In the communication discipline, Fishbein and Cappella (2006) and Cappella and associates (2001) have developed an integrative theory of behavior change that integrates HBM, SCT, and TRA to specify how external variables, individual differences, and underlying beliefs contribute to differential influence pathways for outcome behaviors, intentions, attitudes, norms, and self-efficacy.
Audience Analysis and Campaign Design
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Identifying Audience Segments
Health campaign design begins with a conceptual assessment of the situation to determine opportunities and barriers and to identify which behaviors would to be performed by which people (Atkin & Salmon, 2010; Silk, Atkin, & Salmon, 2011). Rather than attempting to reach the broad public, campaign designers typically identify specific segments of the overall population. There are two major strategic advantages of subdividing the public in terms of demographic characteristics, predispositions, personality traits, and social contexts. First, campaign efficiency is improved if subsets of the audience can be prioritized according to their (a) degree of centrality to attaining the campaign’s objectives, and (b) degree of receptivity to being influenced to adopt the recommendations. Second, effectiveness is increased if message content, form and style, and channels are adapted to the attributes and abilities of subgroups.
The design specifies focal segments of the population whose health practices are at issue, and the primary focal health behaviors that the campaign ultimately seeks to influence. The next step is to trace backward from the focal behaviors to identify the proximate and distal determinants, and then create models of the pathways of influence via attitudes, beliefs, knowledge, social influences, and environmental forces. The next phase is to examine the model from a communication perspective, specifying intended audiences that can be directly reached) and target behaviors (ranging from preliminary acts to focal practices) that can be influenced by campaign messages. This requires a comprehensive plan for combining the myriad strategic components subject to manipulation by the campaigner, drawing on the three clusters of theories.
Formative Evaluation
The application of general campaign design principles depends on an understanding of the specific health context (especially types of audiences and types of products), so effective design usually requires extensive formative evaluation inputs (Atkin & Freimuth, 2012). In the early stages of campaign development, designers collect background information about the focal segments and interpersonal influencers, using statistical databases and custom surveys to measure audience predispositions and their evaluations of prospective sources and appeals.
Formative evaluation provides strategists with information about the nature of the existing problematic behaviors to be addressed by the campaign and the “product line” of responses to be promoted. Audience predispositions toward prospective recommended actions can be assessed in order to select the most promising options. In order to achieve bottom-line behavioral objectives, campaign messages must first have an impact on preliminary or intermediate variables along the response chain. Formative research illuminates the following variables for key segments of intended audiences: (1) entry-level awareness, knowledge, and literacy related to the health topic; (2) beliefs and perceptions pertaining to barriers and opportunities affecting performance of a behavior, to likelihood expectations of experiencing beneficial and harmful outcomes, and to social support; (3) existing attitudes and values, notably evaluations of outcomes and opinions about policy options; (4) salience factors, such as level of involvement in the health topic, agenda ranking of a policy issue, and relative weighting of various outcomes; (5) self-efficacy and confidence in implementation skills; and (6) media channel usage and topical interpersonal communication. Researchers also obtain rating scores for prospective source messengers and message appeals.
As message concepts are being refined and rough versions are created, qualitative reactions are obtained in focus group discussion sessions, and supplemental quantitative ratings of perceived effectiveness are measured in message testing laboratories. A meta-analysis performed by Dillard, Weber, and Vail (2007) found that pretest ratings correlated +.41 with actual message effects, indicating that perceived effectiveness is a moderately strong predictor.
Direct Effects on Focal Audience Segments
Receptivity to a health campaign may be considered as a continuum. Campaigns tend to achieve the strongest impact when disseminating trigger or reinforcement messages designed to promote healthy practices among those who are already favorably predisposed (e.g., adoption of five-a-day fruit and vegetable consumption by already health conscious-persons). A somewhat less receptive (but more important) target is composed of “at risk” people who might try an unhealthy behavior in the near future (e.g., drug use among teens whose peers are experimenting with drugs). On the other hand, those committed to unhealthy practices tend not to be readily influenced by directly targeted campaigns, so a heavy investment of resources to induce immediate discontinuation is likely to yield a marginal payoff.
Campaigners also need to consider demographic, social, and psychological-based subgroups (e.g., high vs. low in income, social support, or sensation seeking). Influencing these varied population segments may require a complex combination of narrowly customized messages, along with widely applicable multitargeted messages presenting broad appeals and optimally ambiguous recommended actions.
The nature of the health problem dictates the broad parameters of the focal audience to be influenced (e.g., adolescents in an antidrug campaign, middle-aged women in a breast cancer campaign). Because audience receptivity tends to be a more central determinant of campaign effectiveness than the potency of the campaign stimuli, there will be differential success depending on which segment is targeted. To achieve the maximum degree of communication effects, campaign designers often focus on receptive target audiences ready to be influenced to perform the practice.
