- Email: [email protected]
The impact of mass communication campaigns in the health field
THE
IMPACT
CAMPAIGNS
OF
MASS
IN THE RIXA
520 Warren
Hall. School
of Public
Health.
COMMUNICATION HEALTH
FIELD*
ALCALA~
University
of California,
Berkelq,
CA 94720. U.S.A
Abstract --This
article analyzes a series of health education projects that used the mass media to change behavior. First, the article dcscrihes how persuasion theories arc used to ma*lmi/e impact in mass communication campaigns. Second. this paper discusses theories of social psychology used in such campaigns. One such theory. cognitive dissonance. explains changes at the level of attitudes. beliefs and opinion. Another theory. social learning. defines strategies of behavior changes. A third theor\, concerning diffusion of innovations. helps understand the network of interpersonal relatlonshlps cssentlal for the adoption of any innovation. McGuire’s inoculation theorq suggests strategies to aid rcsistancc to harmful environmental inHucnccs (e.g. smoking. excessive drinking. etc.). Third. this mark rc\icws public health campaigns that have used one or more of these theories of social psycholog). The first project. dealing with smoking behavior cessation and prevention. mainlq used strategies of intcrpcrsonal communication for inoculating and modeling useful behavior in order to resist social prcssurcs favorable to smoking. The second project. designed to prevent alcoholism. used the mass media primarily. The objective of this campaign was to obtain changes in knowledge, attitude and behavior in the puhllc through modeling desirable behaviors over public service announcements. The third campaign. ;I heart disease prevention program. used a combination of mass media and interpersonal communication to achieve changes in lifestyle of the population. Finally. this article describes limitations in using mas\ media in behavior change health programs.
These projects were based on theoretical concepts drawn from social psychology. The following pages provide: (I) some background on these theories: (2) an analysis of the three projects; and (3) ;I discussion of some of the limitations in the use of mass mcdi:l for health education revealed by these projects.
is an increasing awareness of the importance of preventive health care. Preventive health care can decrease dramatically the risk of disease and thus can save significant human and economic resources. Yet effective preventive health behavior is still fur from a reality in most societies. In most modern nations a great many people smoke. drink excessively. eat nonnutritious food. practice poor sanitation. get insufticient exercise and so on. Effective preventive health measures demand the combined efforts of individuals. communities and health and social organizations. Almost all countries today acknowledge the importance of health education and engage in some form of mass communication effort. Different countries have different priorities regarding which health issues need to be stressed. Nevertheless health education. which increases awareness and can change attitudes and behavior. has been shown to reduce health risks significantly. This article describes three major preventive health education projects conducted recently in the United States. These prqjects were chosen because they deal with major barriers to effective preventive health not only in the United States, but also in other North American. Latin American and European countries. Although the three projects arc oriented toward mass communication. each one has II different emphasis: one is based mostly on interpersonal and group communication, a second used television almost entirely, while the third used :I multi-media approach. There
*I
The field of social communication is not just II specific discipline, but it also drawls on ;I variety of interdisciplinary fields whose focus is tither on one or more communication elements. or on the relationship between ;I series of such elements found in the process of communication. Lasswell [I] said that the study of any communication could be pursued with these well-knoun questions: Who’? Says what’? By hhat channel’! To whom’? With &hat effect‘? Each of these questions determines an ‘area’ or an ‘element’ within the phenomenon of mass communicition. ‘ The first question. ‘Who?‘. concerns the study of the source. Studies of this component have concentrated on the control of the mass media. Disciplines like political science or sociology have lent their thcorctical frameworks and methods to this study. The question. ‘Says what?‘, has given rise to the study of messages through content analysis and semiology. The question. ‘By means of Lvhat channel?‘. is expressed in the study of the medium itself. the concern with identifying those elements that differentiate. for example, radio from television from newspapers. and with selecting the medium most appropriate to each project. The writing of Marshall McLuhan and
wish to acknowledge the comments of Raymond E. Wolfinger. In addition I want to thank Susan Knapp for translating this paper from Spanish. This artxle 1s based on a paper presented at the third meeting of Asociacib Latinamericana de Modificacibn de la Conducta. Santiago. Chile. 19X 1. 87
his theory that the ‘medium is the message’ represent this line of thinking. The question, ‘To whom?‘, gives rise to studies of the audience. The question is concerned with identifying and classifying the receivers in accordance with the categories relevant to the objectives of the study. Finally, the question, ‘With what effect?‘, refers to the impact that the messages have on the audience. Studies on the ctrects of communication comprise this area of study. while impact campaigns use theories of persuasion aild attitude change. It is here. in the efforts to maximize impact. that the areas of mass communication and social psychology coincide. Every communication campaign seeks in some measure to achieve a change in the receiver either in knowledge. attitude or in behavior. In fact. achieving behavior change is the ultimate objective of the majority of communications campaigns in the health field. However. this objective is not always expressed in an explicit form. Most campaigns seek to increase knowledge or to change attitudes, assuming that behavior will change as a consequence. This widely held belief-that an increase in the level of knowledge will effect an attitude change which will in turn cause later behavior changes--- is now being questioned by researchers. SOCIAL
PSYCHOLOGY
HEALTH
THEORIES
EDUCATION
USED IN
CAMPAIGKS
In the following pages, I will review the principal theories that have served as a foundation for communication campaigns. The theories are intended to explain behavior: they do not themselves change behavior. First. I will look at the family of closely related theories concerned with the consequences of ‘inconsistent’ or unharmonious knowledge and attitudes: cognitive dissonance, cognitive balance and so on. Second, I will consider some implications of social learning theory. which explains a behavior change as a consequence of vicarious learning achieved through exposure to models who demonstrate the desired behavior. Third, I will evaluate studies of the networks of interpersonal communication through which innovations are diffused to people who make use of them. And finally, I will analyze McGuire’s theory of inoculation which provides individuals with immunization strategies to resist harmful emotional inlluences (e.g. smoking, alcoholism). These theories have been of critical import to the field of mass communication as shown by the fact that they have provided the theoretical basis for the design of innumerable campaigns of mass communication through mass media, as much in the area of health as in other areas of education.
The assorted dissonance (or balance, or consistency) theories all assume that people are made uncomfortable when various elements of their perceptual fields are inconsistent with each other [Z]. For example. a professor who moves from Harvard to Yale will be made uncomfortable by, evidence that Harvard is prospering. or that Yale IS not. We say that he ‘reduces dissonance’ by his willingness to think poorly of his old school and favorably of his
new one. If an individual admires a public figure and that ligure says something repugnant to the individual. dissonance is said to result, Because dissonance is a source of discomfort. the individual handles it by changing his mind about the topic of the remark. by thinking less of the public figure. or by mispcrceiv)ing what the figure said. thus maintaining both his prcvious opinions.
Social learning theory proposes techniques to stimulate and maintain changes through concrete action. This approach differs from the knowledgeattitude-behavior change model by starting with the opposing assumption that it is possible to change behaviors without previously having modified attitudes. Furthermore. it proposes that behavior change may cause a change in attitudes. This perspective maintains that in order for individuals to act in a different way. the) must learn new behaviors. These new behaviors, -in turn, will bring about beneficial conscquences for the individual which will induce a continuation of such behavior in the future. It is essential, from the standpoint of social learning theory. to provide a mode of new. desirable behavior. Learning the new behavior will occur as the individual experiences its consequences either in a direct form or indirectly by means of ‘vicarious learning’ or ‘modeling’ 131. Behavior change by means of modeling occurs through seeing. hearing, or reading about the process of the new behavior. The relevance that such an approach has to the use of mass media is obvious. The theory of modeling. as noted by Albert Bandura, also helps to explain how the media is able to cause behavior changes in individuals by demonstrating alternative behaviors. We shall see later how the axioms of this theory are being used by the public health campaigns that we will describe.
The theory of ditrusion of innovations focuses on identifying certain characteristics of both the sender and the receiver that are necessary to maximize communicating innovations. This theory defines an innovation as an exchange of an idea, a practice or an object perceived as new by the individual or by the community [4]. The innovative element of this idea can be :Inew understanding. a different attitude, or R decision regarding a different behavior. Some scholars believe that communication of innovation is much more effective when there is a high degree of empathy and similarity between sender and receiver. It is necessary to identify the opinion leaders in the community under study and to incorporate them as agents of change by involving them in the communication chain. In addition. this theory develops a classification of rates of adoption according to a series of psychological and sociological characteristics of receivers. The receivers. according to their rates of acceptance. are divided into innovators. early adopters. late adopters and laggards. In short. these are categories which identify the level of interpersonal communication involved in persuasion. When describing several campaigns of social communication below. it will be seen how the utilization of opinion leaders is fundamental
Impact
of mass commumcation
to projects that seek not only to achieve changes but also to maintain them on the level of complex behaviors. Behavior changes in the domain of health are generally complex. since they imply changes in the individual’s lifestyle. whether these be changes in diet, exercise. smoking, etc.
