524774
research-article2014
HPPXXX10.1177/1524839914524774Health Promotion Practice / Month XXXXO’Hara et al. / Impact of Mass Media Campaign on Get Healthy Information and Coaching Service
Mass Media and Social Marketing
Longer Term Impact of the Mass Media Campaign to Promote the Get Healthy Information and Coaching Service®: Increasing the Saliency of a New Public Health Program Blythe J. O’Hara, PhD1 Philayrath Phongsavan, PhD1 Klaus Gebel, PhD1,2 Debbie Banovic, MPH3 Kym M. Buffett, GDHlthProm3 Adrian E. Bauman, PhD1
The Get Healthy Information and Coaching Service® (GHS) was introduced in New South Wales in February 2009. It used mass reach media advertising and direct mail and/or proactive marketing to recruit participants. This article reports on the long-term impact of the campaign on GHS participation from July 2011 to June 2012. A stand-alone population survey collected awareness, knowledge, and behavioral variables before the first advertising phase, (n = 1,544, AugustSeptember 2010), during the advertising period (n = 1,500, February-March 2011; n = 1,500, June-July 2011; n = 1,500, February 2012), and after the advertising period (n = 1,500, June-July 2012). GHS usage data (n = 6,095) were collated during July 2011-June 2012. Unprompted and prompted awareness of GHS mass media significantly increased (0% to 8.0%, p < .001; and 14.1% to 43.9%, p < .001, respectively) as well as knowledge and perceived effectiveness of the GHS. Those from the lowest three quintiles of socioeconomic disadvantage and respondents who were overweight or obese were significantly more likely to report prompted campaign awareness. The majority (84.4%) of new GHS calls occurred when television advertising was present. Participants who cited mass media as their referral source were significantly more likely to enroll
Health Promotion Practice November 2014 Vol. 15, No. (6) 828–838 DOI: 10.1177/1524839914524774 © 2014 Society for Public Health Education
828
in the intensive coaching program. Mass media campaigns remain an effective method of promoting a telephone-based statewide lifestyle program. Keywords: mass media; recruitment; telephonebased counseling; lifestyle intervention
Background >> Mass media campaigns are used extensively by population health programs to encourage the adoption of health-promoting attitudes, beliefs, and behaviors 1
University of Sydney, Sydney, New South Wales, Australia James Cook University, Cairns, Queensland, Australia 3 NSW Ministry of Health, Sydney, New South Wales, Australia 2
Authors’ Note: The authors would like to acknowledge and thank the NSW Ministry of Health for funding the evaluation of the Get Healthy Service and the Social Research Centre for conducting the tracking survey for the mass media campaign evaluation. The project was funded by the NSW Ministry of Health. Blythe O’Hara and Klaus Gebel received salaries from Prevention Research Collaboration, Sydney School of Public Health, University of Sydney. Kym Buffett received a salary from the NSW Office of Preventive Health, NSW Ministry of Health. The authors declare that there are no competing interests. Address correspondence to Blythe J. O’Hara, Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Medical Foundation Building K25, Sydney, New South Wales 2006, Australia; e-mail: [email protected].
and to a lesser extent service utilization. The effectiveness of mass media campaigns to facilitate behavior change is well understood (Noar, 2006; Snyder et al., 2004; Wakefield, Loken, & Hornik, 2010). The effectiveness of campaigns in increasing health service utilization is also recognized (Grilli, Ramsay, & Minozzi, 2009). Telephone-based smoking cessation services, such tobacco quitlines, across the world have relied on pervasive mass media campaigns to promote calls to their services (Miller, Wakefield, & Roberts, 2003; Wakefield & Miller, 1999; Williams & Bleasdale, 1999; Wilson, Grigg, Graham, & Cameron, 2005). Episodic mass media campaigns have also been used effectively to improve the uptake of early screening and immunization services (Australian Government Department of Health, Research and Marketing Group, 1998; Chen et al., 2005; Perez et al., 2009). With respect to services to support healthy eating, physical activity, and weight management, limited evidence exists on the impact of sustained mass media campaigns in promoting usage or participation in prevention services (O’Hara, Bauman, & Phongsavan, 2012). This in part reflects the dearth of population-wide lifestyle change services of similar scale and characteristics to tobacco quitlines, necessitating high-level mass media campaigning to support implementation. Any new lifestyle behavior change program using mass media campaigns to publicize its existence and promote usage would typically aim to establish its perceived service effectiveness and relevance among the target populations such that they will then be motivated to access the program for support (Flora, Maibach, & Maccoby, 1989; Wakefield & Borland, 2000). Capturing the attention of the target populations in a crowded media environment (Randolph & Viswanath, 2004) and motivating individuals to enroll in a lifestyle program in particular can be challenging, requiring time and extensive resource commitments. It is argued that the support of concerted and strategic mass communication campaigns is critical for marketing a new service (or idea) and for it to quickly diffuse into the community to increase service usage by the intended audiences (Haider & Kreps, 2004; Rogers, 2003; Snyder et al., 2004). The Get Healthy Information and Coaching Service® (GHS) is a free statewide population-based telephone service aimed at helping adults achieve and maintain lifestyle based changes (www.gethealthynsw.com.au). Introduced in 2009 by the state government of New South Wales (NSW), Australia, the GHS is a rare example of a population-wide telephone coaching support service available to free-living, healthy individuals (O’Hara et al., 2013). The GHS represents the translation of efficacious trials (Eakin, Lawler, Vandelanotte, &
