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6 The Public Health Perspective for Communicating Environmental Issues Thomas W. Valente and Darleen V. Schuster The public health field has been engaged in efforts to promote health- related behavior for some time. These efforts include promotion of hygiene behaviors, safety promotion and accident prevention, substance abuse prevention, adoption of healthy lifestyles and eating habits, family plan- ning and contraceptive use, and many other areas. These promotions take many forms and have been accompanied by considerable research on their planning and effectiveness. The purpose of this chapter is to convey some of the experi- ences and lessons learned from these activities and how they might be applied to environmental issues. Although experiences from many fields may be relevant, this chapter will focus somewhat on experiences from the field of family planning promotion for three reasons. First, family planning practices have some similarity to environ- mental behaviors. Second, family planning promotion is one of the larger bodies of research available. Third, the authors have experience working with family planning promotion campaigns. This discussion, however, will be not limited to the family planning literature because our purpose is to provide a broad view from the public health perspective. The chapter consists of five sections: behavior change theory, mass media campaigns, attitudes and attitude change, interpersonal communication networks, and the importance of evaluation research in behavior change promotion. We provide an overview of the public health experiences for each of these topics, and summarize their implications for the promotion of environmental voluntary measures. A guiding principle for these health communication programs has been that they be theory based. 105

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106 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES BEHAVIOR CHANGE THEORY Theory attempts to explain people's behavior and describe factors that moti- vate or present barriers to it. It can provide the basis for effective program design and meaningful evaluation by informing the selection of goals, objec- tives, and techniques to measure them. A theoretical perspective should be stated explicitly to guide the program. Although most behavior change models are individually based, public health research increasingly has recognized the importance of ecological levels of analysis (not to be confused with our more common use of ecology in this volume). The ecological perspective in this instance refers to the interaction of behav- ior and environment. Behavior has many determinants and is influenced by multiple levels of social, cultural, and physical environmental factors. Ecologi- cal models typically consider the following levels of analysis (McElroy et al., 1988; Green et al., 1996~: (1) individual (intrapersonal), (2) interpersonal, (3) institutional, (4) communal, and (5) societal. By including analyses at these levels, researchers can examine and incorporate various sources of influence on behavior in addition to an individual's attributes. The ecological perspective on environmental issues explicitly forces us to look at governmental or organiza- tional policies that present barriers to environmentally sensitive behaviors. For example, many individuals may be positively predisposed to recycling, but fail to comply because their employer lacks a formal policy promoting it. Table 6-1 describes the ecological levels and the advantages and disadvan- tages for interventions targeted at each level. Although multipronged, multilevel interventions are considered the most effective, they can be impractical and cost- ly to implement in many settings. The ecological perspective is not a behavior change theory, but rather sensitizes us to the need to consider different influenc- es on behavior. The most common theories used in public health research (Glanz et al., 1997) are the health belief model (Hochbaum, 1958; Rosenstock, 1960; Rosenstock et al., 1988), theory of reasoned action (Fishbein, 1967; Fishbein and Ajzen, 1975; Ajzen and Fishbein, 1980) and theory of planned behavior (Ajzen, 1991; Ajzen and Driver, 1991; Ajzen and Madden, 1986), social cognitive theo- ry (Mischel, 1973; Bandura, 1977, 1986), stages of change or transtheoretical model (DiClemente and Prochaska, 1983), and diffusion of innovations (Rogers, 1995~. Of these, diffusion of innovations theory is probably the most commonly used theory in the health promotion and communication arena. Diffusion of Innovations Diffusion of innovations theory describes how new ideas, opinions, atti- tudes, and behaviors spread throughout a community (Katz et al., 1963; Rogers, 1995; Ryan and Gross, 1943; Valente, 1993, 1995; Valente and Rogers, 1995~. "Diffusion is the process by which an innovation is communicated through cer-

