Mass media campaign—A su salud

PREVENTIVE

MEDICINE

17, 608-621 (1988)

Mass Media Campaign-A

Su Salud’

AMELIE G. RAMIREZ, M.P.H.,* AND ALFRED L. MCALISTER, PH.D. Center for Health Promotion Research and Development, University of Texas Health Center at Houston, Houston, Texas 77025

Science

A mass media health promotion program directed toward reducing future cancer trends among Mexican Americans, the largest subgroup of Hispanics in the United States, by decreasing smoking and encouraging smoking prevention and other health practices is described. Included is an outline of the program design and its significant features and a discussion of social modeling, the theoretical approach which provides a framework for the program. The development of the program, including the role focus groups played in the identification of areas to be targeted by the program, and the production and implementation of the mass media campaign based upon the targeted program areas are also discussed. 0 1988 Academic Press, Inc.

INTRODUCTION In 1985, A Su Mud, a mass media health promotion program encouraging smoking prevention and cessation among Hispanic Americans, was begun in southwest Texas. The program’s implementation is grounded in Bandura’s (7) social learning theory in which individuals from the community are recruited to model desirable health practices. The program is unique in that it targets the largely overlooked Hispanic population, not only are the role models actual members of the target community but the health behaviors they exhibit are authentic representations of personal health decisions they have implemented in their lives. In the last decade, the United States’ Hispanic population has stimulated increasing interest among marketing researchers. This increased interest has led to an explosion of alcohol and tobacco advertisements aimed at the Hispanic population. Unfortunately, a corresponding increase in attention to the health concerns related to alcoholism and tobacco consumption has not occurred. Indeed, there is a conspicuous absence of health education programs directed at the U.S. Hispanic population. A 1983 census found that 16 million Hispanics reside legally in the United States (18), and this population increased to 65% between 1970 and 1980, a rate nearly seven times greater than that of the total U.S. population (5). Despite the growing numbers, there is a scarcity of information regarding the health characteristics of Hispanics. The sparse evidence available reveals that Hispanics are less knowledgeable of the warning signs and risk factors associated with illnesses such as cancer (3) and

’ This project is a grant-supported research project of the National Cancer Institute, National Institutes of Health, Grant 5 ROl CA 38347-02. ’ To whom reprint requests should be addressed at University Plaza, Room 333B, 7703 Floyd Curl Drive, San Antonio, TX 78284-7979.

608 0091-7435/88$3.00 Copyright 0 1988 by Academic Press. Inc. AU rights of reproduction in any form reserved.

FORUM:

A MASS MEDIA

CAMPAIGN

609

cardiovascular disease (19, 48). A recent survey revealed that when asked about potential causes of cancer, only 43% of Mexican American respondents mentioned cigarettes (54). Because of the rapid growth of the Hispanic population in the United States, the lack of information on Hispanic health characteristics, and the relative lack of awareness among Hispanics of preventive health practices, there is a clear need for health promotion programs directed at the Hispanic American community. Research investigating the media behavior of Mexican Americans has revealed that they prefer viewing Spanish language T.V. over English language T.V. (17). On a typical day, 67% of U.S. Hispanics watch Spanish language T.V., 47% listen to Spanish radio, 21% read Spanish newspapers, and 19% read a Spanish magazine. The Hispanic viewer watches an average of 2.4 hr of Spanish T.V. and listens to 1.2 hr of Spanish radio (46). Guernica and Kasperuk (17) have outlined several reasons why the Spanish language media are attractive to Hispanic Americans. First, they serve as sources of news and information for Hispanics concerning both the local community and the country of origin. Second, the editorial policy of the Spanish media is consistent with conservative Hispanic cultural values emphasizing the importance of harmony with the family. Third, the Spanish media provide programming in the native tongue. With 90% of all adult Hispanic Americans speaking Spanish and 43% speaking no English or only enough to “get by” (53), the importance of the Spanish language to U.S. Hispanics cannot be overestimated. More than color, customs, or beliefs, the Spanish language is the single most important identifying characteristic of the Hispanic American population. Given the Hispanic American preference for Spanish language media, it follows that health programs aimed at influencing the Hispanic population would be most successful if presented in Spanish. There is ample evidence to suggest media effectiveness in relaying health-related information. Researchers at Stanford University (13), for example, found that the presentation of a mass media campaign aimed at decreasing heart disease risk resulted in long-term changes in health practices. Other researchers have found some forms of media effective in increasing participation in a cervical screening program (2). In this campaign, print media such as posters, direct mail, and flyers were ineffective in eliciting program participation. Broadcast media, however, produced a significant response and were second only to personal contact in eliciting program participation. There is a paucity of research investigating the effectiveness of mass media on public health intervention programs among Hispanic Americans. The research that has been conducted is supportive of the effectiveness of mass media in influencing preventive health practices. For example, Ramirez et al. (38) conducted a study in which acculturated and nonacculturated Mexican Americans were exposed to a series of short, radio mini-dramas concerning cardiovascular risks factors on Spanish radio stations. Nonacculturated Mexican Americans, i.e., those who have maintained their Hispanic culture and language, evidenced dramatic increases in both their knowledge and concern about risks for heart disease. These results suggest that Mexican Americans can be reached effectively through media-based public health intervention programs provided that the programs are