McGuire’s inoculation theory [2] is based on an analogy with the process of developing a biological resistance to a disease. This theory is concerned with resistance to social pressure for harmful behaviorsmoking. taking drugs and so on. McGuire maintains that healthy attitudes or behavior can be threatened by not knowing how to defend them against pressure for unhealthy ones. The process used to inoculate the individual consists of presenting the arguments that support the desired behavior, followed by a presentation of arguments used to promote the undesired behavior, followed in turn by answers refuting such arguments. APPLICATIOU COYCEPTS PCBLIC
OF SOCIAL I’v THREE HEALTH
(1) ,I4trss c,o,lli,lloiicutiorl
PSYCHOLOGY
CAMPAIGNS
OF
EDUCATIOU
und t/w preceritiou
of‘srtlokitly
The problem with smoking is that it is a complex behavior to modify and is embedded in a social background that works against the success of efforts to prevent it. In spite of the fact that satisfactory ways to prevent smoking have not yet been found, the majority of researchers in the field conclude that the concepts derived from social learning theory seem to be the most promising in relation to the problem of cigarettes. Social learning concepts have concentrated on trying to: (I) reduce the probability that one begins smoking: (2) increase the probability of stopping and engaging in alternative behavior [S]. Behavior like smoking tends to originate 21s imitations of role models. that is. imitation of people who are attractive or important to the individual. The early adopters as opposed to late adopters (to use the terminology of diffusion of innovations) are generally influenced by observing their parents. peers. models in the mass media or other significant persons. Starting smoking is then reinforced by peer approval and by mass media advertising. Smoking symbolizes daring and mature behavior for the adolescent. Once smoking is begun. the physiological dependence that the cigarette stimulates helps maintain it even after it has lost its original social attractiveness. The Harvard School of Public Health. in conjunction with the Heart Disease Prevention Program at Stanford University. has developed preventive social,’ psychological strategies to counteract the influences that Icad adolescents to begin smoking. These strategies are based in part on the theory of ‘inoculation’ against factors in the environment that are harmful to health. If we want the individual to resist the social equivalent of ‘infectious germs’. we can expose the individual to a weakened dose of such germs, with the aim of developing ‘antibodies’ (or the capacity to
campaigns
in the health
field
x9
resist the social pressure that leads to the adoption of harmful health behaviors). For example. if the adolescent runs the risk of being called a coward by refusing ;I cigarette. the objective of the inoculation is to prepare him beforehand to handle the stituation [6]. Strategies for this prevention are as much general asresponses to a sertlveness trammg c'I‘x developing specific situation. The training could include helping the adolescent prepare answers in advance. such as. “I’m a coward if 1 pay attention to you and smoke” or looking at ;I model figure who smokes and thinking. “if he were really such :I hot-shot he wouldn’t need to smoke to prove it”. This type of response can bc modeled by means of role-playing in groups of young people led by an opinion leader or bq means of movies that model similar situations. followed by discussions. In order to develop an effective prevention program it is not only necessary to develop the capacity to respond to social pressure, but it is also important to provide the adolescent with alternative behavior. There have been many in-depth studies on the motivations behind drug use and on alternative ways to satisfy such motivations. Generally. the alternatives developed can be synthesized in these categories 161: (1) physical activities that involve a risk; (2) activities that help to control tension or stress management: (3) alternatives related to the development of selfesteem and self-identity. In sum, the objective of these programs is to teach specific skills on both the mass and the interpersonal levels emphasizing the behavioral aspect. For example. instead of saying that cigarettes are harmful to health, the studies emphasize the use of exercises (and demonstrate easy exercises) or other ways to eliminate tension. Or. as preventive measures. these programs present typical situations where the adolescent is tempted to smoke and model actions that reject the behavior in a self-asserting way. In other words. these programs try to accept and understand the motivations behind smoking and they provide alternative behavior that also responds to that motivation. High school students who bvere exposed to social learning and inoculation intervention by the Harvard Public Health researchers were significantly less likely to begin smoking than were students in the control high schools. This was onI1 ;I short-term effect. however. Once the situation ended, many of the students in the experimental high schools began smoking, thus largely reducing the difference between the two groups of schools. This suggests that there may be severe limits to behavior change strategies that LISL' only an individual psychological approach. Perhaps ;I more societally based strategy is needed. It is interesting to observe how the initiation of smoking has been declining recently in the United States. This is explained in large part bj the existence of a social setting that is beginning to favor not smoking [7]. This setting includes some of the following factors: (I) the prohibition since 1971 of any advertising of cigarettes over either radio or television; (2) the requirement that each pack of cigarettes and printed cigarette advertisement include a warning that cigar-
ettc smoking is harmful to one‘s health; (3) the change that has occurred in model characters in movies and television. T.V. series or movies that once showed the hero or heroine smoking as a sign of sophistication now show the villain of the picture as the smoker [X]: (4) regulations that separate smokers and nonsmokers in public places such as restaurants. theaters. airplanes and buses. No one likes to feel discriminated against and these separations are a constant sign of disfavor to the smoker or to those who might COIIsider smoking: (5) tinally. the media constantly publicizes new studies that demonstrate the relationship between smoking and heart discase. cancer and other fatal ailments. Thus we can see how the individual experimental level of prevention and cessation of smoking that we described previously. joined with a social setting that increasingly rejects smoking, is giving positive results in the control of this phenomenon in the United States.
A .i-year project to prevjent alcoholism WIS carried out by the University of California. Berkeley. The objective was to reduce alcohol consumption and the problems created by this consumption 191. One set of communities received a series of mcssages by means of the mass media and another set of communities was selected as a control group and was not exposed to the campaign. The expected results were that the campaign would produce an increase in the lcv~elof knowledge and concern about the dangers of excessive alcohol consumption and alcoholism. It was also expected that there would be a change in attitudes and some behavior change in the direction of drinking less. The material developed for the media was based on a positive theme: “Winners Quit While They Are Ahead”. A second theme. “Beware: Excessive C‘onsumption of Alcohol Can Be Harmful to Your Health and Happiness”. w’as rejected after the first year when evaluation disclosed that the positive theme was more effective. The chosen name of “Winners Quit While They Are Ahead”. promotes moderation in alcohol consumption. relating this moderation to compensations such as an increase in self-esteem and the acceptance of one’s peers. Spots and public service messages using this theme were designed and disseminated by radio, television. billboards and posters on buses. The results of this campaign demonstrated from the beginning the difficulty of achieving the proposed goals, The attitudes and behaviors that favor alcohol consumption are very powerful and difficult to combat. Drinking is encouraged by many institutions and social customs. A prevention program. moreover. is at a decided economic disadvantage in comparison to the liquor companies, who virtually saturate the market with sophisticated advertising promoting drinking. A second difficulty was that the campaign‘s messages themselves were often not understood by the intended audience. In fact during the tirst year, several of the broadcast spots were interpreted as encouragements to drinking. For example, one of the spots showed a couple in a restaurant. eating and talking
animatedly. It can bc seen that they have been drinking (their glasses are almost empty). The man tries to till the woman’s glass and she puts her hand over the glass. preventing the young man‘s action. The two continue to converse and laugh animatedly. The purpose of the message was to model the behavior of rejecting a second glass. by showing that one can continue to have an enjoyable evening while rejecting exccssivc alcohol. This message was understood as pro-alcohol by 44”,, of the sample. who confused it with the advertising of a brand of wine. Fortunately. due to the formative evaluation carried out during the campaign, this problem could be remedied. However, the campaign as a whole was a mixed success. The final evaluation found that 80”,, of the sample recognired and was in agreement with the campaign slogan, and that the message was correctly interpreted by 70”,, of the sample. But changes of attitudc or behavior were not obtained. In other words neither drinking patterns nor intentions to drink were significantly reduced. It is necessary to add that. the social setting around alcohol is not as negative a connotation as that of smoking. An analysis of the content of national prime time television programs found that the numhcr of situations in which people are shown drinking exaggerates the actual level of consumption, In real life. alcoholic beverages are the fourth most popular drink, behind water. coffee and tea and soft drinks. On T.V.. the consumption of alcoholic beverages is in first place. followed by coffee, soft drinks and water [IO]. No social sanctions inhibit alcohol use in contrast to the widespread dislike of tobacco smoke and the well-established belief that smoking is a health haxnrd. The opposite case is the norm. To many people. alcohol is almost a necessary condition in any social interaction. whether it be business. pleasure or travel. Finally. modcrate drinking is often considered harmless or perhaps even beneficial to one’s health.