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER TABLE 6-1 Ecological Levels of Analysis and Intervention, Their Advantages and Disadvantages 107 Ecological Level Advantages Disadvantages Individual: Clinics and treatment site Organizational: Worksite, school, etc. Community: Neighboorhoods, associations Mass Media: TV, radio, and print Policy: Local and global levels Multipronged: Address supply and demand for health- related behavior Can be tailored Are direct and immediate Some attempt to use "brief interventions" Working in bounded, closed communities More control over the intervention and setting Generally most effective Empowering and sensitive to community dynamics Reach many people Can change societal/normative perceptions Can change some people's behavior Can target few people Small changes can have big effects Highly visible Addresses both motivations and barriers of change Effectiveness dependent on similarity/empathy between patient and provider Effectiveness depends on organizational factors Variability among organizations of the same type Take a long time to forge collaboration and work with groups Hard to scale up and replicate Usually do not change a large percentage Dependent on quality Specific to the situation Somewhat unpredictable Replication would be uncertain Can be expensive Hard to coordinate diverse organizations and activities lain channels over time among the members of a social system" notes Rogers (1995:5~. Diffusion theory has been used to examine the spread of new comput- er technology, educational curricula, farming practices, family planning meth- ods, medical technology, and many other innovations. Considerable research on the diffusion of family planning practices and fertility preferences has been con- ducted to date (for a recent review see Casterline and Cleland, 2002~. This chapter focuses somewhat on how media campaigns have been used to acceler- ate the adoption of family planning practices and on the public health communi- cation perspective that has been used to study these programs. Diffusion theory has five major assumptions: (1) adoption takes time; (2) people pass through

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108 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES various stages in the adoption process; (3) they can modify the innovation and sometimes discontinue its use; (4) perceived characteristics of the innovation influence adoption; and (5) individual characteristics influence adoption. The first two assumptions will be discussed at length. Diffusion of innova- tions specifies five stages in the behavior change process: knowledge, persua- sion, decision, trial, and adoption (Rogers, 1995~. The diffusion of innovations stages have been expanded into a hierarchy model (McGuire, 1989) that was adapted specifically to the case of family planning (Rogers, 1973, 1995; Piotrow et al., 1997; Valente et al., 1996~. A common outcome variable for health pro- motion programs can be a score on a composite index indicating the stage or step of behavior change. Because people become aware of new behaviors at different times, and be- cause they pass through the stages at different rates, there is considerable lag between the first and last adopters of a new behavior. For example, Ryan and Gross (1943) showed that 14 years passed between first and last adopters of hybrid seed corn in two Iowa counties, in spite of this innovation being far superior to the one it replaced. When the spread of new ideas and practices is graphed, it resembles a typical growth or S-shaped curve (see Figure 6-1~. Diffusion theory classifies individuals in terms of their time of adoption relative to a community or population. The first people to try a new practice are called innovators or pioneers. The second group to adopt is called early adopt- ers. These first two groups constitute the first 16 percent of adopters. The next 34 percent of the population to adopt are the early majority, followed by the late majority, then laggards. This classification initially was devised because adop- tion behavior was thought to follow a normal curve, and thus provided a conve- nient way to compare research studies (in terms of the characteristics associated with each adopter type). More recent research, however, has acknowledged that diffusion curves often deviate from normality, and adoption behavior more often is classified dichotomous (adopter, nonadopter) or left continuous (time of adop- tion). The units for measuring time vary considerably because some innovations diffuse in days and others in years or decades. Similarly, some innovations will reach saturation of 100 percent, while others may attain lower levels of penetra- tion. Early in the diffusion of a new behavior, there are few adopters and the growth in new adopters is slow. Research has found that these early adopters often are persuaded more by mass media and other targeted communications that provide information relevant to the behavior. Moreover, these new adopters sometimes are freed from social norms that would otherwise inhibit them from adopting a new behavior. Because new behaviors often are perceived as uncer- tain and risky, these early adopters often require some form of compensation or rationale for them to adopt. These two components, stages of adoption and the time it takes for diffusion to occur, are graphed in Figure 6-2, showing projected rates of the spread of awareness, positive attitude, and behavior (Valente, 1993~. Expected levels for

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER 100 1 80 60 c' 40 20 O ~ . 109 Late majority I , Early majority Early ,r adopters _~ Laggards I Cumulative New adopters H;~ 1 1 1 1 1 1 1 1 I I I T T T 1 6 11 16 Time FIGURE 6-1 Typical diffusion curve showing the cumulative percent of adopters and percent of new adopters at each point in time, with adoption categories. 100 - 90 - 80 - 70- ~ 60- .> 50- 40 - ' 30 20 10 f / Or / 1 6 11 16 Ti Ime Knowledge I ~ Attitude ~ Practice FIGURE 6-2 Typical knowledge, attitude, and practice diffusion curves used to predict the rate of diffusion and the average time between knowledge and practice.