Owen, 2007; Goode, Reeves, & Eakin, 2012) upscaled to a population-level program. GHS participants have primarily been recruited through self-referral (e.g., mass media advertising including television, press, radio, and digital), secondary referral pathways (e.g., health professionals, workplaces, friends, and family), and proactive marketing (which involves the distribution of a letter of introduction to specifically targeted households and a follow-up phone call inviting GHS participation). In relation to mass media advertising, GHS-specific and GHS-related (that included the GHS phone number as a call to action) mass media campaigns have been implemented. Supportive marketing activities included radio, print, online advertising, and pamphlets being distributed in household letterboxes and home-delivered magazines, specifically targeted to disadvantaged locations (based on geography and unhealthy lifestyle behaviors). A previous study has reported that continuous advertising of the GHS achieves good initial recall among socioeconomically disadvantaged groups (O’Hara, Bauman, King, & Phongsavan, 2011). The evidence to date indicates that television advertising has been more effective at recruiting adults to the one-off contact information component of the GHS, whereas health professional referrals and targeted mail-out information have been most successful in recruiting participants to the intensive 6-month GHS coaching program (O’Hara et al., 2012). Given the ongoing mass communication strategies surrounding the GHS (NSW Office of Preventive Health, 2013), the process of successfully promoting the uptake of an efficacious, scaled-up program, such as the GHS, requires a detailed examination of the ongoing role of mass media if we are to maximize the public health impact of the current and future initiatives. The aims of this research are to examine the longterm impact of mass media advertising on increasing awareness and on the perceived effectiveness of the GHS; the associations between the type of media, referral source, and enrolment in the intensive 6-month GHS coaching program; and the profile of service users over time as a result of sustained mass media campaigns.
Method >> Statewide GHS-Specific and National Obesity Prevention Advertising The aim of the GHS mass media campaign was to encourage adults to call the GHS to get brief verbal and written advice or intensive coaching support on physical activity, nutrition, and healthy weight. The GHSspecific campaign targeted adults aged 25 to 54 years
O’Hara et al. / IMPACT OF MASS MEDIA CAMPAIGN ON GET HEALTHY INFORMATION AND COACHING SERVICE 829
living in NSW and included television advertisements (15- and 30-second messages; 60:40 peak:off-peak television programming); metropolitan, suburban, and primary regional print advertisements; culturally and linguistically diverse print titles; Aboriginal print titles; live radio reads on Australian Traffic Network; online advertising and brochure inserts into periodical magazines distributed to households across regional NSW; and letterbox drops in disadvantaged metropolitan neighborhoods. No GHS-specific advertising was present from July to December 2011, followed with consistent advertising throughout the following 6 months, including 3 weeks of television advertising being present in each of these months with the 30- and 15-second commercials being used during this period. Continuous online advertising occurred from February 2012 to June 2013 and print advertising from mid-January 2012 to June 2013. Radio advertising was used only during May and June 2012 and the brochures were used in the targeted mail-out strategy from mid-January until midApril 2013. Using a national obesity prevention campaign, the GHS was also promoted at the end-of-television advertisements that were aired for 3 weeks in September 2011 and 5 weeks in March 2012. Campaign Tracking Survey To evaluate the effects of the GHS-specific campaigns, a statewide baseline survey was undertaken during the following time periods: August to September 2010 (Time Period 1), a follow-up survey in February to March 2011 (Time Period 2), a follow-up survey in June to July 2011 (Time Period 3), a follow-up survey in February 2012 (Time Period 4), and a final follow-up survey in July 2012 (Time Period 5). The NSW Ministry of Health engaged a market research agency to undertake these cross-sectional population telephone tracking surveys. The target population was English-speaking adults residing in NSW, aged 18 years and older, and living in private dwellings with telephone landlines. The households were randomly sampled, and respondents were recruited based on the “next birthday” selection method using random digit dialing. The sample size was n = 1,500 for each survey.
