Journal of Health Communication, 19:1472–1480, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print=1087-0415 online DOI: 10.1080/10810730.2014.954082
Programmatic Research to Increase the Effectiveness of Health Communication Campaigns NANCY GRANT HARRINGTON, PHILIP C. PALMGREEN, AND LEWIS DONOHEW College of Communication and Information, University of Kentucky, Lexington, Kentucky, USA This article reviews a long program of research designed to investigate ways to increase the effectiveness of televised antidrug public service announcements. The review highlights the importance of audience targeting (adolescent and young adult high sensation seekers) and message design (message sensation value) in campaign research. It also emphasizes the role of theory and evaluation in programmatic research.
Efforts to promote health and prevent disease among our nation’s population involve many different kinds of interventions, including classroom-based programs, community-level initiatives, and health communication campaigns. Campaigns involve the design and dissemination of media-based messages through channels such as television, radio, and print, as well as newer technologies such as social media and the Internet. Researchers know a great deal about how to design and implement health communication campaigns to promote their effectiveness (Atkin & Rice, 2013). This knowledge has been gained through rigorous evaluation research conducted over several decades. Although in practice many campaigns are launched with little regard for formative, process, or outcome evaluation, our scientific knowledge of what works can be determined only through careful, systematic, theorybased evaluation research. This article describes a long program of research designed to investigate ways to increase the effectiveness of televised antidrug public service announcements (PSAs). As we present in greater detail, this research was built around two crucial concepts in campaign research: audience targeting and message design. The research was strongly guided by theory and evolved over several years from formative research to laboratory-based research to field research. Evaluation played an essential role at each stage.
Target Audiences Whether in commercial advertising or health messaging, the concept of a target audience is central. Often, only a subgroup of a population needs to be reached. For example, Axe Body Spray ads are directed at young men, whereas mammography PSAs are directed at women who are older than a certain age. In the program of drug abuse prevention research described in this article, the target audience is high Address correspondence to Nancy Grant Harrington, College of Communication and Information, University of Kentucky, 228 Grehan Building, Lexington, KY 40506, USA. E-mail: nancy.harrington@ uky.edu
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sensation-seeking adolescents and young adults. Sensation seeking is an individual differences variable defined by ‘‘the seeking of varied, novel, complex, and intense sensations and experiences, and the willingness to take physical, social, legal, and financial risks for the sake of such experience’’ (Zuckerman, 1994, p. 27). Considerable research has established a clear connection between sensation seeking and risky health behaviors, including substance use (for a review, see Zuckerman, 1994). High sensation seekers (HSS) are more likely to start using drugs at an earlier age, use a greater variety of drugs, and use more drugs than low sensation seekers (LSS). Therefore, using sensation seeking as an audience segmentation variable makes great sense.
Activation Theory of Information Exposure Theory guides the strategy used to design the antidrug messages for this target audience. According to the activation theory of information exposure (Donohew, 2009; Donohew, Lorch, & Palmgreen, 1998; Donohew, Palmgreen, & Duncan, 1980), attention to a stimulus is partly a function of a person’s need for stimulation and the stimulation provided by a stimulus source. If audience members do not achieve or maintain an optimal level of arousal upon exposure to a message—if they receive too much or too little stimulation—they will likely turn away and seek another source of stimulation. If activation remains within some acceptable range, however, the audience will be more likely to continue exposure to the information. In other words, designing messages with sufficient levels of arousal value increases the likelihood that the audience will pay attention to the message (Donohew, Lorch, & Palmgreen, 1991; Donohew, Palmgreen, & Lorch, 1994). Because HSS are attracted to stimuli that are intense, novel, and arousing and LSS tend to prefer more familiar and less arousing fare, it is reasonable to presume that HSS and LSS would be attracted to messages that are more or less arousing, as well. Message sensation value (MSV) is defined in our research as the degree to which a message is able to elicit sensory, affective, and arousal responses in audience members (Palmgreen, Stephenson, Everett, Baseheart, & Francies, 2002). High sensation value (HSV) messages feature characteristics such as novelty, creativity, intensity, ambiguity, and suspense; low sensation value (LSV) messages are more familiar, predictable, calm, and clear. These definitions are the result of extensive formative research with focus groups of HSS and LSS young adults who viewed and provided evaluations of multiple commercial advertisements and PSAs, describing what they liked, what they disliked, and why. According to the theoretical model, matching the message’s sensation value to the needs of the target audience should result in increased attention to the message, the first step in achieving persuasive effects. According to research on sensation seeking, the HSS audience is the primary one we need to reach in risky behavior prevention campaigns.
