b). Why the campaign had less impact on high school boys than girls is unknown.

Variances in smoking rates among different ethnic groups also were found on several measures. In the first year of the campaign, cigarette smoking declined among non-Hispanic whites and non-Hispanic Blacks, but not among Hispanics and Native American/ Alaskan Native youth (Florida Department of Health, 2000a). By the second year, there was a decline among whites, Blacks, and Hispanics, with no figures reported for Native Americans (Florida Department of Health, 2000b).

National High Blood Pressure Education Program

The National High Blood Pressure Education Program was implemented with the goal of reducing the incidence of death and disability related to high blood pressure, including heart disease and stroke. The campaign assessed progress and program impact by conducting its own surveys and studies, evaluating the results of other major studies, and tracking national surveys such as the National Health Interview Survey and the National Ambulatory Index, among others. At the time of program initiation in 1972, less than one-fourth of the American population was aware of the relationship between hypertension and stroke or heart disease, and misperceptions about high blood pressure were widespread, despite the fact that one in six Americans suffered from the condi-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

tion. Only 51 percent of people with hypertension were told by physicians that they had elevated blood pressure and only 16 percent of them were taking medication to control it.

After the first 5 years of campaign implementation, reports of the National High Blood Pressure Education Program indicated that 69 percent of survey respondents had learned something about high blood pressure and 30 percent of the general population believed they could define normal blood pressure, though this was true of more whites (33 percent) than African-Americans (18 percent). Subsequent communication efforts focused on African-American audiences and their physicians. By the end of the 1970s, hypertension awareness had increased among African-American men (from 41 to 66 percent) and African-American women (from 53 to 87 percent). Actual treatment rates for hypertension among African-Americans increased from 24 to 35 percent for men and from 40 to 63 percent for women. However, African-Americans were still less aware and less likely to be treated for high blood pressure when compared to their white counterparts.

By 1994, three-quarters of the American public reported having their blood pressure measured every 6 months. Significant improvements were observed in awareness and treatment of hypertension among those with hypertension (Cooper et al., 1997), and age-adjusted mortality rates had declined by 53 percent for coronary heart disease and 60 percent for stroke since the 1970s. Mortality declines were observed for both genders and for African-Americans and whites (National Heart, Lung, and Blood Institute, 2000). Although mortality rates for coronary heart disease have declined substantially for all groups, the greatest decline by 1994 was documented for white males and the smallest decline was evident for African-American males (National Heart, Lung, and Blood Institute, 2000).

By 1999, reports of the Behavioral Risk Factor Surveillance System (BRFSS) indicated that as little as 0.3 percent (median) of the general population had never had their blood pressure taken by a health professional, while the median prevalence of blood pressure screening in the past 6 months was nearly 75 percent (Be-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

havioral Risk Factor Surveillance System, 1999b). Past 6-month prevalence of reported blood pressure screening was higher among women (78 percent) than men (70 percent) and increased with age, though there did not seem to be any significant differences by levels of income or educational attainment. Interestingly, African-Americans (79 percent) were most likely to have been screened for high blood pressure within the past 6 months, followed by whites (75 percent), Hispanics (69 percent), and all other ethnic groups (69 percent). Importantly, between 1986 and 1996, overall death rates from cardiovascular diseases decreased an additional 21 percent (American Heart Association, 1998); differences by ethnic group and gender are discussed in Chapter 1.

These impressive declines in high blood pressure and stroke rates closely match the timing of the National High Blood Pressure Education Program. In addition, evidence that some of the specific targets for the program (e.g., awareness and care seeking) were affected along with morbidity and mortality supports an argument that they are related to program efforts. However, the communication-specific program elements were only one component of the broad program, and the program itself operated as a complement to other changes in the environment. It is not possible to make any precise claims as to how much of the effects might have been lost absent the communication-specific elements of the program.

Back to Sleep Campaign

The Back to Sleep Campaign was launched in June 1994 to disseminate the recommendations of the American Academy of Pediatrics, advocating the back (supine) infant sleeping position to help reduce the risk of SIDS. Continuous evaluations to monitor changes in knowledge and behaviors regarding infant sleeping practices are available to the campaign through various surveys. These include the National Infant Sleep Position Study (NISP), an annual telephone survey of nighttime caregivers of infants under 8 months of age, and national surveys of the National Institute for Child Health and Development (NICHD), such as the National

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Study of SIDS, which has evaluated sleep position practices since 1992 (Willinger et al., 1998). These ongoing assessments have allowed for the identification of high-risk populations and existing barriers to behavior change (National Institute for Child Health and Human Development, 1998; 2000).