Survey Measures >> Information was collected via telephone-based interviews on sociodemographic variables (age, gender, geographical location, education, household composition, employment status, income, language spoken at home, Aboriginal status, and postcode); self-reported health, weight (kg), height (cm); campaign awareness
830 HEALTH PROMOTION PRACTICE / November 2014
and recall (where participants were asked to describe any healthy lifestyle advertising they had seen) and campaign recognition (also referred to as “prompted awareness” where the advertising was described to participants who were then asked about recognition); main message understanding; actions as a result of seeing the advertising; and perceived service effectiveness and personal relevance. The survey took less than 10 minutes to complete. GHS Usage Data To examine which referral pathways were associated with GHS service levels, participant usage data from July 2010 to June 2012 were examined. Number of calls to GHS was examined during this period, but the sociodemographic details of GHS participants were only examined between July 2011 and June 2012, as the results of July 2010 to June 2011 have been reported elsewhere (O’Hara et al., 2012). Participants were grouped according to their service-level choice: (a) information-only participants who received (via mail or e-mail) an information package on healthy eating (National Health and Medical Research Council, 2003), physical activity (Australian Government Department of Health, 2005), and achieving or maintaining a healthy weight and (b) coaching participants who received 10 individually tailored calls to support behavior change (Baumeister, Gailliot, DeWall, & Oaten, 2006; Carver & Scheier, 1998; Palmer, Tibbs, & Whybrow, 2003), provided by a university qualified health coach. The health coaches collected sociodemographic characteristics (gender, date of birth, residential postcode, highest level of education obtained, current employment status, language spoken at home, and Aboriginal status; Population Health Division, 2009). The postal code of participants was used to determine Socio-Economic Indexes for Areas (SEIFA), a measure of area-level socioeconomic status, which is reported by quintile of relative area disadvantage (Australian Bureau of Statistics, 2006). The postal code is also used to compute AccessibilityRemoteness Index of Australia Plus (Australian Institute of Health and Welfare, 2004), a measure of remoteness. All participants were also asked how they heard about GHS (referral source). Responses were categorized into four types of referral source: mass media, health professional, proactive marketing, and other. Ethics Approval Informed consent was obtained from all participants prior to their information being included in this study. The study was approved by the University of
Sydney Human Research Ethics Committee (Reference Nos. 02-2009/11570 and 2011-0906/14113). Statistical Analysis Statistical analyses were conducted using SPSS 21.0 (IBM SPSS Inc., 2012). Chi-square tests for linear trends were performed to examine (a) the relationship between the time of the survey and participant sociodemographic variables, and GHS mass media awareness, knowledge, behaviors, and beliefs and (b) the relationship between referral source, participant sociodemographic variables, and participant type. Adjustment for multiple testing was made using the Bonferroni method (Shaffer, 1995). Logistic regression models were used to examine the association between unprompted versus prompted awareness and actions, and sociodemographic variables, and changes over time.
Results >>
Campaign Tracking Surveys The profile of survey participants (n = 7,544) was similar across the five survey periods (data not shown). The majority were female (55.3%); older than 45 years (68.9%); were employed part- or full-time (55.2%); were non-Aboriginal (98.1%); spoke English at home (93.9%); had obtained a certificate, diploma, or bachelor’s degree or higher (56.6%); had a household income greater than AUS$50,000 (58.6%); and were from Sydney (61.0%). Approximately 52.7% of respondents were from the lowest three quintiles of area disadvantage. Approximately 53.3% were classified as being overweight or obese according to their body mass index. Table 1 shows the impact of the GHS campaign on awareness, which was as follows: unprompted awareness increased from 0.0% at baseline to 10.3% at Time Period 