Advances in Consumer Research Volume 5, 1978 Pages 525-527
CONSUMER BEHAVIOR AND HEALTH CARE CHANGE: THE ROLE OF MASS MEDIA
Thomas S. Robertson, The Wharton School
Lawrence H. Wortzel, Boston University
Mass media have considerable potential for affecting health behavior. The pervasiveness of mass media and the exposure levels of broad segments of society suggest that mass media may be an important information source regarding health and a relevant socialization force regarding health attitudes and behavior. Nevertheless, research evidence indicates that most mass media campaigns oriented toward changing health care habits fail. The objectives of this paper are to analyze why health care campaigns fail and to derive generalizations for more effective use of mass media by health care professionals.
The role of mass media in affecting knowledge, attitudes, and behavior toward health care may be thought of in terms of the following two dimensions.
1. Mass media may impact health knowledge, attitudes and behavior both in a deliberate sense through "campaigns" that are specifically designed for such impact, and in an unintended or "incidental learning" sense through material that contains health-related information, but which is not specifically intended to impact health knowledge, attitudes or behavior.
2. In both cases, mass media may act either as a "change agent" or as a "reinforcing agent" -- that is, media may function in such a way as to change knowledge, attitudes and behavior or to confirm existing behavior patterns. In these respects, the role of mass media in affecting health care is similar to their role in affecting knowledge, attitudes and behavior toward other products and services.
CAMPAIGN VERSUS UNINTENDED EFFECTS
Mass media campaigns are intended to communicate certain health care information with a view toward change in health habits. Examples include anti-smoking, seat belt usage, lower cholesterol, and hypertension identification campaigns.
Mass media may also have unintended effects in the sense that the average viewer is exposed to a regular diet of "medical" shows on television and also to large numbers of commercials for proprietary medicines. The learning from such programming and commercials may be in the form of "misinformation" and may not be compatible with good health habits. A national study by the Louis Harris Organization (1973), for example, concluded that mass media were second only to the individual's physician as a source of health information. Furthermore, much of the health information absorbed from television is likely to be under low involvement conditions and, therefore, processed without evaluation.
A logical question then is whether mass media depict an accurate profile of health, illness, and the value of medical services, drug products, or medical treatment. Some social critics suggest that mass media depict a distorted and stereotyped view of these topics with consequences for people's health beliefs, attitudes and behavior and for their probabilities of accessing the medical system under specified conditions. For example, to what extent does advertising for proprietary drugs convince people to search for simplistic solutions to medical symptoms that may be indicative of more serious problems? To what extent does cigarette advertising help people to deny or sublimate the medically dangerous effects of smoking?
The extent to which mass media either positively or negatively impact health is an important empirical question requiring systematic evidence to resolve. One study of television programming found that 30% of the health-related information was "useful" while the remaining 70% was inaccurate or misleading or both (Smith, 1972). This may suggest the magnitude of the potential problem, although this study is only one isolated piece of research evidence. Another study by Frazier et al. (1974) of dental health advertisements concluded that 43% of the information is inaccurate, misleading, or fallacious. The hypothesis may well be that mass media act more to misinform than to educate people about health and appropriate health habits.
CHANGE AGENT OR REINFORCING AGENT
The potential of mass media communications in the health care arena is generally phrased in terms of their promise for changing habits and life styles. However, the history of communication research indicates that the most persistent finding is that mass media act mainly to reinforce existing attitudes and behavior.
The ability of mass media to effect change is actually a function of a number of factors and requires certain conditions which we will develop later in this paper. Basically, however, the probability of change tends to be a function of how much commitment people have to existing behavior patterns. Under high commitment conditions, as is frequently the case in health care, bringing about change may indeed be a difficult undertaking. This is likely to be the case since health behavior is frequently rooted both in long term reinforcement patterns and in support by the individual's social environment. (In some special cases physical and psychological addiction patterns may also be a factor with which to contend.) A look at the evidence on health care campaigns supports the statement that most health care campaigns do not succeed among large numbers of intended subjects. The literature is replete with discouraging case studies.