610

RAMIREZ

AND

MC

ALISTER

designed and implemented in a manner that is culturally meaningful and sensitive to the heterogeneity (e.g., level of acculturation) within the Mexican American community. There is reason to expect that media-based public health intervention programs, generally effective with all population groups, may be particularly effective in reaching Hispanic audiences. Many Hispanics are suspicious of doctors, perhaps due to the high cost of health care and discrimination in access to medical services (32). In a recent American Cancer Society survey, 22% of the Hispanic Americans sampled reported experiencing discrimination while seeking health care (3). Mexican Americans also tend to have less contact with medical professionals (18) and, consequently, are less knowledgeable about the manner in which they might, for example, reduce their risk for cancer or lung disease. This suspicion of doctors, paired with less frequent contact with medical professionals, predisposes Mexican Americans to use T.V. and radio as sources of health information, information sources typically used by individuals who are less informed about preventive health practices (16). The need for media-based public health intervention programs aimed at the Mexican American population is gaining recognition. A variety of studies find that Mexican American youths are now more likely to adopt cigarette smoking than are Anglo American young people (12, 26, 50). Among fourth and fifth graders in Los Angeles, Hispanic boys are six times more likely to report current cigarette smoking than are Anglo boys. These findings point toward the conclusion that, although smoking-related cancer is not presently a problem in the Mexican American population, it threatens to become one in the future. The A Su Salud Program

The A Su Salud study distinguishes itself from other mass media public health promotion programs by its employment of role models within the message design. In addition, it uses target group members in survey administration, formative evaluation sessions, local program promotion activities, and community social service support. Founded on Bandura’s (7) conceptualization of social modeling and social support, it is postulated that behavior can be elicited through the presentation of a role model who serves both as an example of, and as a cue for, desired behavior. The role model functions as a source of new behaviors acquired on a cognitive level (i.e., the person learns how to perform the behavior). The learning and performance of the behavior, however, depends on direct social reinforcement in the form of cueing and feedback. The importance of feedback via encouragement and reinforcement has been illustrated in several studies in which the acquisition of complex behaviors has been undertaken (6, 7, 39, 42). Role modeling has been used successfully in teaching social competency and social skills to children (22), training managers (45), influencing subordinates in corporate settings (l), and treating various clinical problems (8, 9). Mass media marketers have long known that the mass media have a tremendous capacity for modeling desired behaviors. It is only recently, however, that modeling has been systematically used to influence individuals to engage in behaviors that are not only beneficial them, but also benefit the entire community. A s&es

FORUM:

A MASS

MEDIA

CAMPAIGN

611

of longitudinal studies conducted in Finland aimed at reducing cardiovascular disease also has demonstrated the effectiveness of using role modeling through mass media (28,36). These studies used a television series to broadcast the efforts of a group of “average” Finns in their attempts to change health-related behaviors. The A Su Salud intervention program has been modeled after the Finnish studies. In this program, interpersonal communication is provided in the form of cueing feedback and reinforcement to encourage acquisition and performance of the attitudes and behaviors modeled in the mediated communications (i.e., the television broadcasts). Simple forms of verbal cueing and reinforcement that can be widely communicated through brief contact and by volunteers have been selected. These include (a) direct recommendation to imitate mediated communicators, (b) expressions of confidence, (c) praise and other positive feedback for any achievements, and (d) encouragement to continue efforts. These social factors have been associated with successful smoking cessation and with maintenance of behavior change (11,29,43). Similar efforts have been met with success in the Finnish studies in which volunteers were trained to provide social reinforcement directed at the maintenance of smoking cessation to facilitate the effectiveness of a television course on how to quit smoking (27,37). Other programs have used a similar approach (4, 14, 23, 31, 52). In the A Su Salud project, volunteers have been recruited to encourage others within the community to imitate behaviors that are modeled on the television broadcasts. In addition, schools were asked to encourage and instruct students in ways that they might provide cueing and reinforcement for parents who smoke. Other sources of community cooperation include local health care providers (particularly physicians), clerics and lay leadership from community churches, bartenders, shopkeepers, and other persons in key locations. This article describes the development and implementation of a mass media intervention program designed to increase knowledge of health risks associated with smoking and to promote behavior change aimed at smoking cessation or prevention among Mexican Americans in south Texas. The following section provides a brief overview of the design of the health intervention program as well as demographic information about the selected communities and the unique features of the A Su Salud program. The final section describes the development of the approach for a mass media program from the idea stage, as discussed by focus groups, to the production and implementation stages. SUBJECTS