2, and dropped to 2.9%, 5.5%, and 8.0% at the subsequent follow-up periods (all p < .001). Prompted awareness of the GHS increased over time from 14.1% to 37.8%, 33.5%, 38.9%, and 43.9%, χ2(1) = 247.8, p < .001. There was also an increase in number of survey respondents reporting that they had undertaken action as a result of seeing the advertising (from 2.4% to 4.9%, 3.8%, 4.9%, and 5.7%), χ2(1) = 121.1 p < .001; there was a significant and gradual increase in knowledge that the service had a free call number (from 21.5% to 35.2%, 37.1%, 38.0%, and 41.6%), χ2(1) = 15.7 p < .001); and the service was provided by a Government agency. There was a moderate but significant increase in the belief that the GHS would be effective or very
effective (from 47.2% at baseline to 52.0% at Time Period 5; p < .001), but there was no increase in the belief that the GHS was of personal relevance (Table 1). Multivariate logistic regression examining correlates of unprompted and prompted awareness of the GHS campaign (data not shown) found that males were less likely than females to report unprompted campaign awareness (adjusted odds ratio [AOR]: 0.75; 95% confidence interval [CI]: 0.59, 0.95; p < .05) as were those aged 45 years and older compared to those aged less than 45 years (AOR: 0.75; 95% CI: 0.58, 0.97; p < .05). In relation to prompted campaign awareness, those aged 45 years and older were significantly less likely to report prompted campaign recall (AOR: 0.84; 95% CI: 0.72, 0.98; p < .05), as were those whose household income was greater than AUS$50,000 (AOR: 0.84; 95% CI: 0.72, 0.98; p < .01); however, those from the lowest three quintiles of advantage (the most disadvantaged) were significantly more likely to report prompted campaign awareness (AOR: 1.21; 95% CI: 1.05, 1.40; p < .01) as were those respondents who were overweight and obese (AOR: 1.51; 95% CI: 1.33, 1.72; p < .001). GHS Usage Data: GHS Calls and Advertising Between July 1, 2010, and June 30, 2012, the GHS received 15,827 new calls (i.e., not including calls from existing GHS participants). There was a clear relationship between the level of GHS-specific and the national obesity prevention television advertising and the number of new calls to GHS (Figure 1), with 84.4% of new calls occurring during periods when television advertising was present. When advertising was present, there was an average of 890 new calls per month, compared to an average of 275 calls per month when there was no television advertising present (representing a 325% increase in calls). GHS Usage Data: GHS Participants and Referral Sources Between July 1, 2011, and June 30, 2012, a total of 6,593 adults registered with the GHS, of which 6,095 (92.4%) participants consented for their information to be included for research and evaluation purposes. The majority were female (66.6%), aged 50+ years (58.4%), not in paid employment (51.1%), spoke English at home (92.9%), and lived in major cities (58.0%); 49.1% had a high school education, 4.1% identified as being Aboriginal, and 46.3% were from the lowest two quintiles of disadvantage (data not shown). Table 2 shows participant characteristics by referral source; 58.9% of participants contacted the GHS as a
O’Hara et al. / IMPACT OF MASS MEDIA CAMPAIGN ON GET HEALTHY INFORMATION AND COACHING SERVICE 831
832 HEALTH PROMOTION PRACTICE / November 2014 41.6 38.3 0.5 0.5 1.9 2.4 1.5 1.2 0.0 0.4 21.5 15.8
47.2 2.8 45.4 4.6 13.2 7.7 78.4 0.7
87 80 1 1 4 37 23 19 0 6 45 33
728 44 701 71 204 119 1,210 11
229 111 1,148 12
746 60 604 90
13 190 114
44 40 3
74
166 181 19 16 73
154 540
n
15.3 7.4 76.5 0.8
49.7 4.0 40.3 6.0
0.9 35.2 21.1
2.9 2.7 0.2
4.9
30.7 33.5 3.5 3.0 13.5
10.3 37.8
%
Follow-Up Tracking (n = 1,500, March 2011)
188 97 1,192 23
745 63 597 95
9 177 93
23 28 4
57
146 133 13 32 52
44 477
n
12.5 6.5 79.5 1.5
49.7 4.2 39.8 6.3
0.6 37.1 19.5
1.5 1.9 0.3
3.8
30.6 27.9 2.7 6.7 10.9
2.9 33.5
%
Follow-Up Tracking (n = 1,500, June 2011)
217 128 1,139 16
730 83 574 113
25 222 159
30 21 7
74
161 167 9 32 61
83 584
n
14.5 8.5 75.9 1.1
48.7 5.5 38.3 7.5
1.7 38.0 27.2
2.0 1.4 0.5
4.9
27.6 28.6 1.5 5.5 10.4
5.5 38.9
%
Follow-Up Tracking (n = 1,500, February 2012)
NOTE: GHS = Get Healthy Service. a. Significance value for comparison pre- to postcampaign using chi-square for categorical data. *Significance for trend using linear by linear chi-square tests at p < .05. **Significance for trend using linear by linear chi-square tests at p < .001.