Intermediate outcomes indicated that between 1994 and 1998, twice as many child caregivers (38 versus 79 percent) reported receiving the Back to Sleep recommendation from at least 1 of 4 sources (physician, nurse, reading materials, or radio and television) (NISP, 1998). Outcome measures have revealed a drop in prone sleep positioning among the general population, from 70 percent in 1992 to only 21 percent in 1997, with a corresponding drop in the incidence of SIDS rates of nearly 40 percent since 1992.

Between 1994 and 1998, stomach placement decreased 27 percentage points among whites but only 21 percentage points among African-Americans (Centers for Disease Control and Prevention, 1999). Overall, prone infant sleeping placement was 32 percent for African-Americans compared with 17 percent of whites in 1998 (Nagourney, 2000). Indeed, the gap between whites and African-Americans increased from a 9-percent difference in 1994 to a 17-percent difference in 1998. Lower rates of reduction in the incidence of SIDS have been noted among southern states and population groups of lower socioeconomic status, those living in either rural or inner-city environments, African-Americans, and Native Americans/Alaskan Natives. However, rates of change in sleep positioning behaviors have differed between Native Americans/Alaskan Natives and whites, suggesting that the continued high incidence of SIDS among the former group may be because of a higher prevalence of environmental risk factors (e.g., household smoke) in this population (Centers for Disease Control and Prevention, 1999).

Once A Year for A Lifetime

Mammography is among the few areas of health behavior where there is impressive evidence for a clear narrowing of the gap

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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TABLE 3-2 Mammography Use—Women 40 Years of Age and Older (Health United States, 2001)

 

Percent of Women Having a Mammogram in the Past 2 Years

 

1987

1990

1991

1993

1994

1998

White, Non-Hispanic

30.3

52.7

56.0

60.6

61.3

68.0

Black, Non-Hispanic

23.8

46.0

47.7

59.2

64.4

66.0

Hispanic

18.3

45.2

49.2

50.9

51.9

60.2

Health United States, 2001. Department of Health and Human Services. Centers for Disease Control and Prevention, National Center for Health Statistics.

between major ethnic and racial groups. Table 3-2 presents the proportion of women over age 40 who had mammograms in the previous 2 years between 1987 and 1998. A large gap in 1987 between African-Americans and whites had nearly disappeared by 1998, while the Hispanic to non-Hispanic gap had narrowed markedly, but remained. There were many changes in the environment, as well as a wide variety of other interventions operating during this period. Thus, the narrowing of the gaps may have many causes. Still, “Once A Year for A Lifetime,” described in the Annex, is among those interventions that operated during this period. It is not possible to suggest how much of the closing of the gap, if any, can be attributed to the campaign. Still, it is a first step to be able to report an association between the period of the campaign and the period of the closing of the gap. Specific claims of attribution will need more elaborate evidence.

CONCLUSIONS

This review of the communication campaign literature has produced a variety of findings, some of which are assertions about

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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what the committee found to be true, others of which are statements about what was not learned and needs to be better understood.

  1. Nearly all campaigns recognize heterogeneity in the populations whose behavior is of concern. The populations are heterogeneous with regard to the current level of their behavior, the likely causes of their behavior and of behavior change, and the channels and message executions that will be effective in reaching them. Most campaign strategists, recognizing that this heterogeneity will likely make different groups differentially open to campaign influence, choose only some segments of the population for their focus. Sometimes the aspects of heterogeneity that differentiate segments will match the diversity categories of this volume, but often they will not.

  2. Three broad approaches can be used in campaign message development to address heterogeneity. The first is to look for a common-denominator message that will be relevant across most populations. The second is to vary message executions to make them appeal to different segments, while retaining the same fundamental message strategy. The third is to develop distinct message strategies and/or interventions for each target segment. We assume that the first is the least costly and that the third is the most likely to be effective, although the third is often beyond the reach of many campaigns.

  3. Although our survey of campaigns was limited, we believe that nearly all major campaigns plan, and most create, implementations recognizing segment differences. Many of those implementations involve differences in message executions and channels for racial and ethnic groups, for age groups, or for men and women. Perhaps fewer of those campaigns choose different behavioral targets and basic message strategies.

  4. Little evidence has been published about the differential effectiveness of particular diversity strategies across groups. There is limited available evidence about the less subtle questions concerning the extent to which effectiveness of campaigns varied

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

across diverse groups. As often as not, this evidence shows equal responsiveness across target subgroups, although there are exceptions. However, given that these comparisons do not allow simultaneous comparison to diversity strategies and may not focus on the segments that were the targets of the campaigns, they are of only limited helpfulness. We do not know whether and to what extent the special considerations given by campaigns to diversity subgroups pay off.