Obesity. In summarizing the evidence on obesity, Stunkard (1975) sets forth five propositions: most obese people do not enter treatment, (2) of those who do, most drop-out, (3) of those who remain, most do not lose much weight, (4) of those who lose weight most will regain it, and (5) many of those entering treatment pay a high emotional price. Nevertheless, Stunkard registers considerable hope based on behavior modification programs, which recently have improved the treatment of obesity. He implicitly rejects mass media as an important force in changing behavior.
Smoking. Anti-smoking campaigns have had limited success, at best. Cigarette consumption has not declined, despite communication campaigns and public policy initiatives protecting non-smokers. In fact, it is increasing among teenagers, especially among girls. However, there has been a change toward consumption of lower tar and nicotine cigarettes. Perhaps the consequence of messages about lower tar and nicotine cigarettes has been to convince smokers that smoking is becoming safer.
On the other hand, one potentially successful anti-smoking campaign was initiated, when counter-advertising messages were shown on television under the equal time provision of the Federal Communications Commission. Possibly the combination of smoking and counter-smoking commercials presented together acted similarly to a two-sided communication; however, it is unlikely that mass media counter-advertising alone accomplished the job.
Seat Belts. In a review of research on seat belt usage campaigns, Leon Robertson et a1.(1974) report a general lack of positive results. These authors then initiated a well-controlled experimental study using split-cable television whereby one audience received messages advocating seat belt use and a matched audience on the other half of the cable did not receive messages. After a nine month period tracking actual seat belt usage behavior, the authors could only conclude that: "The campaign had no measured effect whatsoever on safety belt use" (p. 1077).
Community Fluoridation Programs. Despite endorsement by the United States Public Health Service and the Surgeon General, controlled fluoridation of community water supplies has more often been rejected than accepted by voters. Between 1950 and 1969, 1139 communities voted on fluoridation; the issue lost in 666 communities and won in 473 (HEW, 1970). One part of the difficulty is the complexity of the fluoridation issue and another part is voters' susceptibility to the fear appeals used by opponents.
Health Maintenance Organizations. Despite the advantages claimed for the HMO concept, enrollment campaigns have met with limited success-- with a few notable exceptions (primarily the Kaiser plan). Perhaps the HMO concept is not as desirable as its advocates claim (Glasgow, 1972) or perhaps the benefits to consumers are not readily apparent and communication campaigns have underestimated the difficulties of changing medical behavior patterns.
Heart Disease. The most encouraging results on a mass media campaign are from the Stanford study conducting a program to reduce susceptibility to heart disease among residents of three communities. Instructional programs used in conjunction with mass media have documented attitudinal and behavioral changes in diet and cigarette smoking. The role of mass media alone in one community on a delayed continuity basis is almost as effective as the personal instruction-mass media combination (Maccoby and Farquhar, 1975). The cost-effectiveness of this campaign, however, is very much in question.
WHY HEALTH CAMPAIGNS FAIL, AND HOW TO HELP THEM SUCCEED
Analysis of the foregoing and other campaigns indicates that there are some basic reasons why most health care campaigns fail. These reasons may be summarized as follows:
1. Most health care campaigns operate without explicit objectives or with inappropriate or unrealistic objectives, probably because they are based on an inadequate understanding of the way mass communications work, and on an inadequate understanding of the marketing requirements of the "product" being promoted.
2. Most health care campaigns are non-programmatic; they are short-run, one-time efforts, while the behavior change they are designed to induce must continue in the long run.
3. The beneficial effects of the recommended behavior change are not immediately apparent to the consumer, and perhaps never will be.
4. Most health care campaigns fail to identify market segments within the total audience who require different communication approaches in line with their specific needs.
Setting Objectives and Assigning a Role to the Mass Media
It is not sufficient to seek knowledge change or attitude change without a mechanism for also achieving behavior change and it is difficult for the mass media to achieve behavior change. For example: most smokers have knowledge of the ill effects of smoking and many have a negative attitude toward smoking. Therefore, presenting them with more knowledge as to the negative effects of smoking is unlikely to have much impact. Instead, a communication campaign must be linked to a behavior change mechanism other than mass communications (such as behavior modification group enrollment) if the campaign is to be successful. But behavior change even so induced is unlikely to persist in the long run unless its beneficial effects are continuously reinforced, since the beneficial results from the behavior change are not apparent in the short run and since there may also be some gratifications attached to the previous behavior.