Measuring MSV In evaluation research, reliable and valid measurement is crucial. In early research, MSV was operationalized as audience members’ subjective responses to messages. The 17-item Perceived Message Sensation Value (PMSV) scale (Palmgreen et al., 2002) assesses how people perceive a message to elicit emotional arousal, dramatic impact, and novelty. Although viewers’ subjective assessments of a message’s sensation value are important, having a more objective indicator of which features comprise HSV messages is more helpful for message designers. Thus, Morgan, Palmgreen, Stephenson, Hoyle, and Lorch (2003) worked to identify specific
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message content, format, and structural features that could define the sensation value of a video message. Their MSV coding system considers visual, audio, and content features of messages. The visual dimension assesses the number of cuts and the use of special visual effects, slow motion, unusual colors, and intense images. The audio dimension assesses sound saturation and use of music and sound effects. The content dimension considers whether the PSA is acted out or presented as a testimonial and whether it uses an unexpected format and has a surprise or twist ending. Results of a study that involved 418 college students assessing 109 antidrug PSAs showed a moderate correlation between MSV and PMSV (r ¼ .46), as well as between MSV and each of PMSV’s three subscales (dramatic impact, r ¼ .38; novelty, r ¼ .45; and emotional arousal, r ¼ .48). The objective MSV features most strongly related to PMSV were intense images, sound saturation, being acted out, and having an unexpected format and a surprise or twist ending.
Formative and Laboratory Research Conducting a health communication campaign is an expensive undertaking. Therefore, before taking messages to the field, researchers should conduct formative and laboratory-based research to increase the potential for message effectiveness. This foundational work in the research program described here involved formative work with focus and reaction groups and then two phases of laboratory research designed to test HSV and LSV PSAs produced for the studies. Message development came first, of course. Using criteria for HSV and LSV messages developed through earlier formative work, the research team created three test message concepts, translated them to storyboard format, and tested them with focus and reaction groups to assess each concept’s ability to attract attention and promote thinking about the message. The message concept that performed best, one that presented a pinball game as a metaphor for ‘‘the game of life,’’ was then produced in two versions, HSV and LSV, for use in the laboratory research. The first phase of the laboratory research involved 207 young adults between 18 and 22 years of age who came to the laboratory in groups of two to five to watch 4 min of television programming, including one version of the test PSA. The goal of the study was to evaluate whether message targeting worked. The primary dependent variable in this study was behavioral intention to call a hotline to learn more about avoiding drugs. Results showed the predicted interaction effect, indicating that LSS were more persuaded by the LSV PSA and HSS tended to be more persuaded by the HSV PSA (Palmgreen et al., 1991). This laboratory setting used a forced attention design, putting research participants in front of a television set, virtually guaranteeing attention. Forced attention is hardly guaranteed in the outside world, though, so the next phase of research evaluated the extent to which the PSAs would have impact in a more natural setting. This more ecologically valid experiment involved 318 adults between 18 and 22 years of age who came to a simulated living room setting one at a time to watch 30 minutes of HSV or LSV television programming (as determined by focus groups) into which one version of the PSAs developed in the previous experiment was embedded. The living room was set up with a sofa, a coffee table with several magazines, a television set, and an unobtrusive camera that recorded participants’ behavior, including whether or not they were watching the television. The primary dependent variable in this study was attention (eyes on screen). Results showed that HSS paid more attention to PSAs in HSV programming and LSS paid more attention to PSAs in LSV programming, but LSS watched HSV PSAs almost as much as HSS did (Lorch et al., 1994). From this, the researchers concluded that in designing
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messages for campaigns, HSV messages were necessary to attract HSS viewers—the prime target audience—but these same messages could reach LSV viewers, as well. Furthermore, placing PSAs in HSV programming that the target audience will actually watch is also quite important.