Finally, UC will look at a mass communication project that used a variety of methods to achieve hehavior. attitude and knowledge changes in entire communities: Stanford University’s Heart Disease Prevention Program. The Stanford Heart Disease Prevention Program is one of the largest preventive medicine research efforts in the United States. The annual education budget alone is $1.5 million [I I]. The study begins with the premise that the majority of deaths or life-threatening incidents from premature heart attacks can be prevented if lifestyles are modilied. According to the American Heart Association, the LISA of cigarettes. excessive consumption of certain foods (especially those high in fat. cholesterol. salt and sugar). excessive weight. lack of exercise. high blood pressure and tension are factors that increase the risk of heart attacks but which can be controlled [I I]. The first phase of this project began in 1972 and ended in 1975. This phase. called “The Three Community Study”. demonstrated that people can be motivated to change their health habits by information disseminated via the mass media combined bith strategies of interpersonal communication. Residents of tuo small California towns selected as the experimental communities. were exposed to a heavy
Impact
of mass communication
barrage of information on heart disease and on methods to change harmful behavior. This information was disseminated in newspapers. radio, television, posters. calendars and printed material sent through the mail. In addition. people in one of the two experimental communities who were considered to be particularly susceptible to heart disease received intensive interpersonal training. The control community did not receive any kind of information. Throughout the entire study the risk factors of the population in the three communities being studied w’ere checked several times. The results of this first phase showed positive changes in the experimental communities in relation to the control community. The experimental communities achieved a 20’?,, reduction in the total risk index in comparison with the control population, (This index includes changes in blood pressure. obesity, cholesterol levels. consumption of fats and smoking.) The changes were significantly greater in the community where interpersonal instruction was added to the mass media campaign [ 121. Dietary changes were very significant. For example there was a 44”:, decrease in egg consumption in the ‘combined‘ community and a 337, decrease in the mass media only experimental community, compared to lh”~,,decrease in the control community [I 11. Dratnatic reductions in the consumption of cholesterol were also obtained. In general, dietary changes were much more successful than changes in either smoking or exercise. The second phase of the project (currently in progress in five cities) includes measurement of the risk factors evaluated in the first phase plus detection of changes in the number of heart attacks and changes in mortality and morbidity related to heart disease. Changes in the risk factors of the population of these communities as well as changes in the percentages of heart attacks are being measured. Thus this second stage of the study adds the measurement of actual heart disease and death from heart disease during the 5-year period to the measurement of changes in risk factors only obtained in the j-year study. This study was begun in 1980 and will continue until 1986 [l3]. The communication strategies used in this phase include a stronger multi-media campaign than during the first study. Public service announcements by T.V. and radio, weekly articles published in local newspapers. frequent television documentaries, books and pamphlets, were mass media utilized. The five-community study also incorporates a stronger component of interpersonal communication. carried out through the participation of community organizations and health professionals. This component is not only used with a sub-sample of high risk population within one experimental community as in the three-community study. but it is incorporated for the whole experimental communities. The interpersonal communication aspect emphasizes the training of skills (e.g. how to reduce tension). The project has stimulated the introduction of changes at the institutional level (e.g. classes to quit smoking; weight control classes in different locations in the communities). In addition, a health education specialist has been hired to coordinate and promote programs on preventing the use of
campaigns
in the health
iield
91
cigarettes and nutrition education programs in high schools. The project expects to create in the communities a shared atmosphere that: (I) stimulates people to think about health care without fear; and (2) provides a program that details the process of helping to affect specific behavior changes in diet and lifestyle. The participation of the community is important to keep the educational programs going after the study ends. An important objective of the Stanford Project is the maintenance of the behavior changes that have been obtained. The Project uses a model of community intervention. that is, its objective is to achieve behavior changes in the population in the setting where the people live and not in a clinical environment [14]. It is trying to affect a multitude of factors that comprise the social risk setting with respect to heart disease. The Project is using a communication focus based principally on Bandura’s social learning theory to introduce behavior changes via the mass media, comand interpersonal relations. munity organizations, The significance of the use of Bandura’s model is that in teaching useful skills to the individual for the modification and control of his own behavior. it has served as a basis for the multi-media and interpersonal strategy approach of the Stanford Project [ 151. Bandura’s theory allows for the teaching of skills by means of modeling behaviors through auditory systems (like radio and cassettes), visual systems (like slides. pamphlets, highway billboards, posters etc.), and audiovisual systems (like movies and T.V.). For example, a scene that shows a family picnic can suggest through its images the type of foods to be taken in a picnic basket when a family is preparing to go on the picnic. The applicability of social learning theory to the design of mass communication messages makes possible, at least potentially. the design of behavior change campaigns at the community level. While it is true that Bandura’s approach attains its greatest effectiveness in interpersonal training situations. the cost of such situations is so high that it makes an intervention to change behavior on the level of entire communities unthinkable. The Stanford Project demonstrates that certain behavior changes. especially if these are simple, are possible by means of mass communication For example, significant dietary changes were a positive result due principally to the mass media campaign. One of the problems with the use of mass communication to achieve behavior changes like stopping smoking or changing a sedentary lifestyle to an active one is that these changes imply the moditication of ingrained and complex behaviors. The acquisition of skills to change complex behaviors is more likely when there can be permanent feedback on the results of practicing the new behaviors. a dimension lacking in mass communication techniques. Although the nature of mass communication does not allow for immediate feedback, it can provide the initial model as well as stimulate the development of systems organizations and support community necessary for the existence of supervised individual practice.
An intervention similar to Stanford’s was used in a community in Finland called North Karelia. This community of 180.000 inhibitants enjoyed the dubious fame of having the highest incidence of heart disease in the world. The project lasted 6 years with very positive results. For example, the rate of heart attacks decreased from 1.6 per 1000 adult men to 1.9 in 4 years. and from 2.8 to I.9 in women. Changes in risk factors were also significant. This project cost much less than Stanford’s, with an average of $1.50 per capita per year, with substantially greater st~cccss. This advantage of the North Karelia project is attributed to a central emphasis on participation of the entire community in the project. In this sense the North Americans must function within a more individualistic and less organized institutional system that serves the public welfare [ 161. DISCUSSION It is useful to conclude with a brief analysis of some of the advantages and limitations of mass media educational campaigns. Paul Lazarsfeld and Robert Merton argue that three conditions determine the impact of mass communication in any given situation : monopolization. channeling and supplementation [ 177. Monopolization occurs when contrary communications do not reach the audience, which instead is exposed only to messages furthering a single point of view. This situation obviously does not occur in many societies with respect to smoking, drinking. diet and other areas of individual behavior. Indeed. the mass media often present undesirable role models: attractive. prestigious people who smoke and drink. Channeling means that, instead of trying to achieve new attitudes and behavior that are antagonistic to those already accepted in the audience. the message instead tries to divert the audience by diverting existing predispositions in a slightly different direction. Mass communication shows how a certain product or service can satisfy an already existing desire in the audience. Advertising can be a good example of channcling when it tries to make the individual choose a specific product of something that he has already decided to LISL”anyway. In the health field this would be the situation when an individual already possessess the commitment to stop smoking and what he needs is to choose between several courses of action for achieving this. A third social condition for impact of mass communication is supplementation: mass communication serves as a supplement to interpersonal communication that already occurs. The Stanford and North Karelia studies used supplementation strategies. Consistent with this typology, the studies show that in general the role of mass communication is the reinforcement. not the change, of existing attitudes and behaviors, Through the mechanisms of selective perception and selective exposure. audiences internalize those messages that reinforce preexisting values and behaviors. There is agreement in the literature that mass communication can be effective in increasing the level of information about a subject. which does not mean that it has an effect of attitude or behavior change. McCoombs suggests that the principal func-
tion of media is agenda setting: in other words. media emphasize the importance of certain subjects and remind us of their existence [IX]. This pessimism about the value of mass communication to achieve behavior change is partially refuted by the application of Bandura’s concepts. whtch often has facilitated behavior change. As we have seen in this paper, it is possible to achieve small behavior changes by means of modeling I new and simple bchavior and by concentrating on the process of how to carry out this new behavior. But it is also true that these changes tend to occur in people who have previously recognized and accepted the need for changes and these are not always the ones most urgently in need of the change. An important limitation of the mass media as an instrument of change comes from the very nature of media: there is no opportunity for active audience participation or immediate feedback. Studies show’ consistently that the active participation of the receiver in an interactive process is much more effective for achieving and maintaining educational objectives (whether these be behavior or attitude changes) than is a passive role. The use of community organizations and the maximization of interpersonal communication are ways in which social communication campaigns can increase their effectiveness in a significant manner. in addition to providing the necessary help for the individuals to maintain the new behavior. This could be appreciated in the Stanford and North Karelia projects. Another way to maximize the impact of social communication is by achieving a closer collaboration between producers and researchers during the planning, implementation and evaluation of the campaigns. Given the impossibility of immediate feedback on the part of the receiver. an evaluation throughout the campaign is fundamental in providing this feedback in order to redefine the messages and objectives of the campaign. A longitudinal research focus is also necessary in order to see how long the results last. Another limitation of campaigns of social communication is that they,operate either not taking into account or in compctttton with the social context of the individual. Not taking into account the social context refers to the fact that many of these campaigns that take the individual as the object of change do not consider the socioeconomic. cultural and cnvironmentnl elements surrounding these individuals. The social context remains unchanged and does not support the individual’s behavior change. When 1 say in competition with the cnvironmcnt. I refer to the fact that these campaigns frequently operate in a disadvantageous situation with respect to those who promote the behaviors that arc considered harmful. A health campaign is an isolated and specific act with respect to a continuous current of advertising that relies on economic resources and an infrastructure that are much more powerful than those of the campaign in question. It is for this reason that only in a context favorable to behavior change can one hope for significant results.
Impact
2. 3. 4. 5.
6.
7.
8.
9.
of mass communication
Co,t~,l~lrr~ic,trriurl(Edited by Schramm W. and Roberts D.). University of Illinois Press. 1972. Insko C. Theories of Arritutir Churl~/e. Prentice-Hall, Englewood Cliffs. NJ. 1967. Bandura A. Socicll Lrurrli!lc/ Tkeory. Prentice-Hall. Englewood Cliffs. NJ. 1977. Rogers E. and Shoemaker F. Cor,lrllur2i~.urior1 (tf Iwwcurio,,s. The Free Press. New York, 1971. McAlistair A. Mass communication of cessation counseling: combining television and self-help groups. Intwwriorltrl Co+wwr 011 Su7okimq. 197X. McAlistair A.. Perry C. and Maccoby N. Adolescent smoking: onset and preventlon. Prdiutrics 63. 650-658, 1979. Syme S. L. and Alcalay R. Social influences on smoking behavior. In Awutrl Rrcirw of Public Hrulth (Edited by Breslow L.). Vol. 3. 1982. Gerbner G. Gross L.. Morgan M. and Signorelli N. Health and medicine on television. ,Verc Em//. J. %f&. 305. YOI-904. 19x1. Wallack L. 7 iw Colifornitr Pwwrrtim Dwwmtrutior~ P,oqrtrm Ertriutrtior~: Descriptim. iwg.~ Alcohol Rcscarch Group.