Indirect Pathways of Influence
It is often valuable for health campaigns to supplement the predominant direct approach (educating and persuading the focal segment) by influencing additional target audiences who can indirectly exert interpersonal influence or help reform environmental conditions that shape the behaviors of the focal segment (Atkin & Salmon, 2010). Thus, campaigners can profitably invest effort and resources in campaign initiatives aimed at (1) direct impact on interpersonal influencers and (2) policy-makers (direct impact on those who make policy combined with indirect impact via interested publics who attempt to influence them). Mass media campaigns have considerable potential for producing effects on institutions and groups at the national and community level as well as motivating personal influencers in close contact with individuals in the focal segment. These influencers can provide positive and negative reinforcement, shape opportunities, facilitate behavior with reminders at opportune moments, serve as role models, and exercise control (by making rules, monitoring behavior, and enforcing consequences). Furthermore, influencers can customize their messages to the unique needs and values of the individual.
Interpersonal Influencers
An important goal of campaigns is to stimulate interpersonal influence attempts by inspiring, prompting, and empowering influencers. Influencers are similar to opinion leaders, but are in a position to exercise means control as well as utilizing persuasion. For example, a variety of peer and authority figures are in a position to personally educate, persuade, or control the prime focal segment of high-risk adolescents: parents, siblings, friends, coworkers, bosses, teachers, club leaders, coaches, medical personnel, and police officers. More generally, interpersonal networks can play a key role in preventing unhealthy practices, assisting with cessation efforts, and encouraging screening visits. Some influencers are responsive to negative appeals that arouse concern about harmful consequences to those they are trying to help behave appropriately. Consequently, a portion of campaign messages can be designed to motivate various interveners, facilitator
s and enforcers to take positive action … or at least to dissuade them from emboldening unhealthy choices. The effectiveness of social network-oriented media campaigns, typically targeted to friends and family members of the focal individuals to be influenced, is reviewed in the health domain by Abroms and Maibach (2008).
Societal Policy Makers
Individuals’ decisions about health practices are clearly shaped by the constraints and opportunities in their daily environment, such as monetary expenses, rules, laws, social pressures, community services, entertainment role models, and commercial messages. Through the interventions of government, business, educational, medical, media, religious, and community organizations, many of these potent forces can be engineered to increase the likelihood of healthy choices or discourage unhealthy practices. Key initiatives include direct service delivery, restrictions on advertising and marketing practices, and the imposition of taxes. Consider the example of smoking: substantial reductions in tobacco use have been attained by instituting policies that increase monetary cost, decrease locations where smoking is permitted, broaden availability of cessation assistance programs, reduce smoking depictions in movies, and tightly restrict ads that promote cigarettes. More fundamental long-range approaches might attempt to reduce health disparities by reducing poverty, improving schools, broadening access to the health care system, or enhancing employment opportunities.
Thus, an important campaign approach is to aim messages at constituencies that can influence government and corporate policy makers, who are in a position to formulate policies that shape the environment for health behaviors. Strategically, this approach relies primarily on a two-step pathway from the campaign to the constituency to the policy makers. First, the campaign seeks to influence public opinion within population segments that are inclined to be involved in addressing the health issue. To facilitate the second step, the campaign provides guidance on techniques to use in contacting and persuading those who determine policy, such as letter writing, petition signing, testifying, boycotting, protesting, or voting. Campaign organizers may also cite public opinion poll findings (or commission custom polls) to demonstrate support for the advocated position. As a supplement, the campaigners may create elaborate persuasive messages (e.g., position paper, testimony, mailing, op-ed piece) that are designed to be submitted directly to the policy makers.
Reformers have developed tactics that combine community organizing and mass media publicity to advance healthy public policies through the media advocacy techniques. News coverage of health can shape both the public agenda and the policy agenda pertaining to new initiatives, rules, and laws related to health in society. An important strategy involves changing the public’s beliefs about the effectiveness of policies and interventions that are advanced, which leads to supportive public opinion (and direct pressure) that can help convince institutional leaders to formulate and implement societal constraints and opportunities.
The four primary activities involved in media advocacy include (1) developing an overall strategy that involves formulation of policy options, identification of stakeholders that have power to create relevant change and apply pressure, and development of messages for these stakeholders; (2) setting the agenda by gaining access to the news media through feature stories, staged news events, and editorial commentary; (3) shaping the debate by framing public health problems as policy issues, by emphasizing social accountability, and by providing evidence for the broader claims; and (4) advancing the policy by maintaining interest, pressure, and coverage over time (Wallack & Dorfman, 2001).
