The Role of Mass Communications in Promoting Public Health

Mary Jane Schlinger, University of Illinois at Chicago Circle
ABSTRACT - The beliefs, attitudes and motives that underlie poor health practices often are deeply-rooted and emotion-laden. For this and other reasons, it typically is difficult to persuade people to engage in activities which relate to health maintenance. Recently published literature indicates that there is some disillusionment with mass media campaigns as a tool for changing health behavior. Although such campaigns can make an impact, they often do not. The present paper discusses the role of mass communications in health marketing programs and suggests some ways in which the planning, implementation and evaluation of media efforts can be improved.
[ to cite ]:
Mary Jane Schlinger (1976) ,"The Role of Mass Communications in Promoting Public Health", in NA - Advances in Consumer Research Volume 03, eds. Beverlee B. Anderson, Cincinnati, OH : Association for Consumer Research, Pages: 302-305.

Advances in Consumer Research Volume 3, 1976      Pages 302-305

THE ROLE OF MASS COMMUNICATIONS IN PROMOTING PUBLIC HEALTH

Mary Jane Schlinger, University of Illinois at Chicago Circle

ABSTRACT -

The beliefs, attitudes and motives that underlie poor health practices often are deeply-rooted and emotion-laden. For this and other reasons, it typically is difficult to persuade people to engage in activities which relate to health maintenance. Recently published literature indicates that there is some disillusionment with mass media campaigns as a tool for changing health behavior. Although such campaigns can make an impact, they often do not. The present paper discusses the role of mass communications in health marketing programs and suggests some ways in which the planning, implementation and evaluation of media efforts can be improved.

INTRODUCTION

In 1969, Kotler and Levy published a seminal article, "Broadening the Concept of Marketing," which stimulated widespread interest in applying the principles and concepts of marketing outside of the traditional for-profit business arena. Concomitantly, marketing researchers began focusing increased attention on the consumer decision-making process as it operates in such diverse areas as politics, religion, education and health.

The entire issue of the July, 1971, Journal of Marketing was devoted to what might be called public service or social marketing, i.e., the marketing of ideas, services, products and organizations that are intended to help accomplish societal goals. The 1971, 1972 and 1973 Association for Consumer Research national conferences each incorporated sessions on broadening the concept of consumer behavior. The following year, a series of papers was delivered on marketing political candidates. And in 1975, the Association for Consumer Research program included a session titled "Consumer Behavior and Public Health."

The purpose of this paper is to examine the "Consumer Behavior and Public Health" presentations and other selected literature for implications about the potential role of the mass media in promoting public health. Before doing that, however, it would be useful to review some of the problems that face would-be marketers of public health.

PROBLEMS FACED BY PUBLIC HEALTH MARKETERS

The marketer of programs, ideas, services and products designed to improve public health faces a formidable task.

For one thing, public health organizations typically aim at eliciting some kind of short- or long-term behavioral response from large numbers of people, often 50% to 100% of a population or population segment (Rosenstock, 1960). In contrast, a ready-to-eat cereal manufacturer probably would be happy, or even ecstatic, if a new brand captured a four per cent share of the cereal market, or if an existing brand improved its sales by a one per cent share.

Not only do health agencies frequently need to reach large audiences, they often also must deal with the "laggards'' and "no nothings," i.e., that fifteen per cent or so of the population which is poorly educated, ill-in-formed, suspicious of innovations, traditional in outlook, and backward rather than forward in orientation (Hyman and Sheatsley, 1947; Rogers and Shoemaker, 1971).

For another thing, public health workers face a paradoxical situation in which the beliefs, attitudes and motives which underlie poor health practices may be deeply-root-ed, intransigent and emotion-laden, whereas the beliefs, attitudes and motives which support good health may be absent or lacking in saliency (Rosenstock, 1960).

Smoking, high cholesterol diets and inadequate exercise are examples of unhealthy habits which can be the firmly established results of years of learning and reinforcement.