AND METHODS

Program Design

The A Su Salud project is a 5-year study funded by the National Cancer Institute which began in 1985. The partially randomized, longitudinal, quasiexperimental design involves the participation of adult residents (H-64 years old) from approximately 1,200 households in two locations in southwest Texas. The locations selected for the first year of study were Eagle Pass, a city of approximately 20,000, and Del Rio, a city of approximately 30,000. Both communities lie

612

RAMIREZ AND MC ALISTER

on the Texas/Mexico border and are virtually 100% Hispanic, with Mexican Americans accounting for a large majority of both populations. Cigarette smoking and variables related to cigarette smoking and cancer are being measured over a 5-year period by household interviews of adults from randomly sampled census blocks in both cities. In subsamples, a biochemical test is used to supplement self-reports of smoking. Del Rio serves as the comparison condition for assessing program effects in Eagle Pass, the treatment location, where different media and community activities are being conducted for smoking prevention and cessation. Three levels of experimental activity were established sequentially in different locations in Eagle Pass: (a) A mass media program in which only a media communication program aimed at smoking cessation/prevention was designed, produced, and implemented; (b) the media program plus direct community orgunization and training in which natural social networks would be used to increase encouragement and reinforcement for responses specifically related to smoking cessation/prevention; (c) the media and community programs with establishment of additional systems for more general social support for stress-coping. A program of individual attention and support for stress-coping was developed to reach persons experiencing difficulty in smoking cessation. The various experimental treatments are based on theoretical principles from the behavioral sciences and have been designed to correspond to meaningful policy options for local and regional planners. All program activities are integrated with existing public health service structures through local authorities to demonstrate effective materials and services that can be continued and adopted by other TABLE 1 EXPERIMENTAL DESIGN

City assignment

No. of HH

Eagle Pass

200 200 200 200 400 300 300 400

(RI Del Rio W

1985

1986

1987

1988

0 x2 0 Xl

0 x3 0 x2 0 x3 0 x2 x2 0x1 0x1 Xl

0x3 0 x2 0 x3 0 x2 x2 0 Xl 0 Xl Xl

0 x3 0 x2 0 x3 0 x2 x2 0x1 0x1 Xl

0x0

1989 0 0 0 0 0 0 0 0

Note. The experimental conditions and measurement are the following (see Cook and Campbell, 1979): X0, Control group Xl, Mediated communication only X2, mediated communication + specific social reinforcement X3, mediated communication + specific social reinforcement + general support for stress coping 0, Survey of risk factors (n = year) (R), Households randomized to X conditions, aggregate to 0 conditions. The present study is designed to experimentally study the effects of activities which enhance the effects of mass media programs to encourage cessation of smoking and prevent the onset of cigarette dependency. Specifically, the design assesses the impact of two levels of community action: (I) Reinforcement for attention/response (X2); (II) reinforcement and social support for stress coping (X3). These levels of action are compared with one another and with a media-only level of action (Xl).

FORUM:

A MASS-MEDIA

CAMPAIGN

613

public health agencies. Cost effectiveness of the different levels of intervention will be estimated. The effect of significant intervening variables and social psychological processes related to smoking cessation/prevention also will be analyzed. The A Su Salud project has several features that differentiate it from previous research efforts directed at Hispanic Americans. First, the investigation of smoking in Mexican American populations is significant because it is directed not at existing health problems of specific populations, but at anticipated problems. Because the barrio communities of south Texas are similar to communities in Mexico and other southern nations of the western hemisphere, this research may also have international application in helping to stem the trend toward the increasing rate of chronic diseases that is expected in less industrialized nations. A second important feature of this mass media intervention program uses local smokers and other individuals who have made or are making health changes as role models. These local smokers are followed before and during the smoking cessation program and as they learn new coping responses to help them maintain abstinence. This mass media intervention program also has enlisted the assistance of local T.V. stations. The local stations helped to prepare the programs that were aired on their stations. The inclusion of the local stations in the planning and preparation of the media intervention programs created a sense of shared responsibility for the outcome of the program as well as a commitment to the programs’ success which resulted in several benefits including greater community involvement and a reduction of costs, since the sponsoring stations provided production time free of charge and air time for a nominal fee. Formative and Program Evaluation Regarding the application of community intervention strategies utilizing mass media channels, three different stages of evaluation can be identified. The basis of the first stage of evaluation was developed through randomly assigned baseline household questionnaires based on the goals of the grant proposal. A profile of preexposure knowledge, attitudes, and behaviors of the target population relating to those goals then formed the core of the initial messageform and content. Yearly surveys are performed during the summer months of each year to provide annual assessment records for both measurement and reference/control communities. Focus groups preview the message design and their visual and literal content before final production and distribution which occurs each year of the study from September through March. At least once a year during the media campaign’s dormant period (April through mid September) samples of the previous year’s video, radio, and print messagesare presented to a series of focus groups in each of the measurement communities. The results are analyzed and incorporated into the following year’s media campaign. While spring and summer are recognized as the most convenient period for formative assessment of the media, this has not precluded modification of media components during the campaign period when significant feedback occurred from