Methods
md
campaigns
12. 13.
14.
15.
16. 17.
FirId-
Berkeley, 1979. IO. Breed W. and De Foe J. The portrayal of the drinking process on prime time T.V. J. Cowlur~. 31. 58~ 67, 19x1. I I. Maccoby N. Farquar J.. Wood P. and Alexander J.
IX.
in the health
field
93
Reducing the risk of cardiovascular disease. J. Com,nutlir. Hlth 3, Winter, 1977. Hofstadter L. The heart fixers. Tllr Stmfbrti Mu~qtciw 9, Winter, 1981. Maccoby N. and Solomon D. Heart disease prevention community studies. In Public Cornnamicutron Ctrrw pctiqns (Edited by Rice R. and Paisley W.). Sage Beverly Hills, 1981. Maccoby N. Promoting positive health behavior in adults. In Competewe md Copimg duri,q Adulthood (Edited by Bond L. A. and Rosen J.). University Press of New England. Hanover, NH, 1980. Maccoby N. and Alexander J. Use of media in lifestyle programs. In Brhtrriorul Mrdicirw: Chyirq Hrtrlth Lijestyles (Edited by Davidson P. 0. and Davidson S. M.). Brunner,‘Mazel, New York. 1980. Breslow L. Risk factor intervention for health maintenancc. Scirwe 200, 1978. Lazarsfeld P. and Merton R. K. Mass communication, popular taste. and organized social action. In T/w Procc’.t.s urld Eficrs of 121tr.ss Corllr,tlr/iic,trtro,1 (Edited by Schramm W. and Roberts D.). University of Illinois Press, 1972. McCoombs M. E. and Shaw D. L. The agenda setting function of the mass media. P&l. Upin. Q. 36, l97- 187. 1972.
Resumen--Este articulo analizn una serie de proyectos de educacihn en salud realizados en 10s Estados Unidos cuyo objetivo ha sido lograr cambios a nivel de conocimiento. actitud. y conducta en la poblacibn a trnv&s dcl uso de medios de comunicaci6n social. El articulo comiewa destacando las diferentes ;ireas comprendidas en el estudio de las comunicaciones. lireas derivadas de las siguientes cinco preguntas del proceso de comunicacicin: ;.Qui&? iDice q&l ;,A trnvCs de quC canal? ;,A quiCn’? LCon quC efecto? Este trabajo se concentra en la tiltima interrogante, o sea. en 10s efectos de la comunicaci6n y en la utilizaci6n de teorias de persuasi6n para la maximizaci6n de1 impact0 en campaiias de comunicaci6n masiva. En segundo lugar se presentan teorias de psicologia social cuyos marcos teciricos son utilizados por campafias de comunicacicin. Las teorias mds utilizadas por proyectos de comunicacidn masiva en el lirea de salud pilblica son: (I) la teoria de disonancia cognitiva; (2) la teoria de aprendizaje social: (3) la teoria dc difusii,n de innovaciones: y (4) la tcoria de inoculaci6n social. La teoria de disonancia cognitive nspira a lograr cambios conductualcs creando disonancia a nivel de conocimientos. opiniones. y creencias. La tcoria de aprendizaje social. principalmente desarrolada por Bandura. persigue lograr cambios conductualcs a travCs de1 modelamiento de nuevas conductas v de sus consecuencias. La teoria de difusihn dc innovaciones aporta una taxonomia titil para ideniificar y utilizar la red de rclaciones interpersonales en una comunidad. Este proceso de identificacibn de lideres de opini6n y redes de relacionea es necessario pnra la adopcibn de una innovacidn. La teoria de inoculaci6n desarrollada por McGuire tiene por objective maximizar resistcncias contra la presihn social conducente a iniciar conductas nocivas para la salud. Esta teoria sugiere estrategias de inmunizacibn de 10s individuos para rwatir infiuenclas del medio ambiente que se quieren cvitar. En tcrccr luger, estc trabajo rcwsa campaiias de educacidn en salud pliblica que han utilizado uno o mds de cstos cnfoques. Estos progectos de educaci6n en salud fueron seleccionados tanto por el contenido dcl quc tratan coma por las estrategias comunicntivas quc utilizan. A pesar de haberse desarrollado cn Ios Estados Unidos. estas campaiias tratan con factores de riesgo a la salud muy importantes en el lirea de aalud preventiva tanto en el continente americano coma en el europeo. Estas campaiias utililaron diferentes estrategias comunicativas para cl logro de sus objectives. El primer proyecto. de prevencibn 1 cesacibn del hibito de fumar en 10s adolescentes. utiliz6 principalmente estratcgias de comunicacihn interpersonal a travCs del modelamiento de conductas Stiles para resistir presiones sociales favorables al hlibito de fumar. Por medio de reuniones en grupos orientados al entrenamiento de ascrtividad dc la personalidad en general y al entrenamiento de repuestas a situaciones concretas. se modelaron situaciones reales de presidn social para fumar. Este proceso tuvo por objective inmunizar a 10s sujctos contra un context0 social quc favorece la conducta de fumar. Rcsultados dc esta campaiia fucron positivos ya quc 10s grupos experimentales mostraron una disminucidn signiticantiva cn la iniciacicin de conducta dc fumar en comparacicin a grupos dc control no expuestos a la intervencicin comunicativa. Estos resultados fueron significativamente diferentes a corto plaza. Despu(ls dc un aiio 10s grupos experimentales y de control deJaron de diferenciarse signiticativamentc. Eatc resultado demuestra que una intervencidn comunicacional aislada quc ocurre en un contexto social que favorece la conductn de fumar no ticne Cxito a largo plaza. El Segundo proyecto desarrolo un programa de prevencibn y cesacibn de alcohohsmo en poblacibn adulta 4 de adolescentes. Este proyecto utllizb primordialmente la televisi6n coma medio de comunicaclan ) spots publicitarios anti-alcohol coma format0 de cxpresitin de 10s mensajes. El objective de esta campaiia fuc la obtenci6n de cnmbios a nivel de conocimiento. actitud y conducta en la poblacibn a travL:s dc modclamicnto de conductas desenbles por medio de spots publicitarios. La campatia logrb
94
RIKA AKALAY
aumentar cl nivel de conciencia acercn de 10s pehgros asociados con cl abuse de alcohol pero no logrci cambios conductuales en la poblaci6n experimental. o sea no se produjo una disminucidn del consumo de alcohol ni una intencidn de hacerlo en lx comunidades experimentales. Estos resultados confirman la limitacidn de 10s medios de comunicacihn masiva coma inkadores de cambios conductuales. La tercera campatia analizada en este articulo two coma objetivo la prevenci6n de enfermedades al corazbn en un conjunto de comunidades en California. Este proyecto utiliz6 una combinacidn de medios de comunicaci6n masiva y medios de comunicaci6n interpersonal para lograr cambios dc cstilo de vida en comunidadcs enteras. Los factores de riesgo asociados con enfermedades al corazbn fueron: cl consumo de cigarrillos. el exceso de ciertos alimentos (con alto contemdo de grasas. colesterol, sal 1 azlicar), el exceso de peso. la falta de activadad fisica, la alta presidn de la sangre 4 la tensi6n. La campaiia desarrolk una serie de estrategias comunicatlvas oricntadas a disminuir estos factores de riesgo. Los resultados demostraron cambios significativos en conductas alimenticias especlalmente en I:I reducci6n del consume de huevos y consumo de colesterol. Menos Cxito se obtuvo en relnci6n a cambios de conductas de fumar o hibitos de vida sedentaria. Por tiltimo este articulo plantea algunos alcances y limitaciones en el uso dc medios de comunicacihn social en programas de cambio conductual para cl hrea de salud. El an&is de estas campaiias sugiere que 10s medios de comunicaci6n masiva alcanzan mayor impact0 cuando son utilizados coma suplementaci6n a medios de comunicaci6n interpersonal y organizacibn comunitaria. En Segundo luger 10s estudios demuestran que cn general 10s medios de comunicacihn refuerran actitudcs y conductas existentes en vez de promovcr cambios. Un tercer obstkulo con campalias masivas en el Area de salud es clue operan ignorando o compitiendo con el entorno social de 10s indlviduos. Frecuentemente el entorno social del indlviduo promueve conductas nocivas para la salud (por ejemplo. propaganda de cigarrillos. de bebidas alcohdlicas, y de alimentos sin valor nutritivo). Por illtimo es importante tener en cuenta un alcance de tipo etico respecto a la utilizacicin de medios de comunicacicin con fines persuasivos. Es precise utilizar 10s medios no con fines manipulativos sino con el objective de aumentar Ins oportunidades y opciones de las personas y obtener la participaci6n de las comunldades cn 10s programas de salud desarrollados.