0.0 14.1
0 209
Awareness: Unprompted awareness of GHS advertisement Awareness: Prompted awareness of GHS advertisement Understanding of main message Physical activity Healthy eating Healthy weight Phone service Help is available and it’s all about you Actions Have undertaken actions Actions undertaken (multiple responses allowed) More healthy eating Become more physically active Called the service or website/encouraged others to call service Other Knowledge of free call number Knowledge that it’s provided by New South Wales Government Perceived effectiveness and relevance of GHS service Belief that telephone service would be effective Very effective/effective Neither effective nor ineffective Ineffective/very ineffective Don’t know/refused Belief that telephone service is personally relevant Very or moderately relevant A little bit relevant Not relevant at all Don’t know/refused
%
n
Baseline (n = 1,544, September 2010)
206 131 1,146 17
780 66 562 92
13 274 182
37 41 8
85
216 246 13 29 79
120 658
n
13.7 8.7 76.4 1.1
52.0 4.4 37.5 6.1
0.9 41.6 27.7
2.5 2.7 0.5
5.7
32.8 37.4 2.0 4.4 12.0
8.0 43.9
%
Postcampaign (n = 1,500, July 2012)
research-article2014
HPPXXX10.1177/1524839914524774Health Promotion Practice / Month XXXXO’Hara et al. / Impact of Mass Media Campaign on Get Healthy Information and Coaching Service
Mass Media and Social Marketing
Longer Term Impact of the Mass Media Campaign to Promote the Get Healthy Information and Coaching Service®: Increasing the Saliency of a New Public Health Program Blythe J. O’Hara, PhD1 Philayrath Phongsavan, PhD1 Klaus Gebel, PhD1,2 Debbie Banovic, MPH3 Kym M. Buffett, GDHlthProm3 Adrian E. Bauman, PhD1
The Get Healthy Information and Coaching Service® (GHS) was introduced in New South Wales in February 2009. It used mass reach media advertising and direct mail and/or proactive marketing to recruit participants. This article reports on the long-term impact of the campaign on GHS participation from July 2011 to June 2012. A stand-alone population survey collected awareness, knowledge, and behavioral variables before the first advertising phase, (n = 1,544, AugustSeptember 2010), during the advertising period (n = 1,500, February-March 2011; n = 1,500, June-July 2011; n = 1,500, February 2012), and after the advertising period (n = 1,500, June-July 2012). GHS usage data (n = 6,095) were collated during July 2011-June 2012. Unprompted and prompted awareness of GHS mass media significantly increased (0% to 8.0%, p < .001; and 14.1% to 43.9%, p < .001, respectively) as well as knowledge and perceived effectiveness of the GHS. Those from the lowest three quintiles of socioeconomic disadvantage and respondents who were overweight or obese were significantly more likely to report prompted campaign awareness. The majority (84.4%) of new GHS calls occurred when television advertising was present. Participants who cited mass media as their referral source were significantly more likely to enroll
Health Promotion Practice November 2014 Vol. 15, No. (6) 828–838 DOI: 10.1177/1524839914524774 © 2014 Society for Public Health Education
828
in the intensive coaching program. Mass media campaigns remain an effective method of promoting a telephone-based statewide lifestyle program. Keywords: mass media; recruitment; telephonebased counseling; lifestyle intervention
Background >> Mass media campaigns are used extensively by population health programs to encourage the adoption of health-promoting attitudes, beliefs, and behaviors 1
University of Sydney, Sydney, New South Wales, Australia James Cook University, Cairns, Queensland, Australia 3 NSW Ministry of Health, Sydney, New South Wales, Australia 2
Authors’ Note: The authors would like to acknowledge and thank the NSW Ministry of Health for funding the evaluation of the Get Healthy Service and the Social Research Centre for conducting the tracking survey for the mass media campaign evaluation. The project was funded by the NSW Ministry of Health. Blythe O’Hara and Klaus Gebel received salaries from Prevention Research Collaboration, Sydney School of Public Health, University of Sydney. Kym Buffett received a salary from the NSW Office of Preventive Health, NSW Ministry of Health. The authors declare that there are no competing interests. Address correspondence to Blythe J. O’Hara, Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Medical Foundation Building K25, Sydney, New South Wales 2006, Australia; e-mail: [email protected].
and to a lesser extent service utilization. The effectiveness of mass media campaigns to facilitate behavior change is well understood (Noar, 2006; Snyder et al., 2004; Wakefield, Loken, & Hornik, 2010). The effectiveness of campaigns in increasing health service utilization is also recognized (Grilli, Ramsay, & Minozzi, 2009). Telephone-based smoking cessation services, such tobacco quitlines, across the world have relied on pervasive mass media campaigns to promote calls to their services (Miller, Wakefield, & Roberts, 2003; Wakefield & Miller, 1999; Williams & Bleasdale, 1999; Wilson, Grigg, Graham, & Cameron, 2005). Episodic mass media campaigns have also been used effectively to improve the uptake of early screening and immunization services (Australian Government Department of Health, Research and Marketing Group, 1998; Chen et al., 2005; Perez et al., 2009). With respect to services to support healthy eating, physical activity, and weight management, limited evidence exists on the impact of sustained mass media campaigns in promoting usage or participation in prevention services (O’Hara, Bauman, & Phongsavan, 2012). This in part reflects the dearth of population-wide lifestyle change services of similar scale and characteristics to tobacco quitlines, necessitating high-level mass media campaigning to support implementation. Any new lifestyle behavior change program using mass media campaigns to publicize its existence and promote usage would typically aim to establish its perceived service effectiveness and relevance among the