Field Research The next step in the program of research was to take the results of the laboratory work and apply them to a campaign setting. For this campaign, the target audience was HSS young adults. Through additional formative research with members of the target audience, the research team developed five new HSV PSAs for the campaign, each of which encouraged viewers to call a hotline to learn about exciting alternatives to drug use. Working with a media buyer, the researchers purchased air time for 615 spots and obtained 887 free spots, and the spots were scheduled during HSV television programming. The campaign ran for 5 months in Lexington, Kentucky. Callers to the hotline received a 20-page booklet called ‘‘A Thrillseeker’s Guide,’’ which explained sensation seeking and its relation to drug use and provided information on a plethora of exciting activities to pursue in the Lexington area. The evaluation was composed of three parts: (a) a pre- and postcampaign in-person survey of a random sample of Lexington residents 16–25 years old (precampaign n ¼ 597; postcampaign n ¼ 525), (b) four within-campaign telephone surveys of random samples of 16–25-year-old Lexington residents, with approximately 100 respondents recruited per month over 4 months (n ¼ 472), and (c) a survey of 18–25-year-olds who called the hotline and agreed to participate in the study (n ¼ 749). The evaluation was designed to assess evidence of targeting effectiveness and PSA recall. Response to the campaign and results across the surveys suggested the campaign was effective (Palmgreen et al., 1995). More than 2,100 people made calls to the hotline; 60% of callers were 18–25 years old, and 80% were 16–25 years old. Callers to the hotline were more likely to be HSS than precampaign participants: 73% versus 50%. Furthermore, hotline callers were more likely to be drug users than precampaign participants: 32% versus 23%. Thus, the campaign seemed to be reaching its target audience. Equally important, the campaign PSAs were having an impact on the target audience. Within-campaign data revealed that HSS were more likely to recall campaign PSAs (55%) than other antidrug PSAs being aired in the Lexington market (45%), whereas LSS were more likely to recall other antidrug PSAs (63%) than campaign PSAs (37%). Postcampaign survey data supported the effect on recall, as well as targeting. Respondents reported how certain they were that they had seen the two most frequently shown campaign PSAs. Results showed that HSS drug users were most likely to report that they had seen these PSAs, followed by LSS drug users, then HSS nonusers, and finally LSS nonusers. That first field study provided evidence for the effectiveness of targeting PSAs toward the young adult HSS audience in an actual campaign. But what about impact on drug use? Compelling evidence for the effectiveness of using HSV messages to reduce drug use among HSS comes from a study by Palmgreen, Donohew, Lorch, Hoyle, and Stephenson (2001). The study tested the effectiveness of a campaign to reduce marijuana use among HSS adolescents. The researchers used a controlled interrupted time-series design and implemented the campaign in Lexington, Kentucky, and Knoxville, Tennessee, two comparable Midwestern cities. Data, including self-reported marijuana use, were collected from random samples of 100 adolescents in each city each month for 32 months. The campaign ran twice in Lexington and once in Knoxville. Interrupted time-series analyses showed that all three campaigns reversed the strong upward developmental trends in 30-day
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marijuana use among HSS adolescents; no campaign effects were evident among LSS teens, who were not targeted and had very low levels of marijuana use. Palmgreen, Lorch, Stephenson, Hoyle, and Donohew (2007) provided further evidence of the effectiveness of HSV PSAs on HSS youths’ drug use in another study that examined effects of the ‘‘Marijuana Initiative’’ put into effect in 2002 as part of the Office of National Drug Control Policy’s National Youth Anti-Drug Media Campaign. The marijuana initiative was developed and launched after evaluations of the initial campaign were showing it to be ineffective. The new PSAs were designed to follow the principles of HSV message design much more closely. Modeling the design of their 2001 study, Palmgreen and colleagues collected data from 100 randomly selected adolescents in Lexington and Knoxville monthly over a 48-month period that included the first 6 months of the marijuana initiative. Again, interrupted time-series analyses showed that the new HSV PSAs were effective in reversing the upward developmental trend in 30-day marijuana use and reducing positive marijuana attitudes and beliefs among HSS teens. Consistent with the 2001 study, there was no discernible impact on LSS given their low levels of marijuana use.
SENTAR All of this research built to and supported an approach used to guide the design of a number of health communication campaigns for at-risk audiences. This approach, called SENTAR (for SENsation seeking TARgeting; Palmgreen & Donohew, 2003, 2010), is summarized by the following principles: Use the sensation-seeking trait as a major audience segmentation variable Design HSV prevention messages to reach HSS . Conduct formative research with members of the HSS target audience . Place prevention messages in high sensation value contexts . .
As the Office of National Drug Control Policy study previously described indicates, ‘‘SENTAR has evolved beyond the sphere of scientific research to guide policy and large-scale prevention interventions’’ (Palmgreen & Donohew, 2010, p. 609). In 2007, the Society for Prevention Research presented the University of Kentucky SENTAR research group with the Prevention Science Award. The award recognizes a large body of research that has used scientific methods to test preventive interventions or policies.