IMPACT
CAMPAIGNS
OF
MASS
IN THE RIXA
520 Warren
Hall. School
of Public
Health.
COMMUNICATION HEALTH
FIELD*
ALCALA~
University
of California,
Berkelq,
CA 94720. U.S.A
Abstract --This
article analyzes a series of health education projects that used the mass media to change behavior. First, the article dcscrihes how persuasion theories arc used to ma*lmi/e impact in mass communication campaigns. Second. this paper discusses theories of social psychology used in such campaigns. One such theory. cognitive dissonance. explains changes at the level of attitudes. beliefs and opinion. Another theory. social learning. defines strategies of behavior changes. A third theor\, concerning diffusion of innovations. helps understand the network of interpersonal relatlonshlps cssentlal for the adoption of any innovation. McGuire’s inoculation theorq suggests strategies to aid rcsistancc to harmful environmental inHucnccs (e.g. smoking. excessive drinking. etc.). Third. this mark rc\icws public health campaigns that have used one or more of these theories of social psycholog). The first project. dealing with smoking behavior cessation and prevention. mainlq used strategies of intcrpcrsonal communication for inoculating and modeling useful behavior in order to resist social prcssurcs favorable to smoking. The second project. designed to prevent alcoholism. used the mass media primarily. The objective of this campaign was to obtain changes in knowledge, attitude and behavior in the puhllc through modeling desirable behaviors over public service announcements. The third campaign. ;I heart disease prevention program. used a combination of mass media and interpersonal communication to achieve changes in lifestyle of the population. Finally. this article describes limitations in using mas\ media in behavior change health programs.
These projects were based on theoretical concepts drawn from social psychology. The following pages provide: (I) some background on these theories: (2) an analysis of the three projects; and (3) ;I discussion of some of the limitations in the use of mass mcdi:l for health education revealed by these projects.
is an increasing awareness of the importance of preventive health care. Preventive health care can decrease dramatically the risk of disease and thus can save significant human and economic resources. Yet effective preventive health behavior is still fur from a reality in most societies. In most modern nations a great many people smoke. drink excessively. eat nonnutritious food. practice poor sanitation. get insufticient exercise and so on. Effective preventive health measures demand the combined efforts of individuals. communities and health and social organizations. Almost all countries today acknowledge the importance of health education and engage in some form of mass communication effort. Different countries have different priorities regarding which health issues need to be stressed. Nevertheless health education. which increases awareness and can change attitudes and behavior. has been shown to reduce health risks significantly. This article describes three major preventive health education projects conducted recently in the United States. These prqjects were chosen because they deal with major barriers to effective preventive health not only in the United States, but also in other North American. Latin American and European countries. Although the three projects arc oriented toward mass communication. each one has II different emphasis: one is based mostly on interpersonal and group communication, a second used television almost entirely, while the third used :I multi-media approach. There
*I
The field of social communication is not just II specific discipline, but it also drawls on ;I variety of interdisciplinary fields whose focus is tither on one or more communication elements. or on the relationship between ;I series of such elements found in the process of communication. Lasswell [I] said that the study of any communication could be pursued with these well-knoun questions: Who’? Says what’? By hhat channel’! To whom’? With &hat effect‘? Each of these questions determines an ‘area’ or an ‘element’ within the phenomenon of mass communicition. ‘ The first question. ‘Who?‘. concerns the study of the source. Studies of this component have concentrated on the control of the mass media. Disciplines like political science or sociology have lent their thcorctical frameworks and methods to this study. The question. ‘Says what?‘, has given rise to the study of messages through content analysis and semiology. The question. ‘By means of Lvhat channel?‘. is expressed in the study of the medium itself. the concern with identifying those elements that differentiate. for example, radio from television from newspapers. and with selecting the medium most appropriate to each project. The writing of Marshall McLuhan and
wish to acknowledge the comments of Raymond E. Wolfinger. In addition I want to thank Susan Knapp for translating this paper from Spanish. This artxle 1s based on a paper presented at the third meeting of Asociacib Latinamericana de Modificacibn de la Conducta. Santiago. Chile. 19X 1. 87
his theory that the ‘medium is the message’ represent this line of thinking. The question, ‘To whom?‘, gives rise to studies of the audience. The question is concerned with identifying and classifying the receivers in accordance with the categories relevant to the objectives of the study. Finally, the question, ‘With what effect?‘, refers to the impact that the messages have on the audience. Studies on the ctrects of communication comprise this area of study. while impact campaigns use theories of persuasion aild attitude change. It is here. in the efforts to maximize impact. that the areas of mass communication and social psychology coincide. Every communication campaign seeks in some measure to achieve a change in the receiver either in knowledge. attitude or in behavior. In fact. achieving behavior change is the ultimate objective of the majority of communications campaigns in the health field. However. this objective is not always expressed in an explicit form. Most campaigns seek to increase knowledge or to change attitudes, assuming that behavior will change as a consequence. This widely held belief-that an increase in the level of knowledge will effect an attitude change which will in turn cause later behavior changes--- is now being questioned by researchers. SOCIAL
PSYCHOLOGY
HEALTH
THEORIES
EDUCATION
USED IN
CAMPAIGKS
In the following pages, I will review the principal theories that have served as a foundation for communication campaigns. The theories are intended to explain behavior: they do not themselves change behavior. First. I will look at the family of closely related theories concerned with the consequences of ‘inconsistent’ or unharmonious knowledge and attitudes: cognitive dissonance, cognitive balance and so on. Second, I will consider some implications of social learning theory. which explains a behavior change as a consequence of vicarious learning achieved through exposure to models who demonstrate the desired behavior. Third, I will evaluate studies of the networks of interpersonal communication through which innovations are diffused to people who make use of them. And finally, I will analyze McGuire’s theory of inoculation which provides individuals with immunization strategies to resist harmful emotional inlluences (e.g. smoking, alcoholism). These theories have been of critical import to the field of mass communication as shown by the fact that they have provided the theoretical basis for the design of innumerable campaigns of mass communication through mass media, as much in the area of health as in other areas of education.
The assorted dissonance (or balance, or consistency) theories all assume that people are made uncomfortable when various elements of their perceptual fields are inconsistent with each other [Z]. For example. a professor who moves from Harvard to Yale will be made uncomfortable by, evidence that Harvard is prospering. or that Yale IS not. We say that he ‘reduces dissonance’ by his willingness to think poorly of his old school and favorably of his
new one. If an individual admires a public figure and that ligure says something repugnant to the individual. dissonance is said to result, Because dissonance is a source of discomfort. the individual handles it by changing his mind about the topic of the remark. by thinking less of the public figure. or by mispcrceiv)ing what the figure said. thus maintaining both his prcvious opinions.
Social learning theory proposes techniques to stimulate and maintain changes through concrete action. This approach differs from the knowledgeattitude-behavior change model by starting with the opposing assumption that it is possible to change behaviors without previously having modified attitudes. Furthermore. it proposes that behavior change may cause a change in attitudes. This perspective maintains that in order for individuals to act in a different way. the) must learn new behaviors. These new behaviors, -in turn, will bring about beneficial conscquences for the individual which will induce a continuation of such behavior in the future. It is essential, from the standpoint of social learning theory. to provide a mode of new. desirable behavior. Learning the new behavior will occur as the individual experiences its consequences either in a direct form or indirectly by means of ‘vicarious learning’ or ‘modeling’ 131. Behavior change by means of modeling occurs through seeing. hearing, or reading about the process of the new behavior. The relevance that such an approach has to the use of mass media is obvious. The theory of modeling. as noted by Albert Bandura, also helps to explain how the media is able to cause behavior changes in individuals by demonstrating alternative behaviors. We shall see later how the axioms of this theory are being used by the public health campaigns that we will describe.
The theory of ditrusion of innovations focuses on identifying certain characteristics of both the sender and the receiver that are necessary to maximize communicating innovations. This theory defines an innovation as an exchange of an idea, a practice or an object perceived as new by the individual or by the community [4]. The innovative element of this idea can be :Inew understanding. a different attitude, or R decision regarding a different behavior. Some scholars believe that communication of innovation is much more effective when there is a high degree of empathy and similarity between sender and receiver. It is necessary to identify the opinion leaders in the community under study and to incorporate them as agents of change by involving them in the communication chain. In addition. this theory develops a classification of rates of adoption according to a series of psychological and sociological characteristics of receivers. The receivers. according to their rates of acceptance. are divided into innovators. early adopters. late adopters and laggards. In short. these are categories which identify the level of interpersonal communication involved in persuasion. When describing several campaigns of social communication below. it will be seen how the utilization of opinion leaders is fundamental
Impact
of mass commumcation
to projects that seek not only to achieve changes but also to maintain them on the level of complex behaviors. Behavior changes in the domain of health are generally complex. since they imply changes in the individual’s lifestyle. whether these be changes in diet, exercise. smoking, etc.