Over the past 25 years, activists seeking to influence public and private sector policy makers to enact reforms that address health problems have concentrated their efforts on smoking, drinking, and breast cancer. Substantial success has been attained in influencing federal and local governments to impose alcohol and tobacco control measures, and to obtain funding for breast cancer prevention research. Policy-oriented campaigns aimed at businesses have also been effective, as shown in a recent analysis health-related advocacy campaigns aimed at changing corporate practices in the alcohol, tobacco, food, pharmaceutical, automobile, and firearms domains; the study concludes that campaigns achieved policy or mobilization outcomes contributing to health and safety improvements in these types of companies (Freudenberg, Bradley, & Serrano, 2009).
Prevention Versus Promotion
Campaigns are generally designed with measurable objectives specifying behavioral responses by audience members. In the health arena, the focal behavior is usually a specific practice or discrete action. However, there are numerous intermediate responses that might be targeted, such as awareness, knowledge, salience priorities, beliefs, expectancies, values, and attitudes; campaigns may seek to change key variables along the pathways leading to the focal behavior. The two fundamental approaches are promotion of healthy behavior or prevention or cessation of unhealthy behavior. Traditionally, prevention campaigns more often present fear appeals highlighting negative consequences of an unhealthy behavior, rather than promoting the desirability of a positive alternative. The negatively oriented prevention approach is more potent for topics where harmful outcomes are genuinely ominous.
The social marketing perspective is more applicable to promoting positive behavior rather than directly combating unhealthy behavior; this approach promises rewarding gains from attractive “products.” Product promotion is better suited for attractive concepts, such as the “designated driver” or “staircase exercising,” rather than for less compelling concepts, such as “alcohol abstinence” or “drug-free lifestyle.” In developing behavioral recommendations in promotional campaigns, designers can draw on an array of options from the “product line.” These target responses vary in palatability based on degree of effort, sacrifice, and monetary expense; in determining the degree of difficulty of the product to be promoted, a central strategic consideration is receptiveness of the focal segment. The prolonged nature of campaigns enables the use of gradually escalating sequential request strategies over a period of months or even years. Campaigns have potential to overcome defensive responses to difficult products by initially featuring simpler or softer products that fall within the audience’s latitude of acceptability.
Persuasive Strategies
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Although designers typically include some awareness messages and a few instructional messages in the campaign mix, persuasive messages constitute the central type of content in health campaigns. Campaigns feature persuasive appeals derived from McGuire’s matrix or health behavior models, such as the theory of planned behavior. These theories provide numerous lines of argumentation to convince the audience to adopt the advocated action or avoid the proscribed behavior. For target audiences that are already favorably inclined toward the recommended behavior, the campaign has the relatively simple persuasive task of reinforcing existing predispositions (e.g., strengthening a positive attitude, promoting postbehavior consolidation, and motivating behavioral maintenance over time). However, for the least healthy segments of society who are most in need of attitude and behavior change, the campaign strategists face a distinct challenge in achieving impact. Because a lengthy campaign generally disseminates a broad array of persuasive messages, strategists have ample opportunity to develop and refine a variety of appeals built around motivational incentives designed to influence attitudes and behaviors.
Incentive Appeals
In creating and presenting persuasive appeals on health topics, the initial strategic decision involves message framing (O’Keefe & Jensen, 2007; Quick & Bates, 2010). For most direct attempts to influence health behaviors, strategists face a basic choice between motivating the audience with prospects of experiencing consequences that are generally regarded as desirable or undesirable. In gain-framed approaches, the messages present incentives that promise the audience that performing a healthy practice (or not performing an unhealthy practice) will either attain a valued outcome or avoid an undesirable outco
me; by contrast, loss-framed message appeals argue that performing an unhealthy practice (or not performing a healthy practice) will lead to either attainment of an undesirable outcome or nonattainment of a desirable outcome. The most prevalent strategies in health campaigns are threats of losses from performing a proscribed practice and promises of gains from performing a recommended practice.
In health campaigns, the most widely used design frameworks employ a basic expectancy-value mechanism, wherein attitudinal and behavioral responses are contingent on each individual’s valuation of outcomes promoted in campaign messages. Messages typically focus on the two expectancy-value components of outcomes: the subjective probability of a consequence occurring and the degree of positive or negative valence of that outcome. For the conventional loss-framed messages threatening undesirable consequences, the operational formula derived from the health belief model is the summation of susceptibility x severity across various outcomes. The prime communication objectives are (1) to change expectancy beliefs to a higher level of probability, (2) to intensify the negativity or positivity of the valence, and (3) heighten the salience of detrimental or beneficial outcomes associated with engaging in recommended practices.
The basic dimensions of incentives include physical health, economic, legal, social, psychological/aspirational, and effort; each has potential positive and negative valuations based on audience predispositions. The most frequently used dimension in health campaigns is physical health, with negatively valued threats (particularly death, illness, and injury) featured more often than positive promises, such as wellness.
The SAGE Handbook of Persuasion Page 57