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110 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES each can be determined by looking at any point in time and expected time be- tween awareness and use by taking the time difference between the two curves. The general model of awareness leading to positive attitudes and eventually to use has been termed the learning hierarchy. Others (Chaffee and Roser, 1986; Valente et al., 1998) have argued that alternative sequences are possible. For example, some behaviors may be adopted first, followed by positive attitudes or knowledge of the benefits. Teeth brushing, for example, usually is adopted because we are forced to do so as young children; only later do we learn the benefits, and still later develop a positive attitude toward it. The same can be said with energy conservation: The benefit of lower electric bills creates positive attitudes toward this practice. Thus, although the learning hierarchy, as depicted in Figure 6-2, may hold for some innovations, other behavior change sequences will characterize most behaviors, particularly those for which evidence on their relative advantage is not readily available. Regardless of the behavior change sequence, health promoters have tried to accelerate behavior change by creating awareness (increasing knowledge), im- proving attitudes, and directly encouraging individuals to adopt healthy behav- iors. Two specific functions of media campaigns have been to spread knowl- edge rapidly so that its curve grows quickly and to shorten the Knowledge, Attitude, and Practice (KAP)-gap, the time between awareness and use. Some argue that media campaigns are most effective early in the diffusion process since there are few other users whom potential adopters can turn to for advice. Later in the diffusion process, media campaigns serve to place the behavior back on the public agenda (McCombs and Shaw, 1972) and stimulate further inter- personal communication. The other three assumptions of the diffusion model can be used to guide message development. For example, because the perceived risk to adoption slows diffusion, promotion programs can attempt to reduce risk. Programs can also emphasize the perceived characteristics of environmental be- haviors, for example, by emphasizing their compatibility. Empirical support for the diffusion theory is spread throughout the behav- ioral sciences, although the most definitive results came from early studies of farmer adoption of new agricultural practices. It has been used extensively to study the diffusion of contraception and family planning in developing countries and in the United States to study adoption of many different health-related be- haviors. In a review of behavior theories used in the mid-199Os, Glanz and colleagues (1997) note that it was the 10th most used theory. Like other behav- ioral theories, diffusion variables alone often explain less variation in behavior than desired. The theory works best when potential adopters can afford and have easy access to the innovations being promoted, and works less well when purely economic considerations influence adoption decisions.

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER MASS MEDIA CAMPAIGNS 111 Early studies on communication campaign effects highlight both successes (Cartwright, 1949; Mendolsohn, 1973; Rogers and Storey, 1987) and failures (Hymen and Sheatsley, 1947; National Public Radio, 1996; Udry et al., 1972~. Communication campaigns fail to achieve their hoped-for results for many rea- sons. Campaigns deemed relatively unsuccessful have, in part, been attributed to unrealistic beliefs in the ability of the media to engender significant and sus- tained behavioral change. The media can be a very powerful influence on peo- ple's attitudes and beliefs, but typically not on behaviors because changing be- havior often requires relinquishing a rewarding behavior and replacing it with another that provides significantly less pleasure or rewards. However, in the event that changes in action are achieved, such as earthquake preparedness or ultraviolet radiation protection, the effects are often of relatively short duration. This is highly characteristic of campaigns targeting habitual behaviors such as smoking, drinking, and sexual behaviors. It is unlikely that someone will stop smoking as a result of viewing a single or series of public service announce- ments. More commonly, the media are effective in priming audiences for change, while other cues to action (such as personal contact) are needed for individuals to implement the desired behaviors. The media have a great capacity to expose large numbers of people to prevention messages. Therefore, media campaigns often are used initially to increase public awareness of a problem, its determi- nants, and strategies for change, while other intervention activities are used to change behaviors. Studies conducted by Lazarsfeld and colleagues (Berelson et al., 1954; Katz and Lazarsfeld, 1955; Lazarsfeld et al., 1948; Merton, 1968; and see Eulau, 1980, for a review) propose a classic two-step flow model of communications (Katz, 1957, 1987; see Gitlin, 1978, for critique). This model of interpersonal communications posits that opinion leaders use the mass media for information more than opinion followers, then these leaders share their opinions with these followers. Consequently, many scholars have argued that the mass media are effective at disseminating information and achieving awareness of campaign messages, but that interpersonal communication is necessary for motivating be- havior change (Hornik, 1989; Valente et al., 1996; Valente and Saba, 1998~. This adage has directed many projects to use the mass media to promote new ideas, and products, then to rely on outreach and peer education programs for adoption. The use of a combinatory approach is illustrated in one of the most success- ful health behavior change campaigns incorporating a significant mass media component: the Stanford Heart Disease Prevention Program (Farquhar et al., 1977~. Inspired by the vision of a cardiologist and a communication scholar, a health communication and education program was developed to reduce individu- al risk factors associated with heart disease (e.g., smoking, obesity, stress, lack