The Role of Theory Thus far, we have been arguing for the importance of evaluation in health communication campaign research. Equally important is theory. Without theory, a researcher has little to guide the design of messages, the implementation of the campaign, or, for that matter, the campaign’s evaluation. As da Vinci argued, ‘‘He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.’’ The activation theory of information exposure guided message design and dissemination for the program of research reviewed in this article. It, along with other theoretical models, also provides direction for future research. For example, even with the success of campaigns based on SENTAR principles, there is much more we need to know about how MSV affects target audiences. We see at least two pressing theoretical questions facing MSV research. The first is related to message targeting and the extent to which messages that vary in sensation value are necessary to reach target audiences; the second is related to message
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processing and the extent to which HSV features that function to attract attention may also function as distractors and inhibit message processing. According to theory, HSV messages should appeal to HSS audiences but not LSS audiences, whereas LSV messages should appeal to LSS but not HSS. A number of early studies supported this contention (e.g., Everett & Palmgreen, 1995; Palmgreen et al., 1991). However, some later studies began to suggest that while HSV messages are necessary to reach HSS youth, LSS youth may find HSV messages just as appealing as LSV messages (Helme, Donohew, Baier, & Zittleman, 2007; Lorch et al., 1994). This lack of differentiation among LSS youth may reflect the changing nature of the media landscape, in which so many of the messages targeting adolescents are HSV that it is difficult to find something low in sensation value; in other words, LSS youth may have become habituated to HSV messages. The empirical question, then, becomes whether HSS youth also have become habituated and therefore need something even higher in sensation value to attract and hold their attention. Although the bounds of ethics and decency may prevent us from exploring the upper end of the MSV continuum, the empirical question remains. A more pressing question may be how HSV actually functions to influence the persuasion process. As mentioned earlier, according to the activation theory of information exposure, message features act as a source of stimulation that can help audience members meet their optimal level of arousal; therefore, effectively targeted messages can attract and hold the attention of a target audience. Attention is just the first step of the persuasion process, however. Some theoretical perspectives suggest that HSV features may compromise message processing, acting as distractors that would impede the ability to centrally process message arguments (the elaboration likelihood model [ELM]; Petty & Cacioppo, 1986) or as drains on limited cognitive resources that would reduce the ability to encode and store message arguments (Lang, 2000). For example, Kang, Cappella, and Fishbein (2006) found as part of a secondary analysis of 60 antimarijuana PSAs that for high-risk adolescents, MSV served as a distractor of attention. In this study, one sample of adolescents provided assessments of argument quality, which was determined by adolescents’ ratings of a number of argument characteristics such as convincingness, believability, and importance; a second sample of adolescents provided data on perceived PSA effectiveness, liking, and thought listing (which has the longest standing tradition as a measure of message processing). Trained coders coded the PSAs for MSV using a slightly modified version of the Morgan and colleagues (2003) classification system. Analysis of variance results showed a three-way interaction between MSV, argument quality, and risk of marijuana use, indicating that among at-risk youth, perceptions of HSV PSA persuasiveness were lower when argument quality was high and higher when argument quality was low. Such an interaction is taken as evidence of peripheral processing, suggesting that HSV was a distractor. (In the experimental setting, PSAs did not have to compete with other stimuli for attention.) Other research, however, suggests that HSV messages actually facilitate processing. Niederdeppe (2005) conducted a study to investigate how specific features related to MSV might be related to message processing. He first coded PSAs used in the Florida ‘‘truth’’ antitobacco media campaign for a variety of MSV features. Then, using data from the Florida Anti-tobacco Media Evaluation surveys, he created a measure of cognitive processing based on the extent to which adolescents thought about, talked about, and liked the PSAs. He found that among older teens (16–18 years), unrelated cuts, intense images, and a ‘‘second-half punch’’ were related to increased cognitive processing. An additive three-item index consisting of these features was related to increased cognitive processing among both older and younger (12–15 years) teens. He suggested that the concept of syntactic
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indeterminacy (Messaris, 1997) may explain the increased processing effects. Syntactic indeterminacy notes that visual images lack the syntax found in text; therefore, audiences must put forth more effort into decoding the meaning of visual images. HSV messages that have a greater number of unrelated cuts increase the amount of cognitive resources needed to make sense of the imagery, which in turn enhances overall message processing. The question of whether HSV promotes or inhibits central processing (and under what conditions it may do so) remains an open one. Even if HSV functions to inhibit central processing, though, such an effect may actually be beneficial for an at-risk audience. Stephenson and Palmgreen (2001) investigated the influence of PMSV and personal involvement with marijuana on cognitive (central), narrative (attention to character and story details), and sensory (attention to audio and video features) processing of antimarijuana PSAs. In this study, 386 students in 9th through 12th grade watched three of six PSAs, all of which had narrative structure and varied on sensation value elements. Students completed the PMSV scale for each PSA and a measure of personal involvement with marijuana, and they completed closed-ended measures for amount and valence of cognitive processing, narrative processing, and sensory processing. Results showed less cognitive processing and more negative cognitive processing among students more personally involved with marijuana and by HSS more so than LSS; HSS also were more involved with marijuana than LSS, a result that is not surprising but is important for targeting. Most important for message design was the finding that higher PMSV facilitated message processing among both HSS and LSS. In other words, higher PMSV facilitated promessage processing and inhibited the negative effects of personal involvement with marijuana for both HSS and LSS. The results of four other studies (including three campaign studies) reported above (Palmgreen et al., 1991, 1995, 2001, 2007) also provide evidence of the positive persuasive effects of HSV messages on HSS audiences. The results of these and other studies on the effects of MSV=PMSV on message processing are complex, and they are complicated by substantial differences in methodologies across the studies. A more thorough understanding of the impact of MSV on message processing and persuasion is of crucial theoretical importance, however, and therefore warrants continued attention by researchers interested in campaign research and drug abuse prevention.
