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CHAPTER 17
Persuasive Strategies in Health Campaigns
Charles K. Atkin and Charles T. Salmon
The dawn of health campaigns in the United States can be traced back almost three hundred years, when Reverend Cotton Mather successfully promoted public inoculations during Boston’s smallpox epidemic of 1721. The temperance movement in the 1800s tenaciously battled alcohol problems by swaying public opinion to support legal restrictions (ultimately resulting in nationwide prohibition), rather than persuading individuals to drink responsibly (Paisley & Atkin, 2012).
In the past half-century, health topics have dominated the public communication campaign agenda, with concerted efforts to prevent smoking, drug use, drunk driving, AIDS, cancer, and obesity. Certain campaigns have attained significant effects on health behavior, while many other campaign efforts have met with only limited success. This chapter will examine factors that determine the degree of persuasive impact of health campaigns.
Health campaigns seek to influence attitudes and behaviors in sizable audiences via strategic development and dissemination of an array of multichannel mediated messages, for purposes of benefitting individuals and/or society. Campaigns utilize systematic frameworks and fundamental strategic principles that have evolved over the past half century. Campaign designers analyze the situation, set objectives, devise strategies, and create a set of messages that are disseminated via mass media, new technologies, and supplemental interpersonal networks.
Theoretical Foundations of Campaigns
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In order to better understand and explain the influence of health campaigns, researchers and strategists have focused on the unique nature of campaigns relative to other persuasive contexts. Those who study and design health campaigns have drawn on perhaps an increasing variety of theoretical perspectives to guide their conceptualizations of campaign influence processes.
Distinctive Features of Campaigns
The health campaign constitutes a relatively distinctive form of persuasive communication, due to the nature of health topic and the nature of campaigning. First, the domain of health is composed of a disparate array of problems, and the unique medical, political, and social aspects of each type of disease or unhealthy practice tend to shape the communication objectives and strategies. Various health-related behaviors and outcomes lend themselves to a differential focus on promotion, prevention, cessation, detection, and/or treatment; for example, campaigners may address certain problems by positively promoting healthy actions while other problems are better suited to use of threats for preventing risky behaviors.
Second, the nature of health campaigning poses a different challenge than conventional forms of persuasion because campaigners are ethically bound to reach the most unhealthy segments of the population. Unlike commercial and political campaigns that focus on the most promising prospects whom are already favorably predisposed, health campaigns must give priority to influencing resistant audiences who do not practice the healthy behavior and are not interested in doing so. Because people in greatest need of change are most difficult to change, the campaigners must allocate resources to low-yield segments and supplement direct messages with messages aimed at those who can exert interpersonal influence or institute environmental change.
Third, campaigns tend to be media based, which means that message exposure becomes a very important stage of response; Hornik (2002) regards lack of exposure as a key factor limiting campaign effects. The uses and gratifications perspective originally developed by Blumler and Katz (1973) provides useful insights into the motivations that lead to selection of messages and utilization of media content (Rubin, 2009). Prominent placement and pervasive quantity of messages may be needed to ensure that the audience encounters the messages, while message qualities such as personal relevance and entertainment value help to attract attention. For example, stylistic factors are important in reaching the key audience of sensation seekers, who prefer visual messages that are novel, fast-paced, explicit, and intense (Palmgreen, Donohew, & Harrington, 2001). Compelling cues and promos may be necessary to motivate people to seek out messages in channels that are not regularly perused. Defensive avoidance of exposure is a major barrier when message content is inconsistent with predispositions.
Fourth, campaigns tend to feature a substantial quantity of diverse messages to be created and coordinated, which affords the campaign team an opportunity to employ a variety of persuasive strategies. With so many message executions, the designer isn’t confined to a single approach, but can choose to utilize a mixture of both implicit and explicit conclusions, gain and loss frames, or one-sided and two-sided arguments as tactics in various campaign contexts. Moreover, campaigns tend to disseminate messages over a lengthy period of time, ranging from several weeks to several decades. This timespan enables utilization of prolonged repetition of message executions, combinations of concentrated and dispersed message placement patterns, and sequential compliance techniques.