614

RAMIREZ

AND

MC ALISTER

the target population, opinion leaders, or community members in the measurement communities. Final summative evaluation data, derived from the five annual surveys, is subjected to time series and ANOVA analysis administered at the end of the fifth year of the study. Mass Media Program Development The development of the A Su Salud health promotion program consisted of three steps: (a) Focus groups were formed within the target communities to identify the communities’ knowledge and perceptions of the relevant health issues, (b) the health promotion program was developed, produced, and broadcasted in the target communities, and (c) the remainder of the mass media health promotion program was implemented. Each of these steps will be discussed in turn. Focus Groups. Focus group interviews, also known as exploratory group sessions, are used to gain insight into a target audience’s perceptions, beliefs, and language regarding a particular product or program (47). A focus group is an informal session in which several participants are asked to discuss in their own words all aspects of a specific topic or subject matter. Such groups are designed to obtain an “in-depth” understanding of a population’s orientation and conceptualization regarding a given product or topic. Analysis of the terminology, expressions, and other verbal communications that surface in the group yield useful guidelines for product promotion or program message design (49). In the A Su Salad program, seven focus groups were organized to learn more about knowledge and perceptions toward cancer and smoking, health care services, preventive health practices, diet, alcohol, and nutrition in the target communities. Four of the focus groups were composed of members from the community group at large while three represented opinion leaders. Of the three opinion leader groups, one included health professionals, one media personnel, and one community leaders such as the mayor. Focus groups ranged in size from 10 to 12 members. Participants were contacted personally or by phone and were told that they would be discussing their thoughts and beliefs about cancer and other health problems. Recruitment was limited to participants who potentially would be affected by the program (e.g., smokers) or who would be important in implementation (e.g., community leaders, health professionals). Analysis of the transcripts of the focus groups revealed four themes. Interestingly, these four themes are echoed in an American Cancer Society survey conducted simultaneously though not in conjunction with the present study (3). The first theme was the perception that individuals have no control over the likelihood that they will contract cancer. Moreover, several members argued that “everything caused cancer,” so why not smoke? This fatalistic view of cancer is similar to Rotter’s (40) conceptualization of an external locus of control in which individuals view outcomes as not contingent on their behavior. A similar fatalistic orientation was found among Hispanics in the American Cancer Society survey in which 47% of those individuals who had not sought a check-up in the last 5 years claimed that such preventive measures were ineffective in preserving health. The

FORUM:

A MASS MEDIA

CAMPAIGN

615

American Cancer Society survey also found that 60% of their sample held the view that virtually everything causes cancer and so there is no use trying to prevent it. A second theme arising from the focus group meetings was one of skepticism. Group members questioned whether smoking cessation really affected longevity. Anecdotal examples of acquaintances who smoked and drank their entire life yet lived into their eighties were cited. This sense of skepticism was also found in the American Cancer Society study with the Hispanics surveyed, when compared to the general public, expressing little faith in the effectiveness of cancer treatment. Two additional themes were revealed and eventually incorporated into the core messages of the media campaign. One of these themes was the perceived prohibitive cost of medical services which acts as a serious impediment to the pursuit of primary health care. The second was a broad lack of preventive health care knowledge and a profound apprehension toward learning about a serious health problem. Surveys conducted by the American Cancer Society have found similar attitudes in Hispanic populations. Production. Based on the findings from the focus groups, two major program areas were developed for the media campaign aimed at tobacco use. The first program area developed was smoking prevention for youth and their families. Primary emphasis was placed on smoking as a lethal, premature cause of death. The cost and addictive nature of smoking were discussed. Viewers also were told to be aware of and resistant to advertising which promoted smoking. Alerting individuals to persuasion tactics that they are or will be exposed to (e.g., smoking is macho) has been found to build their resistance (15). In addition, participants were instructed and shown how to resist peer pressure and how to say “no” in various situations where there was pressure to smoke. The second area developed for the A Su Salud media campaign was smoking cessation. The development of this area was derived from specific theories addressing the process of smoking cessation (21,25, 33-35,41,43) in which change is conceptualized as three stages: preparation, taking action, and maintenance. These stages as well as examples provided by the role models recruited from the community are presented in Table 2. Although there is some overlap between stages, the preparation stage is characterized by dissatisfaction with dependence and by decisional imbalance (20). In the action stage, the individual possesses self-efficacy regarding his/her ability to overcome the dependency. Social support and reinforcement for nonsmoking are important contributors to successful completion of this stage. In addition, the individual goes through a process of reevaluation where the “former” smoker attempts to reform his or her self-concept following this lifestyle change. This includes redefining oneself as a nonsmoker. In the final stage the individual attempts to maintain his/her lifestyle change by avoiding stimuli associated with smoking, acquiring new coping responses, and maintaining a general social support network. Also characteristic of the maintenance stage is an increased sense of self-efficacy regarding the ability to undertake other lifestyle changes. In the smoking cessation section of the A Su Salud media program information about why one should want to become a nonsmoker, how to go about it, how to