Self breast examination is an example of a health-related measure which is suffused with emotion and fear. A Gall-up poll conducted in late 1973 found that few women even claimed to examine their breasts on any regular basis. In part, this may be due to ignorance of the importance of self-examination, lack of knowledge or self-confidence about performing the examination, and uncertainty about possible outcomes if a lump is discovered. But perhaps even more important is the fear of cancer, a disease so dreaded that the word "cancer" once was taboo in polite conversation and in many mass media vehicles. Equally important is the emotion associated with the breast as a symbol of sexuality, femininity and motherhood (Renneker and Cutler, 1952; Goldson, Gerhardt and Handy, 1963). Because of this symbolism, women are perhaps inordinately terrified of mastectomy, and self-examination of the breasts may carry anxiety-producing overtones of masturbation.

Turning to the other side of the coin, that is, the beliefs, attitudes, motives and actions which support health maintenance and disease prevention, it appears that in the absence of overt symptoms many people feel safe or even invulnerable from disease; health concerns are forgotten, suppressed or repressed, interest in the subject can be relatively low, and there may be reluctance to interrupt established daily routines for any but the simplest additional health maintenance measures. Thus the health marketer has three options: (1) to increase the salience of the need for good health, as well as interest in maintaining good health; (2) to appeal to needs that are unrelated to health per se but which will lead to health-related behavior; or (3) to "package" the product or idea with other products or ideas that are desired by the target market. For low income consumers, for example, information on nutrition might be combined with information on how to buy and prepare food economically, assuming that saving money in the grocery store has higher consumer priority than nutrition.

Still another problem facing the public health marketer is the actual and psychological distance that often stands between the consumer and the product, idea or service (Wiebe, 1951-52; Rosenstock, 1960). Marketers of consumer goods try to make it easy, simple, convenient and even pleasurable to obtain their offerings. The user of public health services may have to travel long distances to overcrowded facilities, interact with unfamiliar and perhaps hostile persons, and submit to procedures that are inconvenient, physically or psychologically painful, time-consuming, difficult to understand, and expensive in terms of time, money and effort. Furthermore, the reward for many health-maintenance and disease-prevention actions is intangible, delayed or uncertain.

One final reason why it can be difficult to generate acceptance of public health programs and ideas lies in the nature of the profession and of some health organizations. Custom, ethical codes, budgetary considerations, bureaucratic red tape and sometimes laws prevent many health organizations from most effectively manipulating the four marketing variables: price, distribution, product and promotion. Also, public health professionals who know a great deal about epidemiology, microbiology and other such matters often know little or nothing about modern marketing.

The preceding discussion is not intended to suggest that the principles and practices of marketing as developed by businesses do not apply to the marketing of public health ideas, services and programs. In fact, certain commercial products may share one or more of the marketing problems delineated in the above paragraphs. The point is that the "marketing mix" -- the particular combination of a product, a price, a distribution system, and a promotional program -- must be appropriate to the nature of the public health marketing task.

The remainder of this paper will focus on one aspect of a marketing program: mass media promotion and publicity.

DO MASS COMMUNICATION CAMPAIGNS WORK?

Recently published literature suggests that there is some disillusionment with mass media advertising as a tool for changing health behavior. Haskins (1968) surveyed the literature on the effects of mass communications on drinking while driving and concluded that because most programs either had not been evaluated or had been evaluated inadequately, no one knows whether campaigns on drinking and driving have had any effect. A controlled experiment designed to evaluate an advertising campaign aimed at increasing seat belt usage showed that the promotional effort had no effect on belt use at all (Robertson et. al, 1974). A television campaign urging Illinois employers to hire the disadvantaged actually reduced employers' stated intentions to do so (Haefner, 1975).

In contrast, Maccoby and Farquhar (1975) and Maccoby (1975) have reported on an intensive two-year mass media campaign which was successful in reducing risk factors associated with hearth disease among the target population. However, the behavioral changes brought about by the mass media campaign alone were very small compared to the changes generated by an experimental condition which combined mass media advertising with face-to-face group instruction for high-risk subjects.