Concluding Thoughts As research in health communication campaigns moves forward, researchers must be mindful of the central role of evaluation in understanding campaign effects and advancing their effectiveness. They must also be mindful of the extremely complex and ever-evolving media landscape. In the past few decades, the landscape has evolved from one of primarily print, radio, and television to a heavily Internet-based, interactive, multimedia free-for-all. This evolution has profound implications for message design. While it may increase flexibility in terms of message design and dissemination, it also introduces constraints in terms of platform and channel. We also must recognize that campaigns do not operate in a vacuum. Indeed, there is a multitude of environmental factors that can influence campaign effects. As Hornik and Yanovitzky (2003) observed, ‘‘A . . . typical campaign may depend on operating through multiple channels, diffusion of messages repeatedly over time, and supportive actions from institutions and social networks’’ (p. 212). Evaluation researchers should be mindful of this. Evaluation researchers also should be mindful of sound reporting standards when they publish their studies (Harrington & Noar, 2012). Reports should clearly specify the theory or theories that informed the study and all relevant aspects of
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formative, process, and outcome evaluation (see also APA Publications and Communications Board Working Group on Journal Article Reporting Standards, 2008). Following sound reporting standards will more effectively convey results of evaluation research, will facilitate replication and synthesis, and in turn will help to promote a cumulative science of health promotion and disease prevention research.
References APA Publications and Communications Board Working Group on Journal Article Reporting Standards. (2008). Reporting standards for research in psychology: Why do we need them? What might they be? American Psychologist, 63, 839–851. Atkin, C. K., & Rice, R. E. (2013). Theory and principles of public communication campaigns. In R. E. Rice & C. K. Atkin (Eds.), Public communication campaigns (4th ed., pp. 3–19). Los Angeles, CA: Sage. Donohew, L. (2009). Activation theory of information exposure. In S. Littlejohn & K. A. Foss (Eds.), Encyclopedia of communication theory (pp. 11–15). London, England: Sage. Donohew, L., Lorch, E. P., & Palmgreen, P. (1991). Sensation seeking and targeting of televised anti-drug PSAs. In L. Donohew, H. E. Sypher, & W. J. Bukoski (Eds.), Persuasive communication and drug abuse prevention (pp. 209–226). Hillsdale, NJ: Erlbaum. Donohew, L., Lorch, E. P., & Palmgreen, P. (1998). Applications of a theoretic model of information exposure to health interventions. Human Communication Research, 24, 454–468. Donohew, L., Palmgreen, P., & Duncan, J. (1980). An activation model of information exposure. Communication Monographs, 47, 295–303. Donohew, L., Palmgreen, P., & Lorch, E. P. (1994). Attention, need for sensation, and health communication campaigns. American Behavioral Scientist, 38, 310–322. Everett, M. W., & Palmgreen, P. (1995). Influences of sensation seeking, message sensation value, and program context on effectiveness of anti-cocaine PSAs. Health Communication, 7, 225–248. Harrington, N. G., & Noar, S. M. (2012). Reporting standards for studies of tailored interventions. Health Education Research, 27, 331–342. Helme, D. W., Donohew, R. L., Baier, M., Zittleman, L. (2007). A classroom-administered simulation of a television campaign on adolescent smoking: Testing an activation model of information exposure. Journal of Health Communication, 12, 399–415. Hornik, R., & Yanovitzky, I. (2003). Using theory to design evaluations of communication campaigns: The case of the National Youth Anti-Drug Media Campaign. Communication Theory, 13, 204–224. Kang, Y., Cappella, J., & Fishbein, M. (2006). The attentional mechanism of message sensation value: Interaction between message sensation value and argument quality on message effectiveness. Communication Monographs, 73, 351–378. Lang, A. (2000). The limited capacity model of mediated message processing. Journal of Communication, 50, 46–70. Lorch, E. P., Palmgreen, P., Donohew, L., Helm, D., Baer, S. A., & D’Silva, M. U. (1994). Program context, sensation seeking, and attention to televised anti-drug public service announcements. Human Communication Research, 20, 390–412. Messaris, P. (1997). Visual persuasion: The role of images in advertising. Thousand Oaks, CA: Sage. Morgan, S. E., Palmgreen, P., Stephenson, M. T., Hoyle, R., & Lorch, E. P. (2003). Associations between message features and subjective evaluations of the sensation value of antidrug public service announcements. Journal of Communication, 53, 512–526. Niederdeppe, J. D. (2005). Syntactic indeterminacy, perceived message sensation valueenhancing features, and message processing in the context of anti-tobacco advertisements. Communication Monographs, 72, 324–344.
