Communication in Health Campaigns

Health communication campaigns have long been a tool used to influence the health of the public in countries around the world. Campaigns are an organized set of communication activities to produce health effects or outcomes in a relatively large number of individuals, typically within a specified period of time (Rogers & Storey 1987). The history of campaigns in the United States provides a window into how the general health communication campaign literature has progressed, and is now presented along with some important caveats.

While health communication campaigns in the US can be traced back as far as the 1700s, the modern history of campaigns began in the 1940s and 1950s, when large-scale campaign efforts were carried out and seemingly resulted in minimal or no effects. According to Rogers and Storey (1987), this was an era of minimal effects. The 1960s and 1970s then ushered in a “campaigns can succeed” era, in which campaign successes, most notably the Stanford 3-City Heart Disease Prevention Program, brought new optimism to the campaign literature. Campaign scholars began to blame ineffective campaigns, rather than the recipients of those campaigns, for a lack of effects. Such scholars also began to uncover and formalize principles of effective campaign design, which paved the way for a new era of campaigns. This latest era of campaigns has been referred to as the moderate effects era, and is the period from the 1980s until today. During this period, many additional campaign successes have helped campaign designers to better understand how campaigns work, in terms of both what makes them effective and what their limits may be. While we have witnessed a greater accumulation of campaign successes in this era, campaign “failures” still abound.

Although this historical perspective, put forward by Rogers and Storey (1987), is often presented as a basic history of campaigns, some scholars have criticized it as overly general and missing some important caveats. For instance, while early campaign evaluators may have found minimal or no effects of campaigns, such researchers tended to look only at general population effects. In fact, it is likely that many campaigns had effects but only among particular sub-groups (Ball-Rokeach & DeFleur 1976; Viswanath et al. 1991). From this perspective, it is not so much that early campaigns failed as that campaign effects were limited to particular sub-groups and this fact eluded many scholars at the time. Indeed, campaigns may have differential effects on individuals based upon a variety of factors, including social class (Viswanath et al. 1991), dependence on media (BallRokeach & DeFleur 1976), and personality factors (Zimmerman et al. in press). This realization has led to a much greater focus on audience segmentation in campaigns, which will be discussed below.

Campaign Effectiveness

While campaign effectiveness can be defined in different ways, typically determinations of campaign success are based upon whether a campaign’s goals were met and/or whether the campaign had a practical impact on the health issue at hand. What kinds of outcomes are health communication campaigns typically focused on? And what types of effects are campaigns capable of ? Health communication campaigns are often aimed at modifying one or more of the following outcomes: (1) increasing knowledge and raising awareness about a health issue; (2) increasing positive attitudes about a particular health practice; (3) reinforcing and/or changing social norms surrounding a health practice; (4) increasing individuals’ intentions to engage in a health practice; and (5) impacting the health behavior or practice itself.

Traditionally, campaigns were thought to only be capable of raising awareness and perhaps improving the attitudes and social norms of a particular audience. More recent work, however, has provided evidence that properly designed and implemented campaigns can impact health behaviors and practices (e.g., Hornik 2002; Snyder et al. 2004; Noar 2006a). In fact, a large research synthesis of numerous health communication campaign studies conducted in the US revealed that such campaigns have improved health practices including seat-belt use, oral health, alcohol use, smoking cessation, heart disease, mammography screening, and sexual and other behaviors (Snyder et al. 2004). While the effects of such campaigns have tended to be small (i.e., impacting, on average, 8 percent of individuals in the campaign community), the impact at the population level could be significant. Reviews that have focused on or included campaign studies from countries throughout the world reveal similar conclusions with regard to small but meaningful effects of health communication campaigns (e.g., Piotrow & Kincaid 2001; Derzon & Lipsey 2002; Bertrand et al. 2006).

Principles Of Campaign Design

Perhaps the most valuable lessons being learned in the campaign literature are the conditions under which campaigns tend to be most effective. These can be referred to as principles of effective campaign design, and many were originally derived from the social marketing literature. They include: (1) conducting formative research with the target audience; (2) using theory as a conceptual foundation for a campaign; (3) segmenting one’s audience into meaningful sub-groups; (4) using a message design approach that is targeted at the audience segment(s); (5) utilizing effective channels and strategies widely viewed by and persuasive with the target audience; (6) conducting process evaluation; and (7) using a sensitive outcome evaluation design. These principles and their application have been often written about and discussed within the campaign literature (Rogers & Storey 1987; Salmon & Atkin 2003; Randolph & Viswanath 2004; Noar 2006a; Palmgreen et al. in press). Each principle will now be discussed as it is applied in the campaign literature.