Thus it appears that although mass media campaigns can make an impact on health behavior, they often do not. Disappointment with mass media efforts in the past frequently can be attributed to unrealistic expectations on the part of campaign planners as to what a given effort can accomplish. The real question, them, is not "Do mass communication campaigns work?", but, more appropriately, "How do mass media efforts work and what can they achieve?"

WHAT CAN MASS COMMUNICATIONS CAMPAIGNS DO?

Existing evidence indicates that mass media efforts to improve public health can and have accomplished the following tasks: (1) increase awareness of a health problem; (2) raise the level of information about health topics; (3) make a health topic or problem more salient, thereby sensitizing the audience to ether efforts, such as personal selling, group education or direct-mail brochures; (4) stimulate interpersonal influence via conversations with family, friends, doctors and other experts; (5) generate forms of self-initiated information seeking; and (6) reinforce existing attitudes and behaviors.

Of course, given enough time and money, mass media campaigns occasionally may operate directly to change some health related behavior, much as product advertising can successfully pre-sell certain low-priced consumer grocery and drug items, given advertising budgets that are large enough to achieve adequate levels of exposure. But the point is that there are a number of other possible outcomes of public health advertising and publicity.

PLANNING, IMPLEMENTING, AND EVALUATING PUBLIC HEALTH CAMPAIGNS

Recent efforts at utilizing the mass media to promote health implicitly or explicitly point to some strategies for improving the effectiveness of promotional campaigns, and these will be reviewed in the following paragraphs.

Planning Campaigns

A number of observers have emphasized the importance of setting explicit and specific goals for mass media campaigns (Mendelsohn, 1973; Ray and Ward, 1975). As with any promotional goals, those in the health area must state what target market or markets are to be reached, what message or messages are to be delivered, which media are to be used, and what measurable effects are to be achieved over what time period. The statement of prior goals is important for several reasons. First, the goals provide guidance for copywriting and media selection. Ward (1975) has noted that unless there are explicitly stated goals advertising copywriters may treat public service campaigns like "creative trips," where they are free to let their imaginations run wild without the pressures of accountability that are exerted by commercial clients. Second, the statement of promotional goals guides evaluation, permits evaluative plans to be specified in advance, and allows for the collection of baseline date where that is desirable. And third, the process of stating promotional objectives should aid the campaign planner in estimating budgetary needs and in keeping the objectives realistic, given resource constraints.

Another important element in planning successful health campaigns is pre-research on the target market. Extrapolating from Rosenstock's (1966) widely-known health belief model and research by Bauer and Cox (1963), Wortzel (1975) suggests that the health marketer should study target markets in terms of their perceptions with regard to: (1) their susceptibility to a health disease or problem; (2) the seriousness of the disease or problem if it is encountered; (3) the estimated probability that a given course of action will reduce the threat; and (4) the estimated cost of the action. Wortzel believes that data on the above factors can be combined with other demographic and psychographic information in order to define market segments and select appeals for each that are most likely to motivate behavior

After systematically reviewing two decades of literature on the utilization of health and welfare services, McKinlay (1972) concluded that there is a need for more small-scale exploratory studies designed to generate hypotheses about consumers, and that insufficient attention has been paid to the influence of kin and friendship networks on health and illness behavior.

The point is that mass media campaigns are more likely to be effective if they are based on an understanding of relevant demographic, psychological, and sociological characteristics and experiences of the target consumers. And since consumer behavior literature within the public health field is not ordinarily geared to practical marketing planning, it is quite probable that literature reviews will need to be supplemented with primary research.

Implementing Campaigns

One of the problems faced by any public service marketer is obtaining high-quality, professional creative work. One solution is to ask advertising agencies to donate creative services; many agencies do donate time to worthy causes either through the Advertising Council, local advertising organizations, or independently. The client, of course, must pay the costs of production. However, advertising agencies are not likely to provide the same quantity or quality of time, talent and collateral services to non-paying public service clients that they provide to paying clients, and it is only realistic to recognize that fact. Also, there is the previously mentioned danger of unsupervised copywriters indulging in "creative trips" on public service projects.