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Palmgreen, P., & Donohew, L. (2003). Effective mass media strategies for drug abuse prevention campaigns. In Z. Sloboda & W. J. Bukoski (Eds.), Handbook of drug abuse prevention: Theory, science and practice (pp. 27–43). New York, NY: Kluwer=Plenum. Palmgreen, P., & Donohew, L. (2010). Impact of SENTAR on prevention campaign policy and practice. Health Communication, 25, 609–610. Palmgreen, P., Donohew, L., Lorch, E. P., Hoyle, R., & Stephenson, M. T. (2001). Television campaigns and adolescent marijuana use: Tests of sensation seeking targeting. American Journal of Public Health, 91, 292–296. Palmgreen, P., Donohew, L., Lorch, E. P., Rogus, M., Helm, D., & Grant, N. (1991). Sensation seeking, message sensation value, and drug use as mediators of PSA effectiveness. Health Communication, 3, 217–227. Palmgreen, P., Lorch, E. P., Donohew, L., Harrington, N. G., Dsilva, M., & Helm, D. (1995). Reaching at-risk populations in a mass media drug abuse prevention campaign: Sensation seeking as a targeting variable. Drugs & Society, 8, 29–45. Palmgreen, P., Lorch, E. P., Stephenson, M. T., Hoyle, R. H., & Donohew, L. (2007). Effects of the Office of National Drug Control Policy’s marijuana initiative campaign on high-sensation-seeking adolescents. American Journal of Public Health, 97, 1644–1649. Palmgreen, P., Stephenson, M. T., Everett, M. W., Baseheart, J. R., & Francies, R. (2002). Perceived message sensation value (PMSV) and the dimensions and validation of a PMSV scale. Health Communication, 14, 403–428. Petty, R. E., & Cacioppo, J. T. (1986). Communication and persuasion: Central and peripheral routes to attitude change. New York, NY: Springer-Verlag. Stephenson, M. T., & Palmgreen, P. (2001). Sensation seeking, message sensation value, personal involvement, and processing of antidrug PSAs. Communication Monographs, 68, 49–71. Zuckerman, M. (1994). Behavioral expressions and biosocial bases of sensation seeking. Cambridge, England: Cambridge University Press.
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Programmatic Research to Increase the Effectiveness of Health Communication Campaigns NANCY GRANT HARRINGTON, PHILIP C. PALMGREEN, AND LEWIS DONOHEW College of Communication and Information, University of Kentucky, Lexington, Kentucky, USA This article reviews a long program of research designed to investigate ways to increase the effectiveness of televised antidrug public service announcements. The review highlights the importance of audience targeting (adolescent and young adult high sensation seekers) and message design (message sensation value) in campaign research. It also emphasizes the role of theory and evaluation in programmatic research.
Efforts to promote health and prevent disease among our nation’s population involve many different kinds of interventions, including classroom-based programs, community-level initiatives, and health communication campaigns. Campaigns involve the design and dissemination of media-based messages through channels such as television, radio, and print, as well as newer technologies such as social media and the Internet. Researchers know a great deal about how to design and implement health communication campaigns to promote their effectiveness (Atkin & Rice, 2013). This knowledge has been gained through rigorous evaluation research conducted over several decades. Although in practice many campaigns are launched with little regard for formative, process, or outcome evaluation, our scientific knowledge of what works can be determined only through careful, systematic, theorybased evaluation research. This article describes a long program of research designed to investigate ways to increase the effectiveness of televised antidrug public service announcements (PSAs). As we present in greater detail, this research was built around two crucial concepts in campaign research: audience targeting and message design. The research was strongly guided by theory and evolved over several years from formative research to laboratory-based research to field research. Evaluation played an essential role at each stage.