McGuire’s inoculation theory [2] is based on an analogy with the process of developing a biological resistance to a disease. This theory is concerned with resistance to social pressure for harmful behaviorsmoking. taking drugs and so on. McGuire maintains that healthy attitudes or behavior can be threatened by not knowing how to defend them against pressure for unhealthy ones. The process used to inoculate the individual consists of presenting the arguments that support the desired behavior, followed by a presentation of arguments used to promote the undesired behavior, followed in turn by answers refuting such arguments. APPLICATIOU COYCEPTS PCBLIC
OF SOCIAL I’v THREE HEALTH
(1) ,I4trss c,o,lli,lloiicutiorl
PSYCHOLOGY
CAMPAIGNS
OF
EDUCATIOU
und t/w preceritiou
of‘srtlokitly
The problem with smoking is that it is a complex behavior to modify and is embedded in a social background that works against the success of efforts to prevent it. In spite of the fact that satisfactory ways to prevent smoking have not yet been found, the majority of researchers in the field conclude that the concepts derived from social learning theory seem to be the most promising in relation to the problem of cigarettes. Social learning concepts have concentrated on trying to: (I) reduce the probability that one begins smoking: (2) increase the probability of stopping and engaging in alternative behavior [S]. Behavior like smoking tends to originate 21s imitations of role models. that is. imitation of people who are attractive or important to the individual. The early adopters as opposed to late adopters (to use the terminology of diffusion of innovations) are generally influenced by observing their parents. peers. models in the mass media or other significant persons. Starting smoking is then reinforced by peer approval and by mass media advertising. Smoking symbolizes daring and mature behavior for the adolescent. Once smoking is begun. the physiological dependence that the cigarette stimulates helps maintain it even after it has lost its original social attractiveness. The Harvard School of Public Health. in conjunction with the Heart Disease Prevention Program at Stanford University. has developed preventive social,’ psychological strategies to counteract the influences that Icad adolescents to begin smoking. These strategies are based in part on the theory of ‘inoculation’ against factors in the environment that are harmful to health. If we want the individual to resist the social equivalent of ‘infectious germs’. we can expose the individual to a weakened dose of such germs, with the aim of developing ‘antibodies’ (or the capacity to
campaigns
in the health
field
x9
resist the social pressure that leads to the adoption of harmful health behaviors). For example. if the adolescent runs the risk of being called a coward by refusing ;I cigarette. the objective of the inoculation is to prepare him beforehand to handle the stituation [6]. Strategies for this prevention are as much general asresponses to a sertlveness trammg c'I‘x developing specific situation. The training could include helping the adolescent prepare answers in advance. such as. “I’m a coward if 1 pay attention to you and smoke” or looking at ;I model figure who smokes and thinking. “if he were really such :I hot-shot he wouldn’t need to smoke to prove it”. This type of response can bc modeled by means of role-playing in groups of young people led by an opinion leader or bq means of movies that model similar situations. followed by discussions. In order to develop an effective prevention program it is not only necessary to develop the capacity to respond to social pressure, but it is also important to provide the adolescent with alternative behavior. There have been many in-depth studies on the motivations behind drug use and on alternative ways to satisfy such motivations. Generally. the alternatives developed can be synthesized in these categories 161: (1) physical activities that involve a risk; (2) activities that help to control tension or stress management: (3) alternatives related to the development of selfesteem and self-identity. In sum, the objective of these programs is to teach specific skills on both the mass and the interpersonal levels emphasizing the behavioral aspect. For example. instead of saying that cigarettes are harmful to health, the studies emphasize the use of exercises (and demonstrate easy exercises) or other ways to eliminate tension. Or. as preventive measures. these programs present typical situations where the adolescent is tempted to smoke and model actions that reject the behavior in a self-asserting way. In other words. these programs try to accept and understand the motivations behind smoking and they provide alternative behavior that also responds to that motivation. High school students who bvere exposed to social learning and inoculation intervention by the Harvard Public Health researchers were significantly less likely to begin smoking than were students in the control high schools. This was onI1 ;I short-term effect. however. Once the situation ended, many of the students in the experimental high schools began smoking, thus largely reducing the difference between the two groups of schools. This suggests that there may be severe limits to behavior change strategies that LISL' only an individual psychological approach. Perhaps ;I more societally based strategy is needed. It is interesting to observe how the initiation of smoking has been declining recently in the United States. This is explained in large part bj the existence of a social setting that is beginning to favor not smoking [7]. This setting includes some of the following factors: (I) the prohibition since 1971 of any advertising of cigarettes over either radio or television; (2) the requirement that each pack of cigarettes and printed cigarette advertisement include a warning that cigar-
ettc smoking is harmful to one‘s health; (3) the change that has occurred in model characters in movies and television. T.V. series or movies that once showed the hero or heroine smoking as a sign of sophistication now show the villain of the picture as the smoker [X]: (4) regulations that separate smokers and nonsmokers in public places such as restaurants. theaters. airplanes and buses. No one likes to feel discriminated against and these separations are a constant sign of disfavor to the smoker or to those who might COIIsider smoking: (5) tinally. the media constantly publicizes new studies that demonstrate the relationship between smoking and heart discase. cancer and other fatal ailments. Thus we can see how the individual experimental level of prevention and cessation of smoking that we described previously. joined with a social setting that increasingly rejects smoking, is giving positive results in the control of this phenomenon in the United States.
A .i-year project to prevjent alcoholism WIS carried out by the University of California. Berkeley. The objective was to reduce alcohol consumption and the problems created by this consumption 191. One set of communities received a series of mcssages by means of the mass media and another set of communities was selected as a control group and was not exposed to the campaign. The expected results were that the campaign would produce an increase in the lcv~elof knowledge and concern about the dangers of excessive alcohol consumption and alcoholism. It was also expected that there would be a change in attitudes and some behavior change in the direction of drinking less. The material developed for the media was based on a positive theme: “Winners Quit While They Are Ahead”. A second theme. “Beware: Excessive C‘onsumption of Alcohol Can Be Harmful to Your Health and Happiness”. w’as rejected after the first year when evaluation disclosed that the positive theme was more effective. The chosen name of “Winners Quit While They Are Ahead”. promotes moderation in alcohol consumption. relating this moderation to compensations such as an increase in self-esteem and the acceptance of one’s peers. Spots and public service messages using this theme were designed and disseminated by radio, television. billboards and posters on buses. The results of this campaign demonstrated from the beginning the difficulty of achieving the proposed goals, The attitudes and behaviors that favor alcohol consumption are very powerful and difficult to combat. Drinking is encouraged by many institutions and social customs. A prevention program. moreover. is at a decided economic disadvantage in comparison to the liquor companies, who virtually saturate the market with sophisticated advertising promoting drinking. A second difficulty was that the campaign‘s messages themselves were often not understood by the intended audience. In fact during the tirst year, several of the broadcast spots were interpreted as encouragements to drinking. For example, one of the spots showed a couple in a restaurant. eating and talking
animatedly. It can bc seen that they have been drinking (their glasses are almost empty). The man tries to till the woman’s glass and she puts her hand over the glass. preventing the young man‘s action. The two continue to converse and laugh animatedly. The purpose of the message was to model the behavior of rejecting a second glass. by showing that one can continue to have an enjoyable evening while rejecting exccssivc alcohol. This message was understood as pro-alcohol by 44”,, of the sample. who confused it with the advertising of a brand of wine. Fortunately. due to the formative evaluation carried out during the campaign, this problem could be remedied. However, the campaign as a whole was a mixed success. The final evaluation found that 80”,, of the sample recognired and was in agreement with the campaign slogan, and that the message was correctly interpreted by 70”,, of the sample. But changes of attitudc or behavior were not obtained. In other words neither drinking patterns nor intentions to drink were significantly reduced. It is necessary to add that. the social setting around alcohol is not as negative a connotation as that of smoking. An analysis of the content of national prime time television programs found that the numhcr of situations in which people are shown drinking exaggerates the actual level of consumption, In real life. alcoholic beverages are the fourth most popular drink, behind water. coffee and tea and soft drinks. On T.V.. the consumption of alcoholic beverages is in first place. followed by coffee, soft drinks and water [IO]. No social sanctions inhibit alcohol use in contrast to the widespread dislike of tobacco smoke and the well-established belief that smoking is a health haxnrd. The opposite case is the norm. To many people. alcohol is almost a necessary condition in any social interaction. whether it be business. pleasure or travel. Finally. modcrate drinking is often considered harmless or perhaps even beneficial to one’s health.