Formative Research

Formative research has been defined as a two-phase process. First, pre-production research is carried out. This includes gathering data regarding audience characteristics, the behavior at issue, and message channels. Second, production testing, or pre-testing, is carried out. This includes testing initial campaign messages with target audience members in order to gain feedback on the appropriateness and persuasive impact of those messages (Atkin & Freimuth 2001). No matter what the audience, behavior, or channels to be focused on, formative research is thought to be crucial to truly understanding the target audience. Information gathered from such research can help insure that campaign designers understand the target audiences’ perceptions with regard to the attitudes/ behaviors at hand, develop messages that resonate with the target audience, and place messages in channels that the target audience has a high likelihood of viewing. Insights gathered from such research are traditionally used to help make critical campaign decisions regarding channels and messages and ultimately may have a great impact on whether a campaign is successful or unsuccessful.

Theory-Based Campaigns

Theories serve as important conceptual foundations for any health communication campaign. In fact, theories serve a number of important roles, including suggesting: (1) important behavioral determinants that campaign messages might focus on; (2) variables for audience segmentation (discussed below); and (3) variables to be used in evaluating campaigns (discussed below). In the health communication campaigns area, numerous theories have been used. These include those focused on individual-level determinants of health behavior change, such as the health belief model, social cognitive theory, theory of reasoned action, and the transtheoretical stages of change model, as well as those from media studies research, including agenda setting, exemplification theory, and the knowledge gap hypothesis. Campaigns have also applied dual-model persuasion theories such as the elaboration likelihood model and heuristic systematic model as well as theories of community adoption such as diffusion of innovations.

Audience Segmentation

A key consideration in any campaign has to do with defining a target audience. Who is the specific audience that is being focused on with the campaign? A target audience is typically formed using audience segmentation procedures. This is accomplished by dividing the population of interest into smaller, more homogeneous groups. The ultimate purpose of segmentation is to create groups that have similar message and channel preferences, and can thus be targeted with persuasive messages specifically designed for those audience segments.

Segmentation can be conducted on a variety of variables, including demographic, behavioral, theoretical, individual difference, risk factor, and other variables. At times simple segmentation strategies are utilized, such as defining a target audience based upon basic demographic variables alone (e.g., gender, age). At other times more complex segmentation procedures are used. For instance, after segmenting on demographics, campaigns may segment on additional individual difference and behavioral (e.g., those experimenting with the problem behavior) variables. The question of how homogeneous audience segments need to be can be a challenging one for campaign planners, and different campaigns may use very different segmentation strategies.

Message Design

Once a clear audience segment (or segments) has been defined, messages thought to be persuasive and effective with the audience segment can then be developed. Health behavior change theories (mentioned above in the Theory section) are often used to inform the content of intervention messages. However, additional theoretical perspectives can be used in order to inform the creation of messages that have the greatest likelihood of being persuasive with the target audience. There are a variety of approaches to message design that are applied in health communication campaigns. Some examples include: (1) fear appeals – this approach suggests that messages high in levels of both fear and selfefficacy (building individuals’ confidence that they can carry out the recommended behavior) are most likely to be effective; (2) emotional appeals – this approach suggests that messages that elicit particular kinds of emotions from viewers may be effective (e.g., warmth appeals); (3) message framing – this approach suggests that positive (gainframed) messages are most effective in impacting preventive behaviors, while negative (loss-framed) messages are most effective in impacting screening behaviors. This is different from the widely used conception of framing as mental structures that help people to interpret the world around them, often examined in political and news-related research; (4) sensation seeking targeting – this approach suggests that messages high in novelty, intensity, drama, and a lack of preaching will be most effective with high sensation seekers; and (5) narrative approach – this approach, often used within an entertainment education model, suggests that storylines that provide positive role models and reduce counterarguments may be most effective. Still other approaches that are not theory-based but that appear to have been effective include the Truth campaign’s focus on the US tobacco industry’s manipulative marketing practices and cover-ups by the industry.

Channel And Strategy Selection

Health communication campaigns utilize a number of channels and strategies to reach and affect their intended audience. These include mass communication channels such as television, radio, and print media, as well as small media such as posters, billboards, bus signs, and other materials and outlets. Some campaigns include broader, community-wide components such as community events, workshops, public relations activities, and coordination with school-based programs. Newer campaigns are increasingly taking advantage of the Internet and creating campaign-related websites, where television content can often be viewed and campaign-relevant articles and activities can be found. In addition, evidence exists that concomitant changes in the environment along with a campaign significantly increase the chances of campaign effectiveness, and campaigns sometimes use such a strategy. For instance, seat-belt campaigns are more effective when seat-belt laws are enacted and enforced (Snyder et al. 2004), and anti-tobacco campaigns are more effective when taxes on tobacco products are increased in concert with a campaign (Randolph & Viswanath 2004).