616

RAMIREZ

AND TABLE

Three stages of smoking cessation I. Preparation A. Information about smoking: Decisional balance. B. Dissatisfaction with dependence on cigarettes. II. Taking action A. Positive efficacy expectations. B. Social support and reinforcement for nonsmoking. C. Reevaluation of self. III. Maintenance A. Increasing efficacy expectations for specific situations. B. Avoiding stimuli associated with smoking. C. Acquisition of new coping responses. D. General social support for stress-coping.

MC ALISTER 2 Examples provided by role models “I decided to quit because I was pregnant. It’s o.k. to risk my own life, but not my unborn child.” “I wanted to be here [living] to see my children grown.” “My husband supported my decision and he joined me in the decision to stop smoking.” “I physically feel better, less fatigued, less tense, I feel better.” “In social situations, I would review the reasons why I quit smoking . ” “When nervous due to not smoking, I would talk to someone or eat a piece of candy.”

cope with the decision to stop, and how to maintain the new behavior was provided. Role models throughout the television programs explained how they quit smoking and their reasons for quitting. Although this project emphasizes smoking cessation and prevention, it was felt that other health risk factors should be included to address concerns raised by the smokers and to elicit broad community involvement. More specifically, it was desirable to do something for the nonsmoking audience other than just providing them with methods for reinforcing friends and family who are trying to quit smoking. With that goal in mind, role models were utilized to elicit behavior change relating to improving diet, increasing regular exercise, avoiding drug and alcohol abuse, and encouraging greater use of preventive health care services. A local media professional was subcontracted to write the scripts for the television programs. These scripts were then directed and edited by the staff of the University of Texas Health Science Center, Center for Health Promotion Research. The programs were coproduced by, filmed at, and broadcast in Spanish on two local Spanish stations. Two forms of the television health promotion program were developed. The first form consisted of 15 programs ranging in length from 5 to 10 min. The second form consisted of four programs 30 min in length. In the 5to lo-min programs information from the four program areas was presented in a news format by two community physicians who served as spokespersons for the program. The 30-min programs were presented in a mini-documentary format. A health education specialist from the community served as narrator for both the shorter programs and the 30-min programs. Role models who had recently made a positive health change were recruited from the community to appear in the programs. Individuals who had an appealing character, who looked, talked, and acted like the target audience, and who could describe with clarity the skills they used to change their behavior were chosen. Role models included a grocery store owner, two housewives, and a local public official. The role models discussed what made them decide to change, how they changed, and how they felt after the change. Changes included going in for med-

FORUM: A MASS MEDIA CAMPAIGN

617

ical check-ups, stopping smoking, losing weight, and starting an exercise program. In addition, nonsmoking teenagers were recruited to discuss why they didn’t smoke and how they avoided and/or overcame pressures to smoke from their peers and advertising. Individuals were selected from the community to serve as role models rather than professional actors for three reasons. First, researchers have demonstrated that an audience is more likely to be persuaded by a communicator if they perceive the communicator as similar to themselves (10, 30). The role models in the programs were expected to be perceived by a given viewer as much more similar to him or herself than a professional actor. Second, it was less expensive to recruit volunteers to participate in our program than to hire actors. Finally, the recruitment of “locals” had proven successful in the Finnish studies, and there was no reason to suspect that it would not be successful in our program as well. Implementation. To coincide with the television program and as a kick-off for introducing the 1985 program in the treatment community of Eagle Pass, a press conference was held with the mayor and other individuals from the community who were involved in the study. The Sunday immediately following the press conference, a flyer entitled, Seis Asesinos Zmporantes Andan Sueltos en El Condado de Maverick (Six Important Assassins Are Loose in Maverick County) was circulated. The flyer described the six assassins as lifestyle habits associated with premature death. These were alcohol abuse, cigarette smoking, obesity and inadequate diet, lack of medical check-ups, lack of seat belt usage, and pollution. Also described were the health problems caused by or associated with these six

FIG. 1. Newspaper insert for A Su Salud mass media health promotion campaign.