Both Mendelsohn (1973) and Maccoby (1975) argue that the practitioners who create advertising must understand and be guided by empirically defined principles of communication and persuasion and not allowed to proceed on the basis of subjective insight, guesswork and intuition. In fact, Maccoby believes that an important strength of the previously mentioned Stanford campaign to reduce heart risk factors is that the media campaign was designed, created and pretested by the University's Department of Communication media staff which was trained in communications research.

Many observers agree that copytesting is a key to successful public service advertising. Maccoby (1975) has noted that the advertisements and other materials utilized in the Stanford campaign to "unsell" heart disease were extensively pretested. And Swineheart (1975a, 1975b) reported that the Children's Television Workshop conducted or commissioned some sixty formative research studies in the course of creating the Public Broadcasting System's health program, "Feeling Good."

The importance of copytesting public service advertising is particularly apparent where that advertising addresses emotional or controversial issues, since there may be a substantial danger of viewer distortion. For example, copytests of a number of storyboards designed to promote ethnic plurality and pride in national and racial origin indicated that one of the storyboards delivered exactly the opposite message, i.e., that everyone should be alike so there would be no prejudice, and another storyboard, which intended to portray and then refute prejudiced beliefs, failed to achieve an effective refutation (Leo Burnett U.S.A., 1974).

Ray and Ward (1975) provide an overview of the issues involved in copy pretesting, and suggest a multifaceted set of copytesting procedures.

Evaluating Campaigns

Where properly controlled experiments are feasible, it is important to evaluate promotional efforts in terms of behavioral change. However, a number of researchers offer persuasive arguments for examining the cognitive and affective as well as the behavioral influences of promotion (Clarke and Kline, 1974; Kline, Miller and Morrison, 1975; Ray and Ward, 1975). The values of a multifaceted approach to the evaluation of mass media campaigns are several: (1) if only behavioral change is measured, many effects of the campaign will be overlooked; (2) it will be difficult to understand why or how a campaign succeeded or failed to modify behavior if other responses are not measured; and (3) it is valuable to see how cognitive, affective and behavioral responses relate to one another and to demographic and nondemographic characteristics of the respondents. Swineheart (1975) notes the importance of assessing exposure levels to mass media campaigns, since those serve as a constraint on further effects. Robertson (1975) emphasizes the significance of observing certain kinds of behavioral outcomes, such as seat belt use, where verbal questions may generate overclaiming. And Ray and Ward (1975), Clarke and Kline (1974), and Douglas, Westley and Chafee (1970) point out that evaluative studies should not overlook the influence of mass media on subsequent interpersonal communication.

CONCLUSION

This paper has reviewed recent literature on marketing public health programs and ideas to assess some of the implications for planning, implementing and evaluating mass media campaigns aimed at improving health. It appears that some health professionals may hold an exaggerated view of the mass media's capability for modifying health-related behavior. The actual effects of advertising on deeply-rooted behavior is apt to be relatively small at best, and to require careful planning and substantial resources. The implications of this are several: (1) mass media campaigns in public health may be best suited to the achievement of intermediate goals, such as awareness, increased salience of a topic, etc.; (2) where behavioral change is the goal, it may be necessary to combine mass media with interpersonal and group re-education programs; (3) there is a need to experiment with nontraditional formats for teaching new behavior via the media, perhaps by simulating interpersonal and group learning sessions in some way; and (4) in many cases, such as seat belt usage, where behavior is particularly intractable, persuasive strategies cannot achieve public health goals and other solutions, such as legal sanctions, money incentives, etc., must be sought.

REFERENCES

Raymond Bauer and Donald F. Cox, "Rational Versus Emotional Communication: A New Approach," in Leon Arons and Mark May, eds. Television and Human Behavior. New York: Appleton-Century-Crofts, 1963, 140-54.

Peter Clarke and F. Gerald Kline, "Media Effects Reconsidered: Some New Strategies for Communication Research," Communication Research, 1 (April, 1974), 224-40.