target populations such that they will then be motivated to access the program for support (Flora, Maibach, & Maccoby, 1989; Wakefield & Borland, 2000). Capturing the attention of the target populations in a crowded media environment (Randolph & Viswanath, 2004) and motivating individuals to enroll in a lifestyle program in particular can be challenging, requiring time and extensive resource commitments. It is argued that the support of concerted and strategic mass communication campaigns is critical for marketing a new service (or idea) and for it to quickly diffuse into the community to increase service usage by the intended audiences (Haider & Kreps, 2004; Rogers, 2003; Snyder et al., 2004). The Get Healthy Information and Coaching Service® (GHS) is a free statewide population-based telephone service aimed at helping adults achieve and maintain lifestyle based changes (www.gethealthynsw.com.au). Introduced in 2009 by the state government of New South Wales (NSW), Australia, the GHS is a rare example of a population-wide telephone coaching support service available to free-living, healthy individuals (O’Hara et al., 2013). The GHS represents the translation of efficacious trials (Eakin, Lawler, Vandelanotte, &
Owen, 2007; Goode, Reeves, & Eakin, 2012) upscaled to a population-level program. GHS participants have primarily been recruited through self-referral (e.g., mass media advertising including television, press, radio, and digital), secondary referral pathways (e.g., health professionals, workplaces, friends, and family), and proactive marketing (which involves the distribution of a letter of introduction to specifically targeted households and a follow-up phone call inviting GHS participation). In relation to mass media advertising, GHS-specific and GHS-related (that included the GHS phone number as a call to action) mass media campaigns have been implemented. Supportive marketing activities included radio, print, online advertising, and pamphlets being distributed in household letterboxes and home-delivered magazines, specifically targeted to disadvantaged locations (based on geography and unhealthy lifestyle behaviors). A previous study has reported that continuous advertising of the GHS achieves good initial recall among socioeconomically disadvantaged groups (O’Hara, Bauman, King, & Phongsavan, 2011). The evidence to date indicates that television advertising has been more effective at recruiting adults to the one-off contact information component of the GHS, whereas health professional referrals and targeted mail-out information have been most successful in recruiting participants to the intensive 6-month GHS coaching program (O’Hara et al., 2012). Given the ongoing mass communication strategies surrounding the GHS (NSW Office of Preventive Health, 2013), the process of successfully promoting the uptake of an efficacious, scaled-up program, such as the GHS, requires a detailed examination of the ongoing role of mass media if we are to maximize the public health impact of the current and future initiatives. The aims of this research are to examine the longterm impact of mass media advertising on increasing awareness and on the perceived effectiveness of the GHS; the associations between the type of media, referral source, and enrolment in the intensive 6-month GHS coaching program; and the profile of service users over time as a result of sustained mass media campaigns.
Method >> Statewide GHS-Specific and National Obesity Prevention Advertising The aim of the GHS mass media campaign was to encourage adults to call the GHS to get brief verbal and written advice or intensive coaching support on physical activity, nutrition, and healthy weight. The GHSspecific campaign targeted adults aged 25 to 54 years
O’Hara et al. / IMPACT OF MASS MEDIA CAMPAIGN ON GET HEALTHY INFORMATION AND COACHING SERVICE 829
living in NSW and included television advertisements (15- and 30-second messages; 60:40 peak:off-peak television programming); metropolitan, suburban, and primary regional print advertisements; culturally and linguistically diverse print titles; Aboriginal print titles; live radio reads on Australian Traffic Network; online advertising and brochure inserts into periodical magazines distributed to households across regional NSW; and letterbox drops in disadvantaged metropolitan neighborhoods. No GHS-specific advertising was present from July to December 2011, followed with consistent advertising throughout the following 6 months, including 3 weeks of television advertising being present in each of these months with the 30- and 15-second commercials being used during this period. Continuous online advertising occurred from February 2012 to June 2013 and print advertising from mid-January 2012 to June 2013. Radio advertising was used only during May and June 2012 and the brochures were used in the targeted mail-out strategy from mid-January until midApril 2013. Using a national obesity prevention campaign, the GHS was also promoted at the end-of-television advertisements that were aired for 3 weeks in September 2011 and 5 weeks in March 2012. Campaign Tracking Survey To evaluate the effects of the GHS-specific campaigns, a statewide baseline survey was undertaken during the following time periods: August to September 2010 (Time Period 1), a follow-up survey in February to March 2011 (Time Period 2), a follow-up survey in June to July 2011 (Time Period 3), a follow-up survey in February 2012 (Time Period 4), and a final follow-up survey in July 2012 (Time Period 5). The NSW Ministry of Health engaged a market research agency to undertake these cross-sectional population telephone tracking surveys. The target population was English-speaking adults residing in NSW, aged 18 years and older, and living in private dwellings with telephone landlines. The households were randomly sampled, and respondents were recruited based on the “next birthday” selection method using random digit dialing. The sample size was n = 1,500 for each survey.
