Reviews of mass media campaigns have a special interest for me. They demonstrate what can be done, and as importantly, what cannot be done, by relying on a 1P approach. I have talked about the 5% Solution before, and noted another review of mass media campaigns for changing health behaviors. This post focuses on the findings from a review of recent campaigns to prevent HIV/AIDS. What is interesting in this report are the comparisons it draws to reviews of earlier campaigns in this area as well as the current state of the art and science. The authors used seven principles to guide their analysis: (1) conducting formative research on and about the target audience; (2) using theory as a conceptual foundation; (3) segmenting one’s audience into meaningful subgroups; (4) using a message design approach that is targeted to the audience segment(s); (5) utilizing effective channels widely viewed by and persuasive with the target audience; (6) conducting process evaluation and ensuring high message exposure; and (7) using a sensitive outcome evaluation design that reduces threats to internal validity and allows causal inferences about campaign impact to be made. The question they explore is: to what extent have recent HIV/AIDS campaigns in the literature adhered to these principles?
Noar et al (2009) began with a search of peer-reviewed articles appearing from late 1998 through October 2007. Mass media had to be a central or prominent part of a campaign that focused on increasing safer sexual behaviors, reducing risky sexual behaviors, or encouraging HIV testing. At least one outcome measure had to be reported; 38 articles were identified that met these criteria, representing 34 different campaigns. The results on the variables of interest were:
Formative research - 16 of the 34 studies (47%) reported any type of research with the audience or pretesting of messages. the most commonly reported activity was research about campaign messages, including pretesting messages or examining message preferences of members of the target audience. Only two studies used formative research to develop or test their outcome measures (a neglected part of the research process in too many studies).
Using theory - 44% reported using theory, most often the Health Belief Model, Reasoned Action and Planned Behavior, Social Cognitive Theory, the Transtheoretical Model and Stages of Change and the Information-Motivation-Behavioral Skills Model.
Audience segmentation - 94% (all but 2) described an approach to audience segmentation.
Message design – very few campaigns used theory to guide development of persuasive messages. The authors note that while behavioral theories can suggest the type of content to include, HOW that content is formed into messages is often approached without explicit reference to relevant theoretical models such as message framing, emotional appeals, sensation-seeking, elaboration likelihood model and the use of narratives.
Channels – 21% used a single media channel with television, radio and print media being the channel of choice. The remaining campaigns used other channels (billboards, brochures, Internet, newsletters) and a variety of promotional materials such as baseball cards, postcards, condom packs; a variety of interpersonal strategies including peer education and skill-building workshops and hotlines; and some also included community partners, coalitions and community mobilization in their activities.
Process Monitoring – 82% of the campaigns reported audience exposure to messages, with a mean exposure of 77% of the targeted audience (a range of 35% - 100%). There was little reporting of frequency of exposure to campaign messages, and when those data were reported, it was difficult to make comparisons across studies.
Outcomes – Pre-Post test designs using independent sampling were employed by a plurality of the campaigns (13 of the 34, or 38%). Eleven studies used only a post-test measure. The authors note that this means that 70% of the campaigns used weak outcome evaluation designs. In 24 of the campaigns (71%) behavioral outcomes were reported, most often either condom use or HIV/STD testing. Among the studies that used stronger designs (the other 30%), only 2 of the 10 found no statistically significant effects. Six studies reported significant changes in outcomes including talked with others about safer sex, continued abstinence, initiated condom use, increased condom use, reduced number of sexual partners, or were tested for HIV. The other two reported changes in behavioral intentions (for example, to use condoms and shifts in stages of change).
The authors conclude that, when compared to another review of this literature in 2000, HIV/AIDS mass communication campaigns are increasingly: (1) targeting defined audiences developed through audience segmentation procedures; (2) designing campaign themes around behavior change (rather than solely knowledge or attitude change – though given their selection criteria, this is hardly surprising); (3) using behavioral theories to inform campaign design; (4) achieving higher message exposure to campaign messages; (5) using stronger quasi-experimental designs with control groups for outcome evaluation (although still far too few studies use these stronger designs); and (6) including measures of behavior change (or behavioral intentions) in outcome assessments.
This review highlights how mass communication efforts for HIV/AIDS prevention have shifted from general awareness and knowledge outcomes to ones more tightly focused on achieving behavioral changes among defined segments of the population. While formative research has become commonplace, there are relatively few studies that use research designs that allow for drawing strong conclusions from their findings. This latter point does not mean that research designs must be randomized controlled studies, but as the authors note, even the addition of control groups or using time-series with control communities help address the question of whether there are alternative explanations for the observed effects (for example, that the respondents are not simply placating researchers with favorable or socially desirable responses to their questions).
Social marketing is more than mass communication campaigns, but we often use mass media in conjunction with products and services, providing incentives and reducing costs of engaging in new behaviors, and increasing access and opportunities to perform these behaviors. Learning what works with mass media is important, but as other reviews have pointed out, it is not enough to achieve public health outcomes. Some marketers will note that health communication planners have adopted our practices of segmentation, targeting behavior change and using formative research. However, the importance of using theories that fit the problem of designing persuasive messages is one important takeaway. The other takeaway is the challenge of designing better studies to assess outcomes. Thinking about using comparison populations, or simply delaying intervention among some priority groups while continuing to assess important outcomes, can help us demonstrate that we have more than a very elaborate, and perhaps even effective, placebo.
Noar, S.M., Palmgreen, P., Chabot, M., Dobransky, N. & Zimmerman, R.S. (2009). A 10-year systematic review of HIV/AIDS mass communication campaigns: Have we made progress. Journal of Health Communication, 14: 15-42. [free download]