Finally, UC will look at a mass communication project that used a variety of methods to achieve hehavior. attitude and knowledge changes in entire communities: Stanford University’s Heart Disease Prevention Program. The Stanford Heart Disease Prevention Program is one of the largest preventive medicine research efforts in the United States. The annual education budget alone is $1.5 million [I I]. The study begins with the premise that the majority of deaths or life-threatening incidents from premature heart attacks can be prevented if lifestyles are modilied. According to the American Heart Association, the LISA of cigarettes. excessive consumption of certain foods (especially those high in fat. cholesterol. salt and sugar). excessive weight. lack of exercise. high blood pressure and tension are factors that increase the risk of heart attacks but which can be controlled [I I]. The first phase of this project began in 1972 and ended in 1975. This phase. called “The Three Community Study”. demonstrated that people can be motivated to change their health habits by information disseminated via the mass media combined bith strategies of interpersonal communication. Residents of tuo small California towns selected as the experimental communities. were exposed to a heavy
Impact
of mass communication
barrage of information on heart disease and on methods to change harmful behavior. This information was disseminated in newspapers. radio, television, posters. calendars and printed material sent through the mail. In addition. people in one of the two experimental communities who were considered to be particularly susceptible to heart disease received intensive interpersonal training. The control community did not receive any kind of information. Throughout the entire study the risk factors of the population in the three communities being studied w’ere checked several times. The results of this first phase showed positive changes in the experimental communities in relation to the control community. The experimental communities achieved a 20’?,, reduction in the total risk index in comparison with the control population, (This index includes changes in blood pressure. obesity, cholesterol levels. consumption of fats and smoking.) The changes were significantly greater in the community where interpersonal instruction was added to the mass media campaign [ 121. Dietary changes were very significant. For example there was a 44”:, decrease in egg consumption in the ‘combined‘ community and a 337, decrease in the mass media only experimental community, compared to lh”~,,decrease in the control community [I 11. Dratnatic reductions in the consumption of cholesterol were also obtained. In general, dietary changes were much more successful than changes in either smoking or exercise. The second phase of the project (currently in progress in five cities) includes measurement of the risk factors evaluated in the first phase plus detection of changes in the number of heart attacks and changes in mortality and morbidity related to heart disease. Changes in the risk factors of the population of these communities as well as changes in the percentages of heart attacks are being measured. Thus this second stage of the study adds the measurement of actual heart disease and death from heart disease during the 5-year period to the measurement of changes in risk factors only obtained in the j-year study. This study was begun in 1980 and will continue until 1986 [l3]. The communication strategies used in this phase include a stronger multi-media campaign than during the first study. Public service announcements by T.V. and radio, weekly articles published in local newspapers. frequent television documentaries, books and pamphlets, were mass media utilized. The five-community study also incorporates a stronger component of interpersonal communication. carried out through the participation of community organizations and health professionals. This component is not only used with a sub-sample of high risk population within one experimental community as in the three-community study. but it is incorporated for the whole experimental communities. The interpersonal communication aspect emphasizes the training of skills (e.g. how to reduce tension). The project has stimulated the introduction of changes at the institutional level (e.g. classes to quit smoking; weight control classes in different locations in the communities). In addition, a health education specialist has been hired to coordinate and promote programs on preventing the use of
campaigns
in the health
iield
91
cigarettes and nutrition education programs in high schools. The project expects to create in the communities a shared atmosphere that: (I) stimulates people to think about health care without fear; and (2) provides a program that details the process of helping to affect specific behavior changes in diet and lifestyle. The participation of the community is important to keep the educational programs going after the study ends. An important objective of the Stanford Project is the maintenance of the behavior changes that have been obtained. The Project uses a model of community intervention. that is, its objective is to achieve behavior changes in the population in the setting where the people live and not in a clinical environment [14]. It is trying to affect a multitude of factors that comprise the social risk setting with respect to heart disease. The Project is using a communication focus based principally on Bandura’s social learning theory to introduce behavior changes via the mass media, comand interpersonal relations. munity organizations, The significance of the use of Bandura’s model is that in teaching useful skills to the individual for the modification and control of his own behavior. it has served as a basis for the multi-media and interpersonal strategy approach of the Stanford Project [ 151. Bandura’s theory allows for the teaching of skills by means of modeling behaviors through auditory systems (like radio and cassettes), visual systems (like slides. pamphlets, highway billboards, posters etc.), and audiovisual systems (like movies and T.V.). For example, a scene that shows a family picnic can suggest through its images the type of foods to be taken in a picnic basket when a family is preparing to go on the picnic. The applicability of social learning theory to the design of mass communication messages makes possible, at least potentially. the design of behavior change campaigns at the community level. While it is true that Bandura’s approach attains its greatest effectiveness in interpersonal training situations. the cost of such situations is so high that it makes an intervention to change behavior on the level of entire communities unthinkable. The Stanford Project demonstrates that certain behavior changes. especially if these are simple, are possible by means of mass communication For example, significant dietary changes were a positive result due principally to the mass media campaign. One of the problems with the use of mass communication to achieve behavior changes like stopping smoking or changing a sedentary lifestyle to an active one is that these changes imply the moditication of ingrained and complex behaviors. The acquisition of skills to change complex behaviors is more likely when there can be permanent feedback on the results of practicing the new behaviors. a dimension lacking in mass communication techniques. Although the nature of mass communication does not allow for immediate feedback, it can provide the initial model as well as stimulate the development of systems organizations and support community necessary for the existence of supervised individual practice.
An intervention similar to Stanford’s was used in a community in Finland called North Karelia. This community of 180.000 inhibitants enjoyed the dubious fame of having the highest incidence of heart disease in the world. The project lasted 6 years with very positive results. For example, the rate of heart attacks decreased from 1.6 per 1000 adult men to 1.9 in 4 years. and from 2.8 to I.9 in women. Changes in risk factors were also significant. This project cost much less than Stanford’s, with an average of $1.50 per capita per year, with substantially greater st~cccss. This advantage of the North Karelia project is attributed to a central emphasis on participation of the entire community in the project. In this sense the North Americans must function within a more individualistic and less organized institutional system that serves the public welfare [ 161. DISCUSSION It is useful to conclude with a brief analysis of some of the advantages and limitations of mass media educational campaigns. Paul Lazarsfeld and Robert Merton argue that three conditions determine the impact of mass communication in any given situation : monopolization. channeling and supplementation [ 177. Monopolization occurs when contrary communications do not reach the audience, which instead is exposed only to messages furthering a single point of view. This situation obviously does not occur in many societies with respect to smoking, drinking. diet and other areas of individual behavior. Indeed. the mass media often present undesirable role models: attractive. prestigious people who smoke and drink. Channeling means that, instead of trying to achieve new attitudes and behavior that are antagonistic to those already accepted in the audience. the message instead tries to divert the audience by diverting existing predispositions in a slightly different direction. Mass communication shows how a certain product or service can satisfy an already existing desire in the audience. Advertising can be a good example of channcling when it tries to make the individual choose a specific product of something that he has already decided to LISL”anyway. In the health field this would be the situation when an individual already possessess the commitment to stop smoking and what he needs is to choose between several courses of action for achieving this. A third social condition for impact of mass communication is supplementation: mass communication serves as a supplement to interpersonal communication that already occurs. The Stanford and North Karelia studies used supplementation strategies. Consistent with this typology, the studies show that in general the role of mass communication is the reinforcement. not the change, of existing attitudes and behaviors, Through the mechanisms of selective perception and selective exposure. audiences internalize those messages that reinforce preexisting values and behaviors. There is agreement in the literature that mass communication can be effective in increasing the level of information about a subject. which does not mean that it has an effect of attitude or behavior change. McCoombs suggests that the principal func-
tion of media is agenda setting: in other words. media emphasize the importance of certain subjects and remind us of their existence [IX]. This pessimism about the value of mass communication to achieve behavior change is partially refuted by the application of Bandura’s concepts. whtch often has facilitated behavior change. As we have seen in this paper, it is possible to achieve small behavior changes by means of modeling I new and simple bchavior and by concentrating on the process of how to carry out this new behavior. But it is also true that these changes tend to occur in people who have previously recognized and accepted the need for changes and these are not always the ones most urgently in need of the change. An important limitation of the mass media as an instrument of change comes from the very nature of media: there is no opportunity for active audience participation or immediate feedback. Studies show’ consistently that the active participation of the receiver in an interactive process is much more effective for achieving and maintaining educational objectives (whether these be behavior or attitude changes) than is a passive role. The use of community organizations and the maximization of interpersonal communication are ways in which social communication campaigns can increase their effectiveness in a significant manner. in addition to providing the necessary help for the individuals to maintain the new behavior. This could be appreciated in the Stanford and North Karelia projects. Another way to maximize the impact of social communication is by achieving a closer collaboration between producers and researchers during the planning, implementation and evaluation of the campaigns. Given the impossibility of immediate feedback on the part of the receiver. an evaluation throughout the campaign is fundamental in providing this feedback in order to redefine the messages and objectives of the campaign. A longitudinal research focus is also necessary in order to see how long the results last. Another limitation of campaigns of social communication is that they,operate either not taking into account or in compctttton with the social context of the individual. Not taking into account the social context refers to the fact that many of these campaigns that take the individual as the object of change do not consider the socioeconomic. cultural and cnvironmentnl elements surrounding these individuals. The social context remains unchanged and does not support the individual’s behavior change. When 1 say in competition with the cnvironmcnt. I refer to the fact that these campaigns frequently operate in a disadvantageous situation with respect to those who promote the behaviors that arc considered harmful. A health campaign is an isolated and specific act with respect to a continuous current of advertising that relies on economic resources and an infrastructure that are much more powerful than those of the campaign in question. It is for this reason that only in a context favorable to behavior change can one hope for significant results.
Impact
2. 3. 4. 5.
6.
7.
8.
9.
of mass communication
Co,t~,l~lrr~ic,trriurl(Edited by Schramm W. and Roberts D.). University of Illinois Press. 1972. Insko C. Theories of Arritutir Churl~/e. Prentice-Hall, Englewood Cliffs. NJ. 1967. Bandura A. Socicll Lrurrli!lc/ Tkeory. Prentice-Hall. Englewood Cliffs. NJ. 1977. Rogers E. and Shoemaker F. Cor,lrllur2i~.urior1 (tf Iwwcurio,,s. The Free Press. New York, 1971. McAlistair A. Mass communication of cessation counseling: combining television and self-help groups. Intwwriorltrl Co+wwr 011 Su7okimq. 197X. McAlistair A.. Perry C. and Maccoby N. Adolescent smoking: onset and preventlon. Prdiutrics 63. 650-658, 1979. Syme S. L. and Alcalay R. Social influences on smoking behavior. In Awutrl Rrcirw of Public Hrulth (Edited by Breslow L.). Vol. 3. 1982. Gerbner G. Gross L.. Morgan M. and Signorelli N. Health and medicine on television. ,Verc Em//. J. %f&. 305. YOI-904. 19x1. Wallack L. 7 iw Colifornitr Pwwrrtim Dwwmtrutior~ P,oqrtrm Ertriutrtior~: Descriptim. iwg.~ Alcohol Rcscarch Group.