The persisting and pervasive dissemination of campaign messages featuring certain predominant themes has potential to shape conceptions of reality through cultivation processes (Morgan, 2009). Frequent exposure may cultivate beliefs about the prevalence of various health problems, social norms for practicing promoted as well as proscribed health behaviors addressed in the messages, and expectations of experiencing positive and negative consequences that are regularly portrayed. Similarly, a sustained quantity of prominently placed news items about a health problem or policy solution can raise the salience of these issues through agenda-setting processes (McCombs, 2004). Campaigns are typically able to make only a limited contribution to the media visibility of a health topic, but focused campaign efforts can raise policy issues higher on the media agenda.
Finally, the large quantity of messages enables a campaign to reach multiple intended audiences, as discussed, the audience analysis section of this chapter. Audiences typically are defined and profiled through segmentation analysis that seeks to identify clusters of individuals who are likely to react in a relatively uniform manner to a given campaign message. It should be noted that high-quantity, broad-scale message dissemination often reaches unintended audiences; the problem of unintended effects is discussed near the end of the chapter.
Key Theoretical Perspectives
Health campaign strategies are based on a broad range of theories from the fields of social psychology, public health, communication, and marketing. The applicable conceptualizations can be arrayed in three basic clusters: social marketing and diffusion, health behavior, and the communication-persuasion matrix.
Campaign strategies derived from social marketing typically apply the following approaches: an audience-centered consumer orientation, a sophisticated segmentation of the overall population in to target audiences, a calculated attempt to attractively package pro-health products (while minimizing personal adoption costs), a pragmatic focus on attainable objectives, and a combination of direct persuasion, policy change, and interpersonal communication to influence behavior (Andreasen, 1995, 2006; Kotler & Lee, 2008; McKenzie-Mohr, 2011). Social norms marketing narrowly applies a pro-health form of promotion with messages demonstrating the underestimated popularity of desirable practices, such as responsible drinking (Perkins, 2002). The social marketing approach blends well with the diffusion of innovations theory, which highlights the ideas of relative advantage and trialability of recommended behaviors, moving adopters through stages, opinion leadership for advancing the adoption process via multistep flows through interpersonal channels and social networks (Rogers, 2003).
The segmenting and staging components of social marketing and diffusion approaches are reflected in the popular transtheoretical model (Prochaska & Velicer, 1997), which features different stages (precontemplation, contemplation, preparation, action, or maintenance) that shape subaudience readiness to attempt, adopt, or sustain health behaviors. Campaigns typically need to have multiple strategies to influence subaudien
ces who have progressed to each stage.
McGuire’s (2001) classic communication-persuasion matrix specifies an individual-level array of communication concepts that can be utilized by health campaign strategists. This basic input-output model arranges the conventional input variables (source, message, channel, and receiver) on one axis crossed by a lengthy series of output variables ranging from exposure and processing, to learning and yielding, and finally to enactment of recommended behaviors on the other axis. Among inputs, McGuire emphasizes that campaign impact is importantly determined by source credibility, persuasive appeals to a broad array of motives, message repetition, and multiple paths to persuasion. His matrix serves as a comprehensive organizing structure for a broad range of persuasion theories explaining both input and output processes pertinent to campaigns.
A cluster of health behavior perspectives, which have typically been adapted from social psychology theories and models, have been applied to health campaign strategies. The theory of planned behavior (Ajzen, 1991) is an extension of the theory of reasoned action (Azjen & Fishbein, 1980). The TRA, which has been frequently applied to the health context, formulates a combination of personal attitudes, perceived norms of influential others, and motivation to comply as predictors of intended behavior. A key underlying mechanism is based on the expectancy-value equation, which postulates attitudes are predicted by likelihood beliefs about certain consequences of a behavior, multiplied by one’s evaluation of those consequences. The TRA shares similarities with the health belief model (Janz & Becker, 1984); the HBM components of perceived susceptibility multiplied by severity of consequences are particularly pertinent to designing health threat appeals (Stephenson & Witte, 2001).
The TPB is centrally applicable to health because it bridges the significant gap between intentions and behavior by adding the concept of perceived behavioral control, which originates from Bandura’s (1997) self-efficacy theory. Self-efficacy is a key component of Social Cognitive Theory (Bandura, 1986), which illuminates media influence processes via source role models, explicitly demonstrated behaviors, and depiction of vicarious reinforcement.
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