Survey Measures >> Information was collected via telephone-based interviews on sociodemographic variables (age, gender, geographical location, education, household composition, employment status, income, language spoken at home, Aboriginal status, and postcode); self-reported health, weight (kg), height (cm); campaign awareness
830 HEALTH PROMOTION PRACTICE / November 2014
and recall (where participants were asked to describe any healthy lifestyle advertising they had seen) and campaign recognition (also referred to as “prompted awareness” where the advertising was described to participants who were then asked about recognition); main message understanding; actions as a result of seeing the advertising; and perceived service effectiveness and personal relevance. The survey took less than 10 minutes to complete. GHS Usage Data To examine which referral pathways were associated with GHS service levels, participant usage data from July 2010 to June 2012 were examined. Number of calls to GHS was examined during this period, but the sociodemographic details of GHS participants were only examined between July 2011 and June 2012, as the results of July 2010 to June 2011 have been reported elsewhere (O’Hara et al., 2012). Participants were grouped according to their service-level choice: (a) information-only participants who received (via mail or e-mail) an information package on healthy eating (National Health and Medical Research Council, 2003), physical activity (Australian Government Department of Health, 2005), and achieving or maintaining a healthy weight and (b) coaching participants who received 10 individually tailored calls to support behavior change (Baumeister, Gailliot, DeWall, & Oaten, 2006; Carver & Scheier, 1998; Palmer, Tibbs, & Whybrow, 2003), provided by a university qualified health coach. The health coaches collected sociodemographic characteristics (gender, date of birth, residential postcode, highest level of education obtained, current employment status, language spoken at home, and Aboriginal status; Population Health Division, 2009). The postal code of participants was used to determine Socio-Economic Indexes for Areas (SEIFA), a measure of area-level socioeconomic status, which is reported by quintile of relative area disadvantage (Australian Bureau of Statistics, 2006). The postal code is also used to compute AccessibilityRemoteness Index of Australia Plus (Australian Institute of Health and Welfare, 2004), a measure of remoteness. All participants were also asked how they heard about GHS (referral source). Responses were categorized into four types of referral source: mass media, health professional, proactive marketing, and other. Ethics Approval Informed consent was obtained from all participants prior to their information being included in this study. The study was approved by the University of
Sydney Human Research Ethics Committee (Reference Nos. 02-2009/11570 and 2011-0906/14113). Statistical Analysis Statistical analyses were conducted using SPSS 21.0 (IBM SPSS Inc., 2012). Chi-square tests for linear trends were performed to examine (a) the relationship between the time of the survey and participant sociodemographic variables, and GHS mass media awareness, knowledge, behaviors, and beliefs and (b) the relationship between referral source, participant sociodemographic variables, and participant type. Adjustment for multiple testing was made using the Bonferroni method (Shaffer, 1995). Logistic regression models were used to examine the association between unprompted versus prompted awareness and actions, and sociodemographic variables, and changes over time.
Results >>
Campaign Tracking Surveys The profile of survey participants (n = 7,544) was similar across the five survey periods (data not shown). The majority were female (55.3%); older than 45 years (68.9%); were employed part- or full-time (55.2%); were non-Aboriginal (98.1%); spoke English at home (93.9%); had obtained a certificate, diploma, or bachelor’s degree or higher (56.6%); had a household income greater than AUS$50,000 (58.6%); and were from Sydney (61.0%). Approximately 52.7% of respondents were from the lowest three quintiles of area disadvantage. Approximately 53.3% were classified as being overweight or obese according to their body mass index. Table 1 shows the impact of the GHS campaign on awareness, which was as follows: unprompted awareness increased from 0.0% at baseline to 10.3% at Time Period 2, and dropped to 2.9%, 5.5%, and 8.0% at the subsequent follow-up periods (all p < .001). Prompted awareness of the GHS increased over time from 14.1% to 37.8%, 33.5%, 38.9%, and 43.9%, χ2(1) = 247.8, p < .001. There was also an increase in number of survey respondents reporting that they had undertaken action as a result of seeing the advertising (from 2.4% to 4.9%, 3.8%, 4.9%, and 5.7%), χ2(1) = 121.1 p < .001; there was a significant and gradual increase in knowledge that the service had a free call number (from 21.5% to 35.2%, 37.1%, 38.0%, and 41.6%), χ2(1) = 15.7 p < .001); and the service was provided by a Government agency. There was a moderate but significant increase in the belief that the GHS would be effective or very