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112 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES of exercise). This large-scale intervention combined mass media channels (e.g., television, radio, newspapers, mass-distributed print media) with interpersonal communication methods (e.g., group training classes for smoking cessation and aerobic exercise) to influence knowledge, attitudes, and risk-related behaviors. Significant increases in risk reduction knowledge were attributed to the cam- paign's integrated design and novelty of information dissemination (such as mass-distributed tip sheets and self-help kits). The campaign's widespread ex- posure sparked further information seeking (e.g., tip sheets encouraged the use of booklets) and interpersonal discussions of cardiovascular disease and related issues (Schooler et al., 1993~. In this example, mass media channels were em- ployed in the beginning of the campaign to increase the public's awareness of the need to change, while interpersonal channels were used to present reinforc- ing materials and persuade people to engage in recommended risk reduction behaviors. In spite of its fame, the Stanford program is credited only with modest increases in behavior, as the comparison communities quickly matched behavioral levels initially seen in the intervention ones. Environmental awareness interventions incorporating mass media and inter- personal approaches have been shown to be effective in enhancing knowledge and improving short-term health-protective behaviors (Campbell et al., 2000~. As an example, Dietrich and colleagues (1998) examined the effects of a multi- component intervention designed to change children's sun protection behaviors. Messages encouraging solar protection were delivered to children, families, and caregivers through counseling, educational sessions, displays, educational mate- rials, posters, and sunscreen samples. Based on observations at beach recreation areas, significantly more children in the intervention towns used sunscreen than in the control towns. Other studies of solar protection behaviors combined mass media messages (newspaper, radio, and television) with the dissemination of educational materials to increase melanoma awareness and detection. For in- stance, Graham-Brown (1990) reported significant increases in new patient vis- its at community clinics and the detection of melanomas following a public education campaign promoting the medical assessment of potentially dangerous skin lesions. Similar results were obtained in an Australian campaign, where annual melanoma detection rates increased significantly, from 130 diagnosed cases before a multimedia campaign to 189 during the campaign (Pehamberger et al., 1993~. Such studies provide evidence for the effectiveness of mass media public education campaigns in increasing melanoma awareness and related solar protection behaviors. ATTITUDES AND ATTITUDE CHANGE Although the ultimate goal of an intervention is to change behavior (e.g., to wear sunscreen, to recycle, to rideshare), this is often a difficult task. Although it is relatively easy to raise awareness of a health or environmentally relevant

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER 113 behavior, this is not the case for attitudes that are often fairly well entrenched. Attitudes are important not only because of their presumed ability to direct be- haviors in some instances, but because they also serve many important functions for individuals (Katz, 1960~. Besides summarizing a person's beliefs about a topic (knowledge function), attitudes can serve a value-expressive function, which occurs when holding a particular attitude permits us to convey an impor- tant value or principle to others. For example, the person who has a preference for electric cars because their use demonstrates an important concern about min- imizing pollution has an attitude that serves a value-expressive function. Like- wise, attitudes also may serve a utilitarian function, where the adoption of cer- tain attitudes helps people gain rewards and avoid punishments (Schultz, this volume, Chapter 4~. Individuals may favor the use of nontoxic chemicals in clothing and environmentally safe trash bags, for example, in an attempt to gain approval from important others such as family, friends, and neighbors. Consid- ering the important functions served by attitudes, it follows that a central goal of media campaigns is to promote positive attitudes toward recommended behav- ~ors. Attitudes toward a behavior and attitudes toward the process of adopting a behavior can be important predictors of adoption (Petty and Cacioppo, 1981; Fishbein and Ajzen, 1975~. Attitudes can be complex, comprising one's attitude toward the behavior, toward products and actions associated with the behavior, and toward perceptions of normative behavior. For example, many people may believe that energy conservation is beneficial and hold a positive attitude about fuel-efficient cars, but still buy a larger vehicle because of normative expecta- tions in their neighborhood. Additionally, there may be a perception that engag- ing in a particular behavior is beyond one's control, most likely because of the presence of insurmountable external factors (e.g., lack of financial resources) (Ajzen, 1991~. Despite holding positive attitudes and normative beliefs sur- rounding the purchase of a fuel-efficient car, an individual still may fail to pur- chase one due to financial constraints. Although favorable attitudes toward a behavior are important predictors of adoption, the perception of behavioral con- trol is of equal importance. INTERPERSONAL COMMUNICATION NETWORKS Although media campaigns are conceptualized as broadcasts to a population of disconnected individuals, the audience is a web of human relations connected to one another in complex and nonrandom ways. Consequently, campaign mes- sages are not received in a vacuum, but rather are filtered through these social networks. People often consume messages with others, directly influencing the manner in which messages are interpreted. Furthermore, talking to others about health promotion messages may cause them to reinterpret them. Consistently,

