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



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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations what the committee found to be true, others of which are statements about what was not learned and needs to be better understood. 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. 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. 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. 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

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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. 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. 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.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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. 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-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 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).