Key decisions for campaign planners include which channels and strategies to use in a campaign as well as how to strategically place messages so that the target audience has multiple opportunities for exposure to the messages (Salmon & Atkin 2003). Multiple channels are often used in campaigns in order to try and increase the chances of reaching a large proportion of the audience segment. Traditionally, many campaigns have suffered from low campaign exposure (Hornik 2002; Snyder et al. 2004). Newer campaigns, however, have been increasing both reach and frequency of exposure to campaign messages. This has been achieved by well-funded campaign efforts that have the resources to buy significant media time, and through strategic placement of messages within those media channels (Randolph & Viswanath 2004; Noar 2006a). The term reach is typically used to refer to the percentage of the audience segment exposed to any campaign message, while frequency refers to how often those individuals were exposed.

Process Evaluation

Process evaluation refers to the monitoring and collection of data on fidelity and implementation of campaign activities. Campaign designers may have a good campaign plan, but whether that plan was executed properly is a question that process evaluation attempts to answer. Did campaign messages air in the channels (and specific placements within those channels) in which they were intended to air? Was a significant proportion of the target audience exposed to the campaign messages? With what frequency were individuals exposed? Are there any mid-course corrections that can be made to elements of the campaign to improve reach and/or frequency of exposure to the campaign? These are the kinds of questions that get asked during a process evaluation. The answers to such questions will inform mid-course corrections for the current campaign and improvements for future campaigns. In addition, process evaluation aids in the interpretation of why a particular campaign was or was not successful. If process evaluation is not conducted and a campaign fails, there may be few clues for campaign designers as to why.

Outcome Evaluation

Outcome evaluation is concerned with assessing whether a campaign had its intended impact. For instance, if a campaign was focused on raising awareness and increasing knowledge about a particular health issue, an outcome evaluation asks if this was accomplished. Similarly, if campaign goals aimed to change health attitudes and behavior of a certain proportion of the target population, an outcome evaluation asks whether or not these goals were met.

Outcome evaluation is one of the most challenging aspects of any health communication campaign. Unlike other kinds of health-related interventions that may lend themselves to well-controlled experiments, campaigns are conducted “in the field” and do not lend themselves well to controlled evaluation designs. Consequently, most of the evidence for the effects of campaigns comes from research studies that leave open many threats to internal validity (Valente 2001; Hornik 2002). Indeed, one finds a variety of evaluation designs in this literature, including both standard evaluation designs and variations on such standard designs (Valente 2001; Noar 2006a). Popular designs used to evaluate health communication campaigns include post-test-only designs, where a campaign is followed by a post-only survey assessing campaign exposure and campaign-relevant variables, and pre-test– post-test designs, where a pre-test survey is given, the campaign takes place and is followed by a post-test survey. Some campaigns use designs that are more rigorous and thus decrease threats to internal validity, such as pre-test–post-test control group designs, which include a control community for comparison purposes, and time-series designs, where multiple surveys are given both before and after a campaign is executed.

Most campaign evaluations use cross-sectional or independent samples, where different respondents are surveyed at one or more points in time. However, in some cases panel samples are utilized, which are those in which the same respondents are surveyed over multiple points in time. Occasionally, studies that evaluate campaigns using panel samples will also use cross-sectional samples to get two different viewpoints on the outcomes of a campaign. Both cross-sectional and panel samples have unique advantages and disadvantages (Valente 2001), suggesting that both kinds of evaluation are advantageous where possible.

Future Directions For Campaign Research

Although health communication campaigns have been used to influence the health of the public for decades, researchers are still learning much regarding the effective design, implementation, and evaluation of such campaigns. First, campaign researchers are increasingly looking back over the many published evaluations of campaigns for lessons learned. Research syntheses or meta-analyses have recently appeared and helped to quantify average campaign effects (e.g., Derzon & Lipsey 2002; Snyder et al. 2004), and more of these kinds of reviews are likely to appear in the literature in the future (Noar 2006b). Meta-analyses. however, often cannot make up for weaknesses in the original primary reports, and thus have limits to what they can reveal about the literature. Although theories of health behavior change have been widely applied in campaign research, there has been recent discussion regarding the need for additional communication theories that can be applied to message design (e.g., Noar 2006a; Slater 2006). Such theories might better explicate how certain message features affect health attitude and behavior changes, and could guide campaign designers in the creation of more effective health-related campaign messages. Moreover, campaign evaluators are increasingly recognizing the limits of certain evaluation designs and at the same time suggesting ways to strengthen those weaker designs (e.g., Hornik 2002). In addition, health communication campaign evaluators appear to be increasingly applying more rigorous outcome evaluation designs (Noar 2006a). Thus, a trend for the future may be better outcome evaluations of health communication campaigns, which could have the effect of increasing the quality of the resulting data and the value of this literature as a whole. Finally, a trend that will no doubt continue is in understanding the role of the Internet and other new technologies within health communication campaigns. These technologies unlock seemingly limitless possibilities in terms of potentially affecting health, and their role in health communication campaigns is just beginning to be explored and harnessed.

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