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114 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES one goal of a campaign is to generate interpersonal discussion on the topic in an attempt to set the public's agenda. One of the most significant correlates to behavior and behavior change is the perception of peer approval (Valente et al., 1997; Valente and Saba, 1998; Alex- ander et al., 2001), otherwise referred to as social norms. Individuals deciding on the appropriateness of certain behaviors make social comparisons and use peers as reference points when making decisions, particularly when an ambigu- ous situation arises. Thus, the fact that peers influence behavior is not surpris- ing. Measuring this peer influence, however, presents challenges, and findings on its influence are not uniform. In most studies, peer influence and perceptions of peer behavior often were measured by asking people, "To what degree do your friends approve of X?" Response categories were often likert scales that had a positive correlation with behavior. Unfortunately, the nature of this correlation is unclear because respon- dents may be projecting their beliefs on others, or because they practice it, they think their friends do as well. Social network techniques have been developed to better measure peer influence. Social networks consist of the friends, colleagues, and family members in a person's immediate social circle, and are measured by asking respondents to provide the names or initials of their friends or those people with whom they discuss personal matters (Burt, 1980; Marsden, 1990; Valente and Saba, 1998; Valente and Vlahov, 2001~. Respondents then are asked questions about the persons they named: (1) whether they approve of the behavior, (2) whether they practice it, and (3) whether they talked about it. This measure provides a more refined indication of which friends support and/or practice the behavior. Specif- ic characteristics of these friends that also can be linked to the behavior include socioeconomic level, attitude toward the behavior, and practice of it (Valente and Saba, 2001~. However, personal network data still may be prone to projec- tion bias. Figure 6-3 presents a general evaluation framework. Sociometric network methods overcome this bias by collecting data from all members of a community, such as an organization, a school, a rural village, or a neighborhood. Links between individuals in the network are measured so that a map of the community can be drawn and individual positions within the network determined (Burt, 1980; Marsden, 1990; Rogers and Kincaid, 1981; Scott, 2000; Valente, 1995; Wasserman and Faust, 1994~. An individual's position in the network may influence behavior. Furthermore, because there are reports on every person's behavior, and links between him and her, it is possible to measure how many people in each person's network practice the behavior. Some people, by virtue of their connections, will be surrounded by others that engage in the behavior, while others will be surrounded by few who do. Network exposure is highly correlated with behavior, and its measurement does not suffer from pro- jection bias. Using this technique, for example, Valente and others (1997) showed that women were more likely to practice contraception if they thought

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER Needs identification and assessment Formative: Observations, interviews, FGDs, and community mapping Design: Design and test messages, instruments, and monitoring methods 1 Data collection: Collect baseline data Monitor implementation of program Collect follow-up data ! Analysis: Determine Impact and outcome Interpretation: Share findings with stakeholders and interpret results Disseminate findings FIGURE 6-3 Health promotion evaluation framework. Source: Valente (2002~. 115 their friends used it, regardless of whether the friends' self-reports showed they practiced contraception. Although the correlation between network exposure and behavior is high, there are many individuals who adopt a new behavior before a majority of their network does so. Indeed, in order for diffusion to occur, some people must be