618

RAMIREZ

AND

MC ALISTER

lifestyle habits. The flyer promoted the times the television programs aired and provided a checklist of preventative steps readers could take. The flyer was pretested in two ways. First, 17 individuals waiting in a clinic were requested to read the flyer and respond to a questionnaire assessing, among other things, the flyer’s format, clarity, and visual appeal, and the extent to which the flyer was interesting, informative, and helpful. After extensive revision, the flyer was reevaluated in the focus group sessions. The final version of the flyer was placed in the local newspaper, the “Eagle Pass Guide,” and distributed to 5,000 homes. The flyer was also included in the “Zocalo,” the Spanish newspaper distributed from Piedro Negras, the Mexican community just across the border from Eagle Pass, with a circulation of 5,000 among Eagle Pass residents. The costs incurred in implementing the programs was $48,800 for scripting, filming, and editing, a nominal fee of $2,300 charged by the two local television stations (CSN Channel 3/33, WW TV Channel 7) for filming and editing, and distribution of the brochure in the Spanish and English newspapers cost $325. The campaign began September 20th, 1985 and ran through December, with reruns through June, 1986. The half-hour programs generally aired on Monday, Tuesday, and Friday at 1 and 7 PM. Other air times were given as time permitted. The 5- to IO-min programs aired on Thursday at 6 and 8 PM and on Saturdays at 6 PM. These programs aired right before the national news at 6 PM and right before the local news at 8 PM. As of January 1, 1986, the programs have aired 173 times for a total of 57 hr. Table 3 provides a breakdown of amount of air time for the programs by station. Because the programs are aired on local stations, Neilsen data regarding viewership do not exist. However, a future survey will provide us with an estimate of the number of individuals and families who viewed the programs. Although the A Su Salud health promotion program is still in progress and is not scheduled to end until 1990, the impact of the program will be assessedon a yearly basis and additional communities are being added to test replicability of the A Su Salud model. CONCLUSION

This article has outlined an approach to a mass media health promotion program aimed at decreasing smoking and encouraging smoking prevention among Mexican Americans. There are several features of the A Su S&d project which will TABLE Exposures

3

PERMONTH:STATIONANDFORMAT

TV station

Sept.”

Oct.

Nov.

Dec.

Jan.

Total

CSN TV channel 3/33 (30-min programs) WW TV channel 7 (5min programs) Total exposures

12

26

20

24

24

105

9

14

18

12

14

67

21

40

38

36

38

173

n Program began September 29, 1985.

FORUM:

A MASS MEDIA

CAMPAIGN

619

facilitate its implementation and/or success. First, the coproduction of the television program with local broadcasting stations not only stimulated greater community involvement, but also cut costs as the stations provided services such as filming and air time at a fraction of the cost. Second, the models recruited from the community were not actors and are seen in their home, work place, or other familiar surroundings. Finally, the role models differed from those typically representing other health promotion programs in that the models talked about and performed new strategies and techniques for quitting smoking rather than just giving a testimonial of life before and after the change. The outcome of the A Su S&d program not only will provide information on strategies for decreasing smoking among Mexican Americans in the target community over the next few years, it also will provide information regarding means for reducing the incidence of smoking-related deaths in the target community in the future. It is intended that the A Su Salud project will serve as a model of a minority mass media health promotion program which can be replicated in other communities and by health departments addressing similar health problems. REFERENCES 1. Adler, S. Subordinate imitation of supervisor behavior. The role of supervisor power and subordinate self-esteem. Sot. Behav. Pers. 11, S-10 (1983). 2. Alexander, K., and McCullough, J. Application of marketing principles to improve participation in public health programs. J. Comm. Health 6, 216-222 (1981). 3. American Cancer Society. “A Study of Hispanics’ Attitudes Concerning Cancer and Cancer Prevention.” The American Cancer Society, New York, 1985. 4. Artz, L., Cooke, C., Meyers, A., and Stalgaitis, P. Community change agents and health interventions. Hypertension screening. Amer. J. Comm. Psychol. 9, 361-367 (1981). 5. Astor, D. The Hispanic market: An in-depth profile. Marketing Commun. 7, 15-19 (1981). 6. Bandura, A. Vicarious processes: A case of no-trial learning, in “Advances in Experimental Social Psychology” (L. Berkowitz, Ed.), Vol. 3, pp. l-56. Academic Press, New York, 1965. 7. Bandura, A. “Social Learning Theory.” Prentice-Hall, NJ, 1977. 8. Barbow, A. The effect of modeling in the treatment of agoraphobia. J. Group Psychotherapy, Psychodrama Sociometry 37, 85-86 (1984). 9. Borgers, S. B., and Koenig, R. W. Uses and effects of modeling by the therapist in group therapy. J. Specialists Group Work 8, 133-138 (1983). 10. Brock, T. C. Communicator-recipient similarity and decision change. J. Pen. Sot. Psycho/. 1, 650-654 (1965). 11. DiClemente, C. C., and Prochaska, J. 0. Self-efficacy and the stages of self-change of smoking. Symposium on Self-Efficacy and Health Behavior Change: Smoking Cessation and Relapse, Los Angeles, CA, 1981. 12. D’Onfrio, C., Thier, H., Schnur, A., Buchanan, D., and Omelich, C. The dynamic of adolescent smoking behavior. World Smoking Health, 1982. 13. Farquhar, J. W., Fortmann, S. P., Maccoby, N., Wood, P. D., Haskell, W. L., Taylor, C. B., Flora, J. A., Solomon, D. S., Rogers, T., Adler, E., Breitrose, P., and Weiner, L. The Stanford Five City Project. An overview, in “Behavioral Health: A Handbook of Health Enhancement and Disease Prevention” (J. D. Matarazzo, N. E. Miller, S. M. Weiss, J. A. Herd, and S. M. Weiss, Eds.), pp. 11X-1165. Wiley, New York, 1984. 14. Flay, B. R., Hansen, W. B., Johnson, C. A., and Sobel, J. L. “Involvement of Children in Motivating Smoking Parents to Quit Smoking with a Television Program.” Presented at Fifth World Conference on Smoking and Health, Winnipeg, Manitoba, July, 1983. 15. Freedman, J., and Sears, D. Warning, distraction and resistance to influence. J. Pen. Sot. Psycho/. 1, 262-266 (1965).

