Effectiveness of health promotion programs

The goal of health promotion strategies is to enhance good health and prevent illness. WHO (1986) defined health promotion as “the process of enabling people to increase control over, and to improve their health”.  However, it is not easy to get people to behave in healthy ways because of the many factors that influence health habits, which include such variables as social class, gender, education and culture. There are, of course, also individual differences in approaching health; what motivates one to follow certain principles when it comes to health depends on individual circumstances. For instance, a woman who wants to lose weight may eat healthy food and exercise, but she may also smoke because she believes that it helps her keep her stay slim. Likewise, one may decide to quit smoking and be successful for a year but then relapse.

ATL:  Thinking critically

Below are two videos - each for a different campaign.  One has the goal of making people more active.  The other is trying to raise awareness about child abduction.

Which of the two campaigns do you find more effective?  Why do you think so?

Campaign 1.  Get active

Campaign 2.  Child abduction

Psychologists know that one-on-one contact is an effective way to change behavior in individuals or small groups, but this approach is not possible when one wants to change habits of whole populations. This has led psychologists and health workers to devise methods by which to reach large numbers of people. Modern health promotion activities include:

  • Public health campaigns that aim to change beliefs, attitudes, and motivations - for example, informing smokers about the dangers of smoking and showing them how they can stop.
  • Changing the wider determinants of health - for example, changing the physical environment; more stairs and fewer escalators.
  • Public or private health services that can help people change their behavior - for example, family doctors, pharmacies, or smoking cessation clinics.
  • Political activities - for example, legislation raising tax or implementing bans on smoking; reducing tax on healthy food and raising tax on sugar and fat.

Health campaigns

Health campaigns are often criticized for being ineffective. Some people argue that they cannot make people change their habits and that they do not really help those who need to change the most. According to Holm et al (2002), who conducted a survey on the efficiency of health campaigns in relation to food habits in Denmark, health campaigns are useful, but they cannot stand alone. They must be seen as an integral part of the entire health promotion project. Holms states that a campaign can establish a norm for what is considered to be healthy food and also create a general framework for the understanding of good practice in losing weight but it needs to be based on people’s daily life (e.g. food culture) in order to be effective.

A successful health campaign in Denmark in the 1990's aimed to decrease the use of butter on the national rye bread sandwiches that constitute the Danes’ lunch. From 1985 to 2001, the amount of people who said they did not use butter on the sandwich increased from seven percent to forty percent. The use of low-fat milk has also increased in Denmark after health campaigns. This shows that such campaigns can promote change.

It is difficult to make precise evaluations of the effect of a health campaign but according to Holm, there is a long-term effect of various campaigns in Denmark. Each of them contributes to increased knowledge and motivation to change unhealthy habits. One of the campaigns aimed at increasing physical activity for adults—“30 minutes every day”—has probably contributed to the rise in fitness center memberships. Furthermore, according to Holm, successful campaigns in relation to obesity prevention must address three levels: what the individual can do, what can be done in the community, and what should be done by the government.

What is more, in the modern world the media plays a decisive role in information spreading and thus are one of the main means of health promotion and education. However, there are some limitations to this approach; according to Sepstrup (1999), media campaigns can only be used to convey simple messages. If the goal is to change attitudes and promote behavioral change, the media campaign should be combined with other measures. Although media campaigns are excellent in bringing attention to and communicating knowledge about a specific topic, they may not be enough on their own. People must have access to the necessary means to actually do something. The simple message—such as “smoking kills” or “exercise 30 minutes every day”—must be supported by activity options targeting people in their local area, so they can get the necessary support to change their habits.

Still, it appears that media campaigns are certainly not ineffective.  Huhman et al. (2005) conducted a large-scale survey of children and parents to investigate the effectiveness of VERB – a campaign in the US which used commercial marketing strategies to persuade the target audience (children aged 9–13 years) to be physically active every day. They found that after one year, 74 percent of the children were aware of the VERB campaign and there was also an increase in sessions of free-time physical activity for children who were aware of the campaign compared to those who were unaware of it. The researchers concluded that commercial advertising in health promotion is promising.

The TRUTH campaign

Media campaigns might also be approached in a different and original way, which may increase their influence. An instance of this was TRUTH anti-tobacco campaign in Florida (US) in 1998–99. One of the aims of this campaign was to prevent teen smoking by changing the attitudes of teenagers and encouraging them to form groups and spread the message in the community. The campaign included a massive advertising drive, including 33 television commercials, billboards, posters, the Internet (e.g. YouTube), program sponsorship, merchandise, and local youth advocacy groups. The campaign also sponsored the YouCare video contest at YouTube, where teenagers uploaded their own films.