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116 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES willing to initiate change when no or few others in the community or in their network have done so. These early adopters can be labeled low-threshold adopt- ers because their resistance is low. Low-threshold adopters have reported great- er use of mass media for information and greater use of nonpersonal sources of information for decision making (Valente, 1995~. Promotional programs can increase their effectiveness by appealing to these low-threshold adopters. Promotion of environmental behaviors should consider the social network context of the audience. People are likely to consult with friends and neighbors to gauge what is appropriate behavior. Perceptions of what is normative may or may not be accurate, but they still drive behavior. Changing a norm is likely to require both mass and interpersonal media. For example, Burns (1991) used neighborhood block leaders to promote recycling, recognizing that interpersonal persuasion is likely to be the best strategy for promoting behavior change (Dar- ley and Beniger, 1981~. EVALUATION Theoretical models, past experience, and logic provide guidance on how to launch campaigns to promote knowledge, attitudes, and practices. But every behavior, every culture, and every campaign presents unique challenges (Stern, this volume, Chapter 12; Schultz, this volume, Chapter 4~. Coping with these challenges requires research formative, process, and summative. Although one can launch campaigns without conducting research, the odds of success are in- creased greatly when research is used to set objectives, segment the audience, and understand the behavior from the audience's perspective (Valente, 2002~. Furthermore, without research, once the campaign is completed, no one will know whether it worked or not, the reasons why, and whether it really had a significant impact. Formative research is usually qualitative and is conducted to determine cur- rent perceptions, motivations, barriers, and language used to describe the behav- ior from the audience's point of view. Focus group discussions, in-depth inter- views, and observations can be used to learn how to position the behavior in the audience's mind and what types of appeals are likely to be successful. Process research monitors program implementation to track audience exposure to cam- paign messages. This type of research usually is conducted with viewer logs, counts of the distribution of materials, and ratings. Summative research is quan- titative and conducted to determine whether the intervention was effective, and if so, for whom and to what degree. Summative research usually consists of population-based surveys designed to quantify overall impact. Rules and procedures for evaluating health promotion interventions are well specified (Ross) et al., 1999; Valente, 2001, 2002~. The difficulty lies in the fact that every evaluation presents its own demands in terms of the tradeoff between rigor and cost. Although randomized control trials are the "gold standard" for

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER evaluating the impact of an intervention, they are rarely feasible or population-based programs. Tradeoffs between rigor and feasibility are inev- itable, and are best addressed by informed researchers who can control relevant threats to validity. In health communication campaign evaluation, the diffusion/hierarchy steps to behavior change have been used to formulate campaign objectives. These objectives generally stipulate larger changes in knowledge and attitudes and modest yet significant changes in behavior. Although deviations from this pattern have been and can be expected (Valente et al., 1998), it provides a reasonable guide for setting goals. Meta-analysis studies by Snyder (2001) have shown five to nine percentage-point changes in behavior attributable to mass media cam- pa~gns. 117 for community- LESSONS LEARNED The history of campaigns and public health interventions has yielded several lessons learned about what works, how to improve interventions, and most im- portant, why we often think that interventions do not work. Some researchers and many policymakers argue that interventions to promote behavior change have, by and large, failed. The reasons for concluding lack of success originate from a variety of factors. First, we often fail to recognize that behavior change is a process that takes time a long time and we rarely have the patience to wait. Most communication campaign studies collect postcampaign data immediately following a broadcast to capitalize on higher recall levels, but fail to wait for effects on behavior to emerge. Second, most designers have unrealistic expecta- tions regarding the effect sizes to be expected from promotional campaigns. Most mass media campaigns realistically can be expected to increase behavior by one to five percentage points over baseline levels. Although these effect sizes may seem small, they represent a large absolute impact when translated to the number of people reached. Third, we often conclude campaigns have failed because studies designed to test their effects have not collected data from suffi- ciently large samples to detect these small effects (Borenstein et al., 1997; Krae- mer and Thieman, 1987; Valente, 2002~. Fourth, the variety of campaigns and campaign objectives has given rise to a diversity of measures making compari- sons across studies difficult (but see Snyder et al., 2001; Freimuth and Taylor, 1998~. Finally, many interventions lack a theoretical foundation. Designers and researchers have not worked in concert to follow accepted behavior change models, but rather have expended more effort on addressing tension over what is "creative" versus "effective." Nonetheless, many campaigns have achieved some success, and some pre- scriptions for creating successful campaigns can be described. These sugges- tions apply to the message content, campaign strategy developed, the choice of media, timing, dose, and so on. In terms of strategy, first, use active strategies