RECOMMENDATIONS

These findings led the committee to make some essential recommendations both about the construction of communication campaigns and about what needs to be better understood.

  1. There is an urgent need for evidence about differential effectiveness of campaigns in the context of particular diversity strategies. All campaigns, and most experts in health communication, act as if diversity matters. However, they do so with a remarkably thin evidence base about which ways of addressing diversity matter, and how much they matter given their cost.

  2. It makes sense to segment a population under many circumstances, reflecting the recognition that populations vary in their behaviors and causes of behavior, as well as in the message executions that will appeal to them and the channels through which they can be reached. However, in choosing which segments are appropriate for a campaign focus, campaigns should clearly identify the rationale for the selection of the populations to be addressed, including ethical considerations. These rationales sometimes will lead to segment choices matching one or more of the diversity groups that are the focus of this volume; however, this will not always be true. Sometimes racial or ethnic groups, gender groups, and others will be quite heterogeneous with regard to a behavior and to their susceptibility to a message strategy. If other segmentation schemes better locate homogeneous groups for effective behavior change, they should be preferred.

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×
  1. There are alternative strategies for addressing multiple audiences, as already described; a particular program will need to choose its approach depending on what resources it has available for creating multiple campaigns and on the observed variation across populations with regard to behaviors and promising message strategies.

  2. Research with consumers is an essential aspect of all health communication interventions. Campaigns need to be committed to systematic formative and statistically projectable monitoring research among different potential segments of the population. Such research is needed to understand the target audiences within their cultural context as a basis for designing effective communication strategies. The research should prove more productive if it is driven by theory, as described in Chapter 2. For example, behavior change theory will suggest what the potential causes of behavior are, and drive the search for appropriate message strategies.

ANNEX: CHANGING HEALTH BEHAVIORS: THE MAMMOGRAPHY CASE STUDY

In the late 1980s, most women in the United States were not getting regular mammograms. Over the past two decades, mammography screening rates have increased significantly for women age 40 and over across all races. Although it is difficult to ascribe causal relationships, one can make the case for associating increases in screening rates with national campaigns initiated at this time. The synergy of these often opportunistic national activities as well as a multitude of local interventions track with increases over time. Government agencies, nonprofits, activists, and corporations have played a role. Although there was considerable focus on communications to women, broad, multilevel strategies addressed research, screening guidelines, access to mammography services, insurance coverage, and changes in regulation, legislation, and judicial actions (e.g., malpractice suits). The multilevel efforts targeting individual, system, and environmental changes demon-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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strate the magnitude, scale, and duration of initiatives needed to achieve behavior change.

As the lead federal agency, the National Cancer Institute (NCI) had a central role in increasing mammography rates. In support of its screening guidelines, NCI launched a mammography campaign called Once A Year for A Life Time. The initial message strategy for the campaign encouraged all women age 50 and over to get annual mammograms, not only those who had found a lump or had a family history of breast cancer.

The NCI campaign used multiple materials and distribution channels. There were also distinct campaign executions to increase the relevance of the message to African-American and Hispanic audiences. Once a Year produced print background, media, and public education materials on breast cancer and mammography in English and Spanish. These were widely distributed to national community-based organizations and print media and made available through NCI’s 1-800-4-CANCER telephone line. In partnership with the Susan G. Komen Foundation, NCI distributed television public service announcements featuring singer Nancy Wilson, placed the spots on two home video releases of movies with particular appeal to African-Americans (Glory and Strapless), and began a television publicity effort on Nancy Wilson’s involvement.

NCI also began several major public-private partnerships to leverage additional resources. The campaign placed emphasis on reaching diverse audiences through celebrity involvement. One example was two half-hour television specials produced by Revlon/ University of California-Los Angeles’ Women’s Cancer Research Program. The programs differed not only in language, but also in the use of culturally specific settings and celebrities. Jane Pauley and actress Phylicia Rashad hosted the initial English version. The program was aired during prime time by NBC and its affiliates. The Spanish program, hosted by Edward James Olmos and Cristina Saralegui, a Spanish talk show host, was aired by Univision in more than 600 cities.

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Additional strategies designed for African-American and Hispanic audiences included annual efforts for Minority Cancer Awareness Weeks and NCI’s early detection campaigns—Spike Lee’s Do the Right Thing and Una communidad saludable. Para toda una vida. NCI also worked with the YWCA and the Auxiliary of the National Medical Association to conduct community outreach with free and low-cost mammograms in poor urban areas.