However, what was extraordinary about this campaign was the active involvement of its target audience - one of the core components of the campaign was young people confronting the tobacco industry and accusing them of manipulating young people to encourage them to smoke. The campaign leaders conducted focus-group interviews with teenagers to identify appropriate ways of running the campaign. They found that teenagers were well aware of the dangers of smoking, so this should not be the message of the campaign. Instead, the strategy of a youth movement against the tobacco industry was decided by teen delegates at the Teen Tobacco Summit in 1998: “Truth, a generation united against tobacco”. The campaign included the formation of a new youth anti-tobacco advocacy group called SWAT (Students Working against Tobacco), who worked at grass-roots levels.

In order to measure the effect and awareness of the campaign, as well as changes in attitude among adolescents, the campaign organizers carried out a number of telephone surveys of its target audience. One of the findings was that teenagers’ negative attitude to smoking had risen. Follow-up surveys indicated that non-smoking teens, who refrained from smoking because of the campaign, were more likely to say that they had been influenced by the campaign. The Florida Youth Tobacco Survey (FYTS), conducted in February 1999, found that the number of middle- and high-school teenagers defined as “current smokers” went down by 19.4 percent and 8 percent respectively. During this time period, 29 000 teenagers from Florida made the decision not to smoke, which was at the time one of the largest annual declines observed in the US since 1980.

Sly et al. (2002) carried out a survey 22 months after the campaign to investigate if the anti-tobacco advertisements had had an effect on attitude changes such that the non-smokers would remain non-smokers. They found that amount of exposure to the ads with the key message theme—that is, that the tobacco industry manipulates teenagers’ attitudes to smoking—during the campaign predicted that the subject had remained a non-smoker.

The findings from this campaign indicate that it is possible to change people’s attitudes and behavior if the campaign is clear and focused on a target group. Furthermore, this demonstrates that a campaign may be more successful if it directly involves its target group in its development and creation.

An effective campaign: TRUTH

Overall, smoking decreased as a result of the TRUTH anti-tobacco campaign in Florida in 1998-99. One of the aims of this campaign was to prevent teen smoking by changing their attitudes and encourage them to form groups and spread the message in the community.

The campaign included a massive advertising including 33 television commercials, billboards, posters, the Internet, program sponsorships, merchandise and the local youth advocacy groups. The campaign also sponsored the YouCare video contest at YouTube where teens uploaded their own films.

Here is an example of a Truth video from that campaign.

Do you find the PSA effective?  Why or why not?

Finally, McVey and Stapleton (2000) demonstrated that anti-smoking television advertising was successful in motivating people to give up smoking and preventing those who had stopped from starting again. They chose four different TV regions of the United Kingdom and created four intervention groups – a control group, two groups which received an intervention in the form of anti-smoking TV spots and one group which received an intervention in the form of anti-smoking TV spots and also locally organized anti-tobacco campaigning. From the selected regions, they randomly picked 5468 participants, out of which 2997 were smokers and 2471 were ex-smokers. They interviewed these people before the intervention, then interviewed them again after six months and finally after eighteen months. Some of the subjects quit the study before the final follow-up, thus the end sample was comprised of 2381 participants.

The results showed that after eighteen months, 9.8% of smoker participants stopped smoking while 4.3% of the ex-smokers started smoking again. The group, which was also additionally subjected to locally organized anti-tobacco campaigning, did not show significantly different results to the groups with the TV spots alone. All in all, the intervention was successful – the TV campaign managed to reduce smoking in the tested population by 1.2% overall. Interestingly, the campaign did not show as effective after six months, even though in the end it demonstrated to be effective after the final check-up.

Still, this study may be limited by its cultural relevance; would these same advertisements work as well in a different population? Effectiveness may also vary from advert to advert – there are many different aspects which make a marketing campaign impactful and it is essential to also consider these when evaluating the usefulness of TV advertising in changing a certain behavior. It is quite vague to say that TV advertising either works or it does not – this decision should possibly be more nuanced and should consider more variables.

The principles described above can be applied to health campaigns overall; it is difficult to generally state whether they are effective or not. However, there are plenty of specific campaigns which has been shown as impactful in specific populations. This is why academic studies are very important in this area – it may be beneficial to clinically test campaigns before they are implemented in the first place and to consider general rules of marketing in creation of these campaigns in order for them to be attractive and influential. In the end, in principle they really are no different to commercial marketing campaigns and perhaps just as commercial campaigns, some will be successful and some will fail. However, this does not mean they should be abandoned overall.

ATL:  Communication

Obesity is a problem in most developed countries. You have been hired as part of a team to help your country address this issue by creating a video that would help to change individual behaviour and reduce the level of obesity.  Your team has to put together a proposal for your statewide campaign.

As a team, you should write a proposal for how you think that they could address the problem. As part of your proposal you should:

  • Identify which health promotion model they are going to use.  It may be one of the two outlined in the previous lesson, or it may be one of the ones listed as areas of inquiry.
  • Justify the choice of this model and note its limitations.
  • Develop a visual for the campaign - e.g. a poster, a film, a slide show - that could be used to try to affect the desired change. The visualization must reflect the health promotion model that has been chosen.