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118 PUBLIC HEALTH PERSPECTIVE FOR COMMUNICATING ENVIRONMENTAL ISSUES rather than passive ones, by engaging the audience in street fairs, group activi- ties, or neighborhood events. Second, use multifaceted interventions rather than unifaceted ones. Different media have different strengths, and a good campaign uses a variety of media to disseminate messages. Third, create continuous rather than static (one-shot) programs. Rarely does a single campaign provide the needed persuasion to change audiences; a more effective strategy is to use a series of strategically planned, integrated communications. Fourth, consider in- tervening on multiple ecological levels by targeting individual behavior, forming appropriate policies, and reducing barriers to behavior change. Finally, use in- terpersonal media rather impersonal media whenever possible. Humans respond to humans, and adding a personal dimension to a campaign can be beneficial. In terms of messages, first, provide positive reinforcements to the behavior. People respond to being rewarded, even if the reward is nominal in nature. Acknowledge positive behavior: There is nothing like a pat on the back. Second, provide those rewards immediately, rather than delaying them. Link the reward more closely with the behavior. Third, provide role models with which the audience identifies to stimulate observational learning. Humans learn by imita- tion, and role models enable people to vicariously enact new behaviors, breaking down barriers and providing solutions to overcome those barriers. Fourth, use campaigns to change mediating variables such as outcome expectations, self- and collective efficacy (confidence in the ability to perform the behavior), moti- vations, and beliefs. Often campaigns are effective at priming the audience for behavior change by modifying these mediators, rather than creating overt behav- ior. Such modifications are important to accelerating change. Many implications concerning campaign design, implementation, and eval- uation can be gleaned from past research. Although these prescriptions may seem daunting for most, three simple rules will help keep both designers and researchers focused. Nothing is for certain, but observations presented in this chapter may help avoid some past mistakes. First, pretest! Pretest! Pretest! Every message, piece of material, and survey instrument should be tested with the audience prior to implementation. Second, formative research will provide clues as to what is needed and how to frame the intervention. Finally, keep the audience involved through formative and process research, and use researchers trained to translate behavioral research into message design. CONCLUSIONS The field of public health provides us with many lessons learned and caveats to keep in mind. From an economic point of view, it would seem rational to simply lower the costs to adoption and provide incentives to behavior change in order to bring about a public good. If we want more people to exercise, we lower the cost of exercising, and increase the incentive to do so. In the context of family planning for population control, for example, one might argue that we should

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THOMAS W. VALENTE AND DARLEEN V. SCHUSTER 119 provide economic incentives for women to use contraception and find an equilibri- um point at which the incentives are sufficient to create the right population growth. From a public health as well as an ethical vantage point, however, these arguments confront the reality that we are then imposing burdens on decision making among those who are less able financially to resist such incentives. Con- sequently, the behavioral burden will fall on those who need the economic in- ducements. These incentives thus do not appeal to an individual's altruism or enlightened self-interest; instead, the incentives appeal to the pocketbook. A1- though economic incentives are motivational, they are not always the best ave- nues to sustained behavior change. Instead, we prefer to educate and persuade our audiences. Empowerment is the final outcome of successful communication when individuals, armed with information, take charge of their own lives. The goal is to create an informed public capable of making rational choices in their self-interest that still benefit the public good. In the case of contraception, most women (and men) in high- fertility countries report wanting fewer children than they have. The reported ideal family size throughout the world has dropped dramatically in a relatively short period of time. As people become educated about the consequences of unchecked fertility, and learn about options to control it, they generally make choices in the aggregate that are beneficial to society. Environmental behaviors are likely to discover similar patterns. Economic self-interest is an important motivator, and clearly individuals need to provide food and shelter for themselves. Economic incentives may drive many behaviors that are environmentally damaging and for which enforcement and coercion are necessary. Use of pesticides and herbicides may be environmentally damaging, but to someone who needs to provide a livelihood, such considerations may seem tangential. Some people, however, are willing to change behaviors for altruistic reasons if the benefits are communicated clearly to them and the barri- ers to practice are not excessive. Our admonition, however, is to expect gradual changes in public percep- tions and behaviors. Any given intervention designed to promote environmental behavior is likely to have modest effects on action. Interventions can, however, inform publics and seed changes in attitudes that will continue to pay behavior change dividends later. These interventions, if accompanied by evaluation re- search, will inform policymakers of successful elements and enable continued planning for future efforts at behavior change. Importantly, the research will provide fodder to further engage the audience by elevating the environment on the public's agenda. For example, research findings for promotional study can be released to the media and disseminated to a wider audience. This activity can further stimulate changes in other communi- ties not directly affected by the initial campaign. Moreover, once a campaign is completed, diffusion through interpersonal contacts is likely to continue, and

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