"Communication Study of Six Storyboards." Chicago: Leo Burnett U.S.A., 1974. (author same as publisher)

Dorothy F. Douglas, Bruce H. Westley, and Steven H. Chef-fee, "An Information Campaign That Changed Community Attitudes,'' Journalism Quarterly, 47 (Autumn, 1970), 479-87, 492.

Rose K. Goldsen, Paul Gerhardt, and Vincent Handy, "Patient Delay in Seeking Cancer Treatment: Behavioral Aspects,'' Journal of Chronic Diseases, 16 (1963), 427-36.

James E. Haefner, "Television Advertising: A Study on its Applicability for Promoting the Disadvantaged to Employers,'' in Mary Jane Schlinger, ed., Advances in Consumer Research, Vol. 2. Chicago: Association for Consumer Research, 1975.

Jack B. Haskins, "Evaluation of Effects of Educational and Mass Communication Techniques "Transactions. National Safety Congress, 24, (1968), 77-109.

Herbert Hyman and Paul B. Sheatsley, "Some Reasons Why Information Campaigns Fail," Public Opinion Quarterly, 11, (1947), 412-23.

F. Gerald Kline, Peter V. Miller, and Andrew J. Morrison, "Communication Issues in Different Public Health Areas," in B. B. Anderson, ed., Advances in Consumer Research, Vol. 3. Cincinnati, Ohio: Association for Consumer Research, in press.

Philip Kotler and Sidney Levy, "Broadening the Concept of Marketing," Journal of Marketing, 33 (January, 1969), 10-15.

Nathan Maccoby, "Communication in Disease Prevention," presentation at the national conference of the Association for Consumer Research, Cincinnati, Ohio, 1975.

Nathan Maccoby and John W. Farquhar, "Communicating for Health: Unselling Heart Disease," Journal of Communication, 25 (Summer, 1975), 114-26.

John B. McKinlay, "Some Approaches and Problems in the Study of the Use of Services - An Overview," Journal of Health and Social Behavior, 13 (June, 1972), 115-52.

Harold Mendelsohn, "Some Reasons Why Information Campaigns Can Succeed," Public Opinion Quarterly, 37 (Spring, 1973), 50-61.

Michael L. Ray and Scott Ward, "Experimentation for Pretesting Public Health Programs: The Case of the Anti-Drug Abuse Campaigns," in B. B. Anderson, ed., Advances in Consumer Research, Vol. 3. Cincinnati, Ohio: Association for Consumer Research, in press.

R. Renneker and M. Cutler, "Psychological Problems of Adjustment to Cancer of the Breast," Journal of the American Medical Association, 148 (1952), 833-8.

Leon S. Robertson, Albert B. Kelley, Brian O'Neill, Charles W. Wixom, Richard S. Eisworth, and William Had-don, Jr., "A Controlled Study of the Effect of Television Messages on Safety Belt Use," American Journal of Public Health, 64 (November, 1974), 1071-1080.

Everett M. Rogers and F. Floyd Shoemaker, Communication of Innovations (New York: The Free Press, 1971).

Irwin M. Rosenstock, "What Research in Motivation Suggests for Public Health," American Journal of Public Health, 50 (March, 1960), 295-302.

Irwin M. Rosenstock, "Why People Use Health Services," Milbank Memorial Fund Quarterly, 44 (1966), 94-127.

James W. Swinehart, "Creative Use of Mass Media to Affect Health Behavior," paper presented at the National Cancer Institute conference on Cancer Control and the Behavioral Sciences, January, 1975a.

James W. Swinehart, "Developmental and Evaluative Research for a Television Series on Health," presentation at the national conference of the Association for Consumer Research, Cincinnati, Ohio, 1975b.

Scott Ward, letter to A. Sawyer dated October 22, 1975.

G. D. Wiebe, "Merchandising Commodities and Citizenship on Television," Public Opinion Quarterly, 15 (Winter, 1951), 679-91.

Lawrence H. Wortzel, "The Behavior of the Health Care Consumer: A Selective Review," in B. B. Anderson, ed., Advances in Consumer Research, Vol. 3. Cincinnati, Ohio: Association for Consumer Research, in press.

---------------------------------------