620

RAMIREZ AND MC ALISTER

16. Gombeski, W. R., Moore, T. J., Contant, C. F., Ramirez, A. G., Farge, E. J., and Kautz, J. A. Health information sources of the poorly informed: Implications for health educators and communicators. Health Values 5, 199-206 (1981). 17. Guemica, A., and Kasperuk, I. “Reaching the Hispanic Market Effectively.” McGraw-Hill, New York, 1982. 18. Heckler, M. M. “Report of the Secretary’s Task Force on Black and Minority Health.” U.S. Department of Health and Human Services, Washington, DC, 1985. 19. Hazuda, H. P., Stem, M. P., Gaskil, G. P., Haffner, S. M., and Gardner, L. I. Ethnic differences in health knowledge and behaviors related to the prevention and treatment of coronary heart disease. Amer. J. Epidemiol. 117, 717-728 (1983). 20. Janis, I. L., and Mann, L. “Decision Making: A Psychological Analysis of Conflict, Choice and Commitment.” Free Press, New York, 1977. 21. Jarvik, M. E., Cullen, J. W., Gritz, E. R., Vogt, T. M., and West, L. J. “Research on Smoking Behavior.” NIDA Research Monograph No. 17, pp. 122-148, U.S. Department of Health, Education, and Welfare, Washington, DC, 1977. 22. Johnston, C., and Iannou, S. Social competence in the kindergarten: A pilot study of peer modeling. J Child Cure 1, 51-58 (1984). 23. Kasl, S. V. A social-psychological perspective on successful community control of high blood pressure: A review. J. Behav. Med. 1, 347-381 (1978). 24. Kautz, J. A., Bradshaw, B. F., and Fonner, E., Jr. Trends in cardiovascular mortality in Spanishsurnamed, other White, and Black persons in Texas, 1970-1975. Circulation 64,730-735 (1981). 25. Lichtenstein, E. The smoking problem: A behavioral perspective. J. Consult. Clin. Psychof. 50, 804-819 (1982). 26. McAlister, A. L., Perry, C., and Maccoby, N. Adolescent smoking: Onset and prevention. Pediatr. Clin. 63, 650-658 (1979). 27. McAlister, A., Puska, P., Salonen, J. T., Tuomilehto, J., and Koskela, K. Theory and action for health promotion: Illustrations from the North Karelia Project. Amer. J. Public Health 72, 43-50 (1982). 28. McAlister, A., Puska, P., Wiio, J., Smolander, A., Pekkola, J., and Koskela, K. Community organization to increase effects of a mass communication campaign. The Finnish “Keys to Health” program. Unpublished manuscript. University of Texas Health Science Center, Houston, 1983. 29. Mermelstein, R., Cohen, S., and Lichtenstein, E. “Psychosocial Stress, Social Support and Smoking Cessation and Maintenance.” Presented at the Annual Meeting of the American Psychological Association, Anaheim, CA, August, 1983. 30. Mills, J., and Jellison, J. M. Effect on opinion change between the communicator and the audience he addresses. J. Pen. Sot. Psychof. 9, 153-156 (1968). 31. Morisky, D. D., Levine, D. M., Green, L. W., Shapiro, S., Russel, R. P., and Smith, C. R. Five-year blood-pressure control and mortality following health education for hypertensive patients. Amer. J. Public Health 73, 153-162 (1983). 32. Novelli, W. D. Presented at the American Cancer Society, Meeting on Cancer Communication to Hispanic Audiences, New York. November, 1985. 33. Ockene, J. K., Nutall, R., Benfari, R. C., Hurwitz, I., and Ockene, I. S. A psychosocial model of smoking cessation and maintenance of cessation. Prev. Med. 10, 623-638 (1981). 34. Pechacek, T. F., and Danaher, B. G. How and why people quit smoking: A cognitive-behavioral analysis, in “Cognitive-Behavioral Interventions: Theory, Research, and Procedures” (P. C. Kendall and S. D. Hollon, Eds.), pp. 38w22. Academic Press, New York, 1979. 35. Prochaska, J. O., and DiClemente, C. C. Stages and processes of self-change of smoking: Toward an integrative model of change. J. Consult. Clin. Psycho/. 51, 390-395 (1983). 36. Puska, P., McAlister, A., Pekkola, J., and Koskela, K. Television in health promotion: Evaluation of a national programme in Finland. Znt. J. Health Educ. 24, l-14 (1981). 37. Puska, P., Tuomilehto, T., Salonen, J., Neittaanmaki, L., Maki, J., Virtamo, J., Nissinen, A., Koskela, K., and Takalo, T. Changes in coronary risk factors during comprehensive five-year community programme to control cardiovascular diseases (North Karelia Project). Brit. Med. J. 2, 1173-1178 (1979).