effective (from 47.2% at baseline to 52.0% at Time Period 5; p < .001), but there was no increase in the belief that the GHS was of personal relevance (Table 1). Multivariate logistic regression examining correlates of unprompted and prompted awareness of the GHS campaign (data not shown) found that males were less likely than females to report unprompted campaign awareness (adjusted odds ratio [AOR]: 0.75; 95% confidence interval [CI]: 0.59, 0.95; p < .05) as were those aged 45 years and older compared to those aged less than 45 years (AOR: 0.75; 95% CI: 0.58, 0.97; p < .05). In relation to prompted campaign awareness, those aged 45 years and older were significantly less likely to report prompted campaign recall (AOR: 0.84; 95% CI: 0.72, 0.98; p < .05), as were those whose household income was greater than AUS$50,000 (AOR: 0.84; 95% CI: 0.72, 0.98; p < .01); however, those from the lowest three quintiles of advantage (the most disadvantaged) were significantly more likely to report prompted campaign awareness (AOR: 1.21; 95% CI: 1.05, 1.40; p < .01) as were those respondents who were overweight and obese (AOR: 1.51; 95% CI: 1.33, 1.72; p < .001). GHS Usage Data: GHS Calls and Advertising Between July 1, 2010, and June 30, 2012, the GHS received 15,827 new calls (i.e., not including calls from existing GHS participants). There was a clear relationship between the level of GHS-specific and the national obesity prevention television advertising and the number of new calls to GHS (Figure 1), with 84.4% of new calls occurring during periods when television advertising was present. When advertising was present, there was an average of 890 new calls per month, compared to an average of 275 calls per month when there was no television advertising present (representing a 325% increase in calls). GHS Usage Data: GHS Participants and Referral Sources Between July 1, 2011, and June 30, 2012, a total of 6,593 adults registered with the GHS, of which 6,095 (92.4%) participants consented for their information to be included for research and evaluation purposes. The majority were female (66.6%), aged 50+ years (58.4%), not in paid employment (51.1%), spoke English at home (92.9%), and lived in major cities (58.0%); 49.1% had a high school education, 4.1% identified as being Aboriginal, and 46.3% were from the lowest two quintiles of disadvantage (data not shown). Table 2 shows participant characteristics by referral source; 58.9% of participants contacted the GHS as a
O’Hara et al. / IMPACT OF MASS MEDIA CAMPAIGN ON GET HEALTHY INFORMATION AND COACHING SERVICE 831
832 HEALTH PROMOTION PRACTICE / November 2014 41.6 38.3 0.5 0.5 1.9 2.4 1.5 1.2 0.0 0.4 21.5 15.8
47.2 2.8 45.4 4.6 13.2 7.7 78.4 0.7
87 80 1 1 4 37 23 19 0 6 45 33
728 44 701 71 204 119 1,210 11
229 111 1,148 12
746 60 604 90
13 190 114
44 40 3
74
166 181 19 16 73
154 540
n
15.3 7.4 76.5 0.8
49.7 4.0 40.3 6.0
0.9 35.2 21.1
2.9 2.7 0.2
4.9
30.7 33.5 3.5 3.0 13.5
10.3 37.8
%
Follow-Up Tracking (n = 1,500, March 2011)
188 97 1,192 23
745 63 597 95
9 177 93
23 28 4
57
146 133 13 32 52
44 477
n
12.5 6.5 79.5 1.5
49.7 4.2 39.8 6.3
0.6 37.1 19.5
1.5 1.9 0.3
3.8
30.6 27.9 2.7 6.7 10.9
2.9 33.5
%
Follow-Up Tracking (n = 1,500, June 2011)
217 128 1,139 16
730 83 574 113
25 222 159
30 21 7
74
161 167 9 32 61
83 584
n
14.5 8.5 75.9 1.1
48.7 5.5 38.3 7.5
1.7 38.0 27.2
2.0 1.4 0.5
4.9
27.6 28.6 1.5 5.5 10.4
5.5 38.9
%
Follow-Up Tracking (n = 1,500, February 2012)
NOTE: GHS = Get Healthy Service. a. Significance value for comparison pre- to postcampaign using chi-square for categorical data. *Significance for trend using linear by linear chi-square tests at p < .05. **Significance for trend using linear by linear chi-square tests at p < .001.
0.0 14.1
0 209
Awareness: Unprompted awareness of GHS advertisement Awareness: Prompted awareness of GHS advertisement Understanding of main message Physical activity Healthy eating Healthy weight Phone service Help is available and it’s all about you Actions Have undertaken actions Actions undertaken (multiple responses allowed) More healthy eating Become more physically active Called the service or website/encouraged others to call service Other Knowledge of free call number Knowledge that it’s provided by New South Wales Government Perceived effectiveness and relevance of GHS service Belief that telephone service would be effective Very effective/effective Neither effective nor ineffective Ineffective/very ineffective Don’t know/refused Belief that telephone service is personally relevant Very or moderately relevant A little bit relevant Not relevant at all Don’t know/refused
%
n
Baseline (n = 1,544, September 2010)
206 131 1,146 17
780 66 562 92
13 274 182
37 41 8
85
216 246 13 29 79
120 658
n
13.7 8.7 76.4 1.1
52.0 4.4 37.5 6.1
0.9 41.6 27.7
2.5 2.7 0.5
5.7
32.8 37.4 2.0 4.4 12.0
8.0 43.9
%
Postcampaign (n = 1,500, July 2012)