Although non-smoking is a regularly repurchased "product," this is a different marketing situation from the usual consumer packaged goods situation in which advertising is used to achieve trial, and in which reinforcement from use of the product is a significant force in accomplishing continuing use of the product. An important function of mass communications in changing health behavior must be to reinforce new behavior, since use of the "product" is insufficient reinforcement in itself. Fortunately, this is a role which mass media have continually demonstrated an ability to perform well. Nevertheless, behavior change must be accomplished first, and by means other than mass media.
As we have noted, most health campaigns are short-run, start and stop efforts, with little long-term systematic and programmatic planning. Yet, changing health is likely to involve both multiple channels of persuasion and regular long term reinforcement. In summary, people must be moved through a decision sequence which is likely to take some significant amount of time and different means of persuasion may have complementary and cumulative impact, and may be necessary to achieve persistent behavior change.
Most health care campaigns try to reach everyone. Yet, not all segments of the market are as likely to change and different segments may require different incentives for change. It is incumbent on the change agent to specify the market segments likely to be receptive to change and to expect that different messages focused on different needs may be effective with different demographic and psychographic segments.
Examination of needs by segment may be mandatory. For example: smoking provides gratification for smokers; it fulfills certain needs. These needs may relate to anxiety patterns or may be tied to social interaction patterns (Wortzel and Clarke, 1977). Programs to help reduce smoking, we might argue, should help find alternatives for the continued satisfaction of these needs. Basically, if we are to change health we must do so in line with people's needs. It does little good to scare people, insult people, etc., except under certain extreme conditions. Changed health patterns must be shown to be in line with the audience's self-perceived needs.
Segmentation is also critical if mass media are used to support a campaign in which behavior change has been accomplished by other means. Reaching the yet unchanged will be wasteful, if not counter-productive in light of possible future efforts. It is essential to reach the changed in order to reinforce the behavior changing mechanism.
CONCLUSION: PRINCIPLES FOR HEALTH CARE CHANGE
Following is a set of tentative propositions for the successful design and implementation of health care campaigns.
1. Mass media communication by itself may be effective in initiating change, but generally only if the change sought is minor and consumers have low information needs. This is seldom the case in health care.
2. Mass media communication will generally be most effective at an early point in the health decision change process whereas personal sources will generally be most effective later in the decision change process.
a. Mass media communication objectives, therefore, must be tied toward encouraging people to access the professional health care system, or to sensitize them to other sources of communication.
b. The peer and professional system will constitute the subsequent supporting mechanism necessary to bring about actual change.
3. It is the cumulative effect of a communication campaign that eventually results in behavior change.
a. This indicates the need for repetition and reinforcement over time. Reinforcement of health change is a particularly important role for mass media.
b. This indicates the need for multiple information sources which play complementary roles -- including advertising, personal selling, peer support, and professional intervention.
4. Peer sources (personal influence) will be a particularly important source of legitimation and "reality testing" when the benefits of change are not obvious or cannot be demonstrated in the short run. This is likely to be the case in much of health care.
5. Communication campaigns for health care -- even when they make use of donated public media time and space -- are not free. The real cost is the opportunity cost if the communication campaign could have been more successful.
6. A health care communication campaign must explicitly recognize the problem of selective perception -- that those who see the message may be those who are already concerned about the issue and engaging in recommended change activities.
7. A communication campaign may have to provide support for change within a family or peer group context. Obesity, for example, may be tied to family diet habits and change may depend on family involvement.
8. Communication messages must be keyed to the needs of the market segment being reached. It is necessary to offer positive alternatives and not simply to denigrate the individual's existing health habits.
9. Low returns should be expected in a communication campaign. Most advertising and persuasion seeks small levels of change -- in the range of 3 to 5 percent of the audience per year. Mass conversion in the short-run is indeed a rare phenomenon.
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