FORUM: A MASS MEDIA CAMPAIGN

621

38. Ran&z, A. G., Cousins, J. H., Santos, Y., and Supik, J. D. A media-based acculturation scale for Mexican-Americans: Application to public health education. Family Comm. Health, in press. 39. Rogers, E. “Communication Strategies for Family Planning.” Free Press, New York, 1973. 40. Rotter, J. Generalized expectancies for internal versus external control of reinforcement. Psychol. Monogr. 80, (1, Whole No. 609), 1966. 41. Schwartz, J. L. “Progress in Smoking Cessation.” American Cancer Society, World Health Organization, International Union Against Cancer. New York, 1978. 42. Sheffield, F. D. Theoretical considerations in the learning of complex sequential tasks from demonstration and practice, in “Student Response in Programmed Instruction” (A. A. Lumsdaine, Ed.). National Academy of Science National Research Council, Washington, DC, l%l. 43. ShifTman, S. Relapse following smoking cessation: A situational analysis. J. Consult. C/in. Psychol. 50, 71-86 (1982). 44. Stem, M. P., Gaskill, S. P., Allen, C. F., Garza, V., Gonzales, J. L., and Waldrop, R. H. Cardiovascular risk factors in Mexican-Americans in Larado, Texas. I. Prevalence of overweight and diabetes and distributions of serum lipids. Amer. J. Epidemiol. 113, 546-555 (1981). 45. Stimpson, D. V., and Revel, L. K. Management style: Modeling or balancing? .I. Psychol. 116, 169-173 (1984). 46. “U.S. Hispanic Market, 1984.” Strategy Research Corp., New York, 1984. 47. U.S. Department of Health and Human Services. “Pretesting in Health Communications.” NIH Publication No. 84-1493. National Cancer Institute, Bethesda, MD, 1984. 48. Vega, W. A., Sallis, J. F., Patterson, T., Rupp, J., Atkins, C., and Nader, P. R. Assessing knowledge of cardiovascular health related diet and exercise behaviors in Anglos and Mexican Americans. Unpublished manuscript, University of California, San Diego, 1985. 49. Weaver, F. J., Herrick, K. R., and Ramirez, A. G. Methodology for the development of a consumer health education program. Health Values Achieving High Level Wellness 2, 319-323 (1978). 50. Wheeler, R. C., Marcus, A. C., Cullen, J. W., and Konugres, E. Chronic disease risk factors in a racially heterogeneous pediatric population: The “Know Your Body” program, Los Angeles. Prev. Med. 12, 569-587 (1983). 51. Winett, R. A., Leckliter, I. N., Chinn, D. E., Stahl, B., and Love, S. Q. Effects of television modeling on residential energy conservation. J. Appl. Eehav. Anal. 18, 33-44 (1985). 52. Worden, J. K. “Adult Communication Skills Training to Prevent Adolescent Smoking.” Presented at the American Public Health Association Annual Meeting, Dallas, TX, November, 1983. 53. Yankelovich, Skelly, and White. Spanish USA, A study of the Hispanic market in the United Sates--Origins, characteristics and lifestyle, marketing and media behavior. New York, 1981. 54. Telephone survey developed by UTHSC-Houston, Tarrance, Hill, Newport, and Ryan of Houston, l/87,600 households in South Texas. “Cancer Awareness for South Texas,” administered by Rio Grande Radiation Treatment and Cancer Research Foundation, Inc., in coordination with UTHSC-H, funded by the Texas Cancer Council.