Target Audiences Whether in commercial advertising or health messaging, the concept of a target audience is central. Often, only a subgroup of a population needs to be reached. For example, Axe Body Spray ads are directed at young men, whereas mammography PSAs are directed at women who are older than a certain age. In the program of drug abuse prevention research described in this article, the target audience is high Address correspondence to Nancy Grant Harrington, College of Communication and Information, University of Kentucky, 228 Grehan Building, Lexington, KY 40506, USA. E-mail: nancy.harrington@ uky.edu
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sensation-seeking adolescents and young adults. Sensation seeking is an individual differences variable defined by ‘‘the seeking of varied, novel, complex, and intense sensations and experiences, and the willingness to take physical, social, legal, and financial risks for the sake of such experience’’ (Zuckerman, 1994, p. 27). Considerable research has established a clear connection between sensation seeking and risky health behaviors, including substance use (for a review, see Zuckerman, 1994). High sensation seekers (HSS) are more likely to start using drugs at an earlier age, use a greater variety of drugs, and use more drugs than low sensation seekers (LSS). Therefore, using sensation seeking as an audience segmentation variable makes great sense.
Activation Theory of Information Exposure Theory guides the strategy used to design the antidrug messages for this target audience. According to the activation theory of information exposure (Donohew, 2009; Donohew, Lorch, & Palmgreen, 1998; Donohew, Palmgreen, & Duncan, 1980), attention to a stimulus is partly a function of a person’s need for stimulation and the stimulation provided by a stimulus source. If audience members do not achieve or maintain an optimal level of arousal upon exposure to a message—if they receive too much or too little stimulation—they will likely turn away and seek another source of stimulation. If activation remains within some acceptable range, however, the audience will be more likely to continue exposure to the information. In other words, designing messages with sufficient levels of arousal value increases the likelihood that the audience will pay attention to the message (Donohew, Lorch, & Palmgreen, 1991; Donohew, Palmgreen, & Lorch, 1994). Because HSS are attracted to stimuli that are intense, novel, and arousing and LSS tend to prefer more familiar and less arousing fare, it is reasonable to presume that HSS and LSS would be attracted to messages that are more or less arousing, as well. Message sensation value (MSV) is defined in our research as the degree to which a message is able to elicit sensory, affective, and arousal responses in audience members (Palmgreen, Stephenson, Everett, Baseheart, & Francies, 2002). High sensation value (HSV) messages feature characteristics such as novelty, creativity, intensity, ambiguity, and suspense; low sensation value (LSV) messages are more familiar, predictable, calm, and clear. These definitions are the result of extensive formative research with focus groups of HSS and LSS young adults who viewed and provided evaluations of multiple commercial advertisements and PSAs, describing what they liked, what they disliked, and why. According to the theoretical model, matching the message’s sensation value to the needs of the target audience should result in increased attention to the message, the first step in achieving persuasive effects. According to research on sensation seeking, the HSS audience is the primary one we need to reach in risky behavior prevention campaigns.
Measuring MSV In evaluation research, reliable and valid measurement is crucial. In early research, MSV was operationalized as audience members’ subjective responses to messages. The 17-item Perceived Message Sensation Value (PMSV) scale (Palmgreen et al., 2002) assesses how people perceive a message to elicit emotional arousal, dramatic impact, and novelty. Although viewers’ subjective assessments of a message’s sensation value are important, having a more objective indicator of which features comprise HSV messages is more helpful for message designers. Thus, Morgan, Palmgreen, Stephenson, Hoyle, and Lorch (2003) worked to identify specific
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message content, format, and structural features that could define the sensation value of a video message. Their MSV coding system considers visual, audio, and content features of messages. The visual dimension assesses the number of cuts and the use of special visual effects, slow motion, unusual colors, and intense images. The audio dimension assesses sound saturation and use of music and sound effects. The content dimension considers whether the PSA is acted out or presented as a testimonial and whether it uses an unexpected format and has a surprise or twist ending. Results of a study that involved 418 college students assessing 109 antidrug PSAs showed a moderate correlation between MSV and PMSV (r ¼ .46), as well as between MSV and each of PMSV’s three subscales (dramatic impact, r ¼ .38; novelty, r ¼ .45; and emotional arousal, r ¼ .48). The objective MSV features most strongly related to PMSV were intense images, sound saturation, being acted out, and having an unexpected format and a surprise or twist ending.