Each team should then present their idea to the class.  After all of the presentations have been shown, the following three questions should be discussed:

  • Which campaign do you think will be the most successful?  Why?

  • What factors do you think a country or company would look for in order to make a decision about which campaign to choose?

  • To what extent is it truly possible to predict the success of a campaign?

Evaluating effectiveness of health promotion strategies

In order to find whether or not health promotion is a good investment, the World Health Organization [WHO] commissioned a  group to provide guidance on the appropriate methods to evaluate health promotion and to increase their quality (WHO, 1998).

Their recommendations were:

  • Evaluations should draw on a variety of disciplines and employ a broad range of information gathering procedures - in other words, data, researcher and method triangulation should be used.

  • Those who have a direct interest in a health promotion initiative should have the opportunity to participate in all stages of its planning and evaluation. 

  • Health promotion initiatives should be evaluated in terms of their processes as well as their outcomes.

  • The use of randomized controlled trials to evaluate health promotion is, in most cases, not an appropriate strategy for evaluating public campaigns.

The final point is rather interesting as often we believe that experimental data is the most helpful.  The  problem is that experimental data relies on "outcome."  Health promotion campaigns, very similarly to therapy in abnormal psychology, need to look at how behaviour changes over time.   This may mean that there is a short-term change that is not sustained.  If you only look at the outcome, then you may judge the campaign a failure.  If, however, the campaign leads to positive results even in the short-term, this could be seen as having been effective.  For example, Gobins et al (2013) looked at the effectiveness of a Social Cognitive Theory based multimedia campaign in the UK to promote STD testing.  While the campaign was in the media, the number of young people being tested for STDs increased significantly.  However, once the campaign was off the air, the number of people being tested returned to the previous baseline.  Would you consider this a total failure because the final outcome was not a sustained increase in testing?

Difficulties in evaluating effectiveness of campaigns

Even though it appears that the TRUTH campaign was a success, we have to note that there are several difficulties in evaluating the effectiveness of a public health campaign.  Here is a list of just a few problems.

  • It is not possible to isolate variables when studying a large population being exposed to public media.  Therefore, although a correlation between exposure to the campaign and change in behaviour can be observed, cause and effect cannot be determined.

  • Levels of exposure to the media can only be measured through self-reported data.  It is unlikely that the average person can accurately determine the number of times that they have been exposed, either directly or indirectly, to the campaign.

  • Sampling is often problematic, so the results may not reflect the diversity of the population.

  • Even if a public health campaign is judged to be effective, often the findings are not transferable to other populations.

  • As noted above, it is difficult to measure the effectiveness over a large period of time to determine if the results are simply short-term change or a durable, long-lasting change in behaviour.

  • Simply measuring health outcomes through hospital or work-related data is not enough to determine that the campaign itself made a difference.

  • Even if a campaign fails, it is difficult to know whether it failed because of the actual campaign or the way that it was delivered.

  • Much of the data obtained is self-reported, leading to potential demand characteristics influencing the final outcome.

  • Who is doing the research is very important. Often those that design the program play an integral role in its evaluation, potentially leading to a lack of objectivity and researcher bias.

  • Strong evaluation requires triangulation.  This is time-consuming and expensive.

Checking for understanding

1. Why is triangulation important in assessing the effectiveness of a public health campaign?

Triangulation is important because it helps to show that the method used to measure the effectiveness of the health campaign is not the reason for the results.  So, data and researcher triangulation means that I have data collected by different groups of researchers in different parts of the state - and we all see the same trends!  Method triangulation means that I took I did a statewide questionnaire, carried out a series of focus groups and did observations in areas where teens hang out - and I got the same results each time. So, it was not simply the method that used that led to the findings.

2. Why are randomized controlled trials not a good way to evaluate health promotion campaigns?

Randomized controlled trials are done under lab conditions.  This does not reflect the natural environment in which public campaigns take place.  They also have limited sample size and the sample tends to not be representative of the general population.

3. Why can causation not be established between a health promotion campaign to decrease smoking and an actual decrease in smoking?

Because it is impossible to control other variables.  We do not know how many people wanted to actually stop smoking before the campaign.  Since these were teens, we cannot know the role of the school policies or education in changing behaviour. There may have been other variables which contributed to the change in behaviour.

4. What are the sampling problems involved in assessing the effectiveness of a campaign?

It is difficult to get a representative sample of a large population.  Health effects are usually judged by hospital data or absentee data from schools or work.  This excludes a significant amount of a population.

5. What is the difference between outcome based and process-based research?

An outcome-based approach looks only at the final results - that is, after the campaign is over, was it successful.  A process-based approach looks at changes in behaviour over time.  The expectation is not that the change be linear, but it may be cyclical or even only short-term.

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