Methods
md
campaigns
12. 13.
14.
15.
16. 17.
FirId-
Berkeley, 1979. IO. Breed W. and De Foe J. The portrayal of the drinking process on prime time T.V. J. Cowlur~. 31. 58~ 67, 19x1. I I. Maccoby N. Farquar J.. Wood P. and Alexander J.
IX.
in the health
field
93
Reducing the risk of cardiovascular disease. J. Com,nutlir. Hlth 3, Winter, 1977. Hofstadter L. The heart fixers. Tllr Stmfbrti Mu~qtciw 9, Winter, 1981. Maccoby N. and Solomon D. Heart disease prevention community studies. In Public Cornnamicutron Ctrrw pctiqns (Edited by Rice R. and Paisley W.). Sage Beverly Hills, 1981. Maccoby N. Promoting positive health behavior in adults. In Competewe md Copimg duri,q Adulthood (Edited by Bond L. A. and Rosen J.). University Press of New England. Hanover, NH, 1980. Maccoby N. and Alexander J. Use of media in lifestyle programs. In Brhtrriorul Mrdicirw: Chyirq Hrtrlth Lijestyles (Edited by Davidson P. 0. and Davidson S. M.). Brunner,‘Mazel, New York. 1980. Breslow L. Risk factor intervention for health maintenancc. Scirwe 200, 1978. Lazarsfeld P. and Merton R. K. Mass communication, popular taste. and organized social action. In T/w Procc’.t.s urld Eficrs of 121tr.ss Corllr,tlr/iic,trtro,1 (Edited by Schramm W. and Roberts D.). University of Illinois Press, 1972. McCoombs M. E. and Shaw D. L. The agenda setting function of the mass media. P&l. Upin. Q. 36, l97- 187. 1972.
Resumen--Este articulo analizn una serie de proyectos de educacihn en salud realizados en 10s Estados Unidos cuyo objetivo ha sido lograr cambios a nivel de conocimiento. actitud. y conducta en la poblacibn a trnv&s dcl uso de medios de comunicaci6n social. El articulo comiewa destacando las diferentes ;ireas comprendidas en el estudio de las comunicaciones. lireas derivadas de las siguientes cinco preguntas del proceso de comunicacicin: ;.Qui&? iDice q&l ;,A trnvCs de quC canal? ;,A quiCn’? LCon quC efecto? Este trabajo se concentra en la tiltima interrogante, o sea. en 10s efectos de la comunicaci6n y en la utilizaci6n de teorias de persuasi6n para la maximizaci6n de1 impact0 en campaiias de comunicaci6n masiva. En segundo lugar se presentan teorias de psicologia social cuyos marcos teciricos son utilizados por campafias de comunicacicin. Las teorias mds utilizadas por proyectos de comunicacidn masiva en el lirea de salud pilblica son: (I) la teoria de disonancia cognitiva; (2) la teoria de aprendizaje social: (3) la teoria dc difusii,n de innovaciones: y (4) la tcoria de inoculaci6n social. La teoria de disonancia cognitive nspira a lograr cambios conductualcs creando disonancia a nivel de conocimientos. opiniones. y creencias. La tcoria de aprendizaje social. principalmente desarrolada por Bandura. persigue lograr cambios conductualcs a travCs de1 modelamiento de nuevas conductas v de sus consecuencias. La teoria de difusihn dc innovaciones aporta una taxonomia titil para ideniificar y utilizar la red de rclaciones interpersonales en una comunidad. Este proceso de identificacibn de lideres de opini6n y redes de relacionea es necessario pnra la adopcibn de una innovacidn. La teoria de inoculaci6n desarrollada por McGuire tiene por objective maximizar resistcncias contra la presihn social conducente a iniciar conductas nocivas para la salud. Esta teoria sugiere estrategias de inmunizacibn de 10s individuos para rwatir infiuenclas del medio ambiente que se quieren cvitar. En tcrccr luger, estc trabajo rcwsa campaiias de educacidn en salud pliblica que han utilizado uno o mds de cstos cnfoques. Estos progectos de educaci6n en salud fueron seleccionados tanto por el contenido dcl quc tratan coma por las estrategias comunicntivas quc utilizan. A pesar de haberse desarrollado cn Ios Estados Unidos. estas campaiias tratan con factores de riesgo a la salud muy importantes en el lirea de aalud preventiva tanto en el continente americano coma en el europeo. Estas campaiias utililaron diferentes estrategias comunicativas para cl logro de sus objectives. El primer proyecto. de prevencibn 1 cesacibn del hibito de fumar en 10s adolescentes. utiliz6 principalmente estratcgias de comunicacihn interpersonal a travCs del modelamiento de conductas Stiles para resistir presiones sociales favorables al hlibito de fumar. Por medio de reuniones en grupos orientados al entrenamiento de ascrtividad dc la personalidad en general y al entrenamiento de repuestas a situaciones concretas. se modelaron situaciones reales de presidn social para fumar. Este proceso tuvo por objective inmunizar a 10s sujctos contra un context0 social quc favorece la conducta de fumar. Rcsultados dc esta campaiia fucron positivos ya quc 10s grupos experimentales mostraron una disminucidn signiticantiva cn la iniciacicin de conducta dc fumar en comparacicin a grupos dc control no expuestos a la intervencicin comunicativa. Estos resultados fueron significativamente diferentes a corto plaza. Despu(ls dc un aiio 10s grupos experimentales y de control deJaron de diferenciarse signiticativamentc. Eatc resultado demuestra que una intervencidn comunicacional aislada quc ocurre en un contexto social que favorece la conductn de fumar no ticne Cxito a largo plaza. El Segundo proyecto desarrolo un programa de prevencibn y cesacibn de alcohohsmo en poblacibn adulta 4 de adolescentes. Este proyecto utllizb primordialmente la televisi6n coma medio de comunicaclan ) spots publicitarios anti-alcohol coma format0 de cxpresitin de 10s mensajes. El objective de esta campaiia fuc la obtenci6n de cnmbios a nivel de conocimiento. actitud y conducta en la poblacibn a travL:s dc modclamicnto de conductas desenbles por medio de spots publicitarios. La campatia logrb
94
RIKA AKALAY
aumentar cl nivel de conciencia acercn de 10s pehgros asociados con cl abuse de alcohol pero no logrci cambios conductuales en la poblaci6n experimental. o sea no se produjo una disminucidn del consumo de alcohol ni una intencidn de hacerlo en lx comunidades experimentales. Estos resultados confirman la limitacidn de 10s medios de comunicacihn masiva coma inkadores de cambios conductuales. La tercera campatia analizada en este articulo two coma objetivo la prevenci6n de enfermedades al corazbn en un conjunto de comunidades en California. Este proyecto utiliz6 una combinacidn de medios de comunicaci6n masiva y medios de comunicaci6n interpersonal para lograr cambios dc cstilo de vida en comunidadcs enteras. Los factores de riesgo asociados con enfermedades al corazbn fueron: cl consumo de cigarrillos. el exceso de ciertos alimentos (con alto contemdo de grasas. colesterol, sal 1 azlicar), el exceso de peso. la falta de activadad fisica, la alta presidn de la sangre 4 la tensi6n. La campaiia desarrolk una serie de estrategias comunicatlvas oricntadas a disminuir estos factores de riesgo. Los resultados demostraron cambios significativos en conductas alimenticias especlalmente en I:I reducci6n del consume de huevos y consumo de colesterol. Menos Cxito se obtuvo en relnci6n a cambios de conductas de fumar o hibitos de vida sedentaria. Por tiltimo este articulo plantea algunos alcances y limitaciones en el uso dc medios de comunicacihn social en programas de cambio conductual para cl hrea de salud. El an&is de estas campaiias sugiere que 10s medios de comunicaci6n masiva alcanzan mayor impact0 cuando son utilizados coma suplementaci6n a medios de comunicaci6n interpersonal y organizacibn comunitaria. En Segundo luger 10s estudios demuestran que cn general 10s medios de comunicacihn refuerran actitudcs y conductas existentes en vez de promovcr cambios. Un tercer obstkulo con campalias masivas en el Area de salud es clue operan ignorando o compitiendo con el entorno social de 10s indlviduos. Frecuentemente el entorno social del indlviduo promueve conductas nocivas para la salud (por ejemplo. propaganda de cigarrillos. de bebidas alcohdlicas, y de alimentos sin valor nutritivo). Por illtimo es importante tener en cuenta un alcance de tipo etico respecto a la utilizacicin de medios de comunicacicin con fines persuasivos. Es precise utilizar 10s medios no con fines manipulativos sino con el objective de aumentar Ins oportunidades y opciones de las personas y obtener la participaci6n de las comunldades cn 10s programas de salud desarrollados.