At the same time, the Centers for Disease Control and Prevention (CDC) became active in improving access to mammography. In 1990, CDC block grants created the country’s first national screening program for cervical and breast cancers. Nearly half of all screening tests provided have been for women of racial and ethnic minorities.

Activists played a key role in lobbying for regulatory changes and pressuring government agencies to put breast cancer high on their agendas. As noted, the Komen Foundation played a key role in NCI’s early efforts, initiating White House Breast Cancer Summits and the successful Race for the Cure, the largest series of 5-kilometer runs/fitness walks in the world, raising more than $300 million.

In response to concerns that many providers were using mammography procedures of insufficient quality, Congress enacted the Mammography Quality Standards Act in 1992, requiring all mammography facilities to meet quality criteria in order to operate. The Food and Drug Administration now certifies all mammography facilities in accordance with the act. Important gains also have been made in insurance coverage. In 1985, only two states, Illinois and Virginia, required health insurers to cover the cost of screening mammograms. As of March 15, 2000, all but five states required some insurance coverage. Legislation also has been proposed for Medicaid coverage of annual mammograms and enhanced reimbursement under the Medicare program.

National Breast Cancer Awareness Month—originating as an effort by pharmaceutical companies—is another annual breast cancer awareness promotion, occurring every October. The most ob-

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

vious activity is the pink ribbon signifying support for the fight against breast cancer. Breast Cancer Awareness Month is now sponsored by a variety of partners, including the American Cancer Society, American Society of Clinical Oncology, American Academy of Family Physicians, CDC, and NCI.

During the past decade, breast cancer became an appealing cause for many corporations to adopt as “good citizens.” Avon has been one of the most notable. In 1991, it launched its pink ribbon campaign, selling pink ribbons through its catalog and sales representatives to raise funds for local community efforts such as mobile mammography vans and local education. In its first year, Avon raised $6 million. Avon continues to sell pink ribbon products today and supports a variety of breast cancer-related activities through its an annual 3-day walking event. General Electric, a manufacturer of mammography equipment, and Kellogg’s were also among the early participants, running breast cancer awareness advertising in the early 1990s in support of their corporate positioning. Today, countless corporations involve themselves in breast cancer promotions and cause-related marketing. American Airlines, American Express, and Yoplait are only a few of the corporate partners helping the Komen Foundation to support its annual run.

The issue of mammography also has been kept alive by scientific disagreement over the benefits associated with screening. In 1993, debate occurred over the recommendations of when women should start getting mammography. For example, the American Cancer Society recommended baseline mammograms at age 35 in contrast to NCI recommendations. Scientific debates continue to play out in the media today, as researchers debate mammography and its ability to reduce mortality given new screening procedures and advanced forms of treatment (e.g., high-dose chemotherapy procedures).

Suggested Citation:"3 Health Communication Campaigns Exemplar." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Next: 4 The Mammography Exemplar »
Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Get This Book
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We are what we eat. That old expression seems particularly poignant every time we have our blood drawn for a routine physical to check our cholesterol levels. And, it's not just what we eat that affects our health. Whole ranges of behaviors ultimately make a difference in how we feel and how we maintain our health. Lifestyle choices have enormous impact on our health and well being. But, how do we communicate the language of good health so that it is uniformly received-and accepted-by people from different cultures and backgrounds?

Take, for example, the case of a 66 year old Latina. She has been told by her doctor that she should have a mammogram. But her sense of fatalism tells her that it is better not to know if anything is wrong. To know that something is wrong will cause her distress and this may well lead to even more health problems. Before she leaves her doctor's office she has decided not to have a mammogram-that is until her doctor points out that having a mammogram is a way to take care of herself so that she can continue to take care of her family. In this way, the decision to have a mammogram feels like a positive step.

Public health communicators and health professionals face dilemmas like this every day. Speaking of Health looks at the challenges of delivering important messages to different audiences. Using case studies in the areas of diabetes, mammography, and mass communication campaigns, it examines the ways in which messages must be adapted to the unique informational needs of their audiences if they are to have any real impact.

Speaking of Health looks at basic theories of communication and behavior change and focuses on where they apply and where they don't. By suggesting creative strategies and guidelines for speaking to diverse audiences now and in the future, the Institute of Medicine seeks to take health communication into the 21st century. In an age where we are inundated by multiple messages every day, this book will be a critical tool for all who are interested in communicating with diverse communities about health issues.

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