Formative and Laboratory Research Conducting a health communication campaign is an expensive undertaking. Therefore, before taking messages to the field, researchers should conduct formative and laboratory-based research to increase the potential for message effectiveness. This foundational work in the research program described here involved formative work with focus and reaction groups and then two phases of laboratory research designed to test HSV and LSV PSAs produced for the studies. Message development came first, of course. Using criteria for HSV and LSV messages developed through earlier formative work, the research team created three test message concepts, translated them to storyboard format, and tested them with focus and reaction groups to assess each concept’s ability to attract attention and promote thinking about the message. The message concept that performed best, one that presented a pinball game as a metaphor for ‘‘the game of life,’’ was then produced in two versions, HSV and LSV, for use in the laboratory research. The first phase of the laboratory research involved 207 young adults between 18 and 22 years of age who came to the laboratory in groups of two to five to watch 4 min of television programming, including one version of the test PSA. The goal of the study was to evaluate whether message targeting worked. The primary dependent variable in this study was behavioral intention to call a hotline to learn more about avoiding drugs. Results showed the predicted interaction effect, indicating that LSS were more persuaded by the LSV PSA and HSS tended to be more persuaded by the HSV PSA (Palmgreen et al., 1991). This laboratory setting used a forced attention design, putting research participants in front of a television set, virtually guaranteeing attention. Forced attention is hardly guaranteed in the outside world, though, so the next phase of research evaluated the extent to which the PSAs would have impact in a more natural setting. This more ecologically valid experiment involved 318 adults between 18 and 22 years of age who came to a simulated living room setting one at a time to watch 30 minutes of HSV or LSV television programming (as determined by focus groups) into which one version of the PSAs developed in the previous experiment was embedded. The living room was set up with a sofa, a coffee table with several magazines, a television set, and an unobtrusive camera that recorded participants’ behavior, including whether or not they were watching the television. The primary dependent variable in this study was attention (eyes on screen). Results showed that HSS paid more attention to PSAs in HSV programming and LSS paid more attention to PSAs in LSV programming, but LSS watched HSV PSAs almost as much as HSS did (Lorch et al., 1994). From this, the researchers concluded that in designing
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messages for campaigns, HSV messages were necessary to attract HSS viewers—the prime target audience—but these same messages could reach LSV viewers, as well. Furthermore, placing PSAs in HSV programming that the target audience will actually watch is also quite important.
Field Research The next step in the program of research was to take the results of the laboratory work and apply them to a campaign setting. For this campaign, the target audience was HSS young adults. Through additional formative research with members of the target audience, the research team developed five new HSV PSAs for the campaign, each of which encouraged viewers to call a hotline to learn about exciting alternatives to drug use. Working with a media buyer, the researchers purchased air time for 615 spots and obtained 887 free spots, and the spots were scheduled during HSV television programming. The campaign ran for 5 months in Lexington, Kentucky. Callers to the hotline received a 20-page booklet called ‘‘A Thrillseeker’s Guide,’’ which explained sensation seeking and its relation to drug use and provided information on a plethora of exciting activities to pursue in the Lexington area. The evaluation was composed of three parts: (a) a pre- and postcampaign in-person survey of a random sample of Lexington residents 16–25 years old (precampaign n ¼ 597; postcampaign n ¼ 525), (b) four within-campaign telephone surveys of random samples of 16–25-year-old Lexington residents, with approximately 100 respondents recruited per month over 4 months (n ¼ 472), and (c) a survey of 18–25-year-olds who called the hotline and agreed to participate in the study (n ¼ 749). The evaluation was designed to assess evidence of targeting effectiveness and PSA recall. Response to the campaign and results across the surveys suggested the campaign was effective (Palmgreen et al., 1995). More than 2,100 people made calls to the hotline; 60% of callers were 18–25 years old, and 80% were 16–25 years old. Callers to the hotline were more likely to be HSS than precampaign participants: 73% versus 50%. Furthermore, hotline callers were more likely to be drug users than precampaign participants: 32% versus 23%. Thus, the campaign seemed to be reaching its target audience. Equally important, the campaign PSAs were having an impact on the target audience. Within-campaign data revealed that HSS were more likely to recall campaign PSAs (55%) than other antidrug PSAs being aired in the Lexington market (45%), whereas LSS were more likely to recall other antidrug PSAs (63%) than campaign PSAs (37%). Postcampaign survey data supported the effect on recall, as well as targeting. Respondents reported how certain they were that they had seen the two most frequently shown campaign PSAs. Results showed that HSS drug users were most likely to report that they had seen these PSAs, followed by LSS drug users, then HSS nonusers, and finally LSS nonusers. That first field study provided evidence for the effectiveness of targeting PSAs toward the young adult HSS audience in an actual campaign. But what about impact on drug use? Compelling evidence for the effectiveness of using HSV messages to reduce drug use among HSS comes from a study by Palmgreen, Donohew, Lorch, Hoyle, and Stephenson (2001). The study tested the effectiveness of a campaign to reduce marijuana use among HSS adolescents. The researchers used a controlled interrupted time-series design and implemented the campaign in Lexington, Kentucky, and Knoxville, Tennessee, two comparable Midwestern cities. Data, including self-reported marijuana use, were collected from random samples of 100 adolescents in each city each month for 32 months. The campaign ran twice in Lexington and once in Knoxville. Interrupted time-series analyses showed that all three campaigns reversed the strong upward developmental trends in 30-day
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marijuana use among HSS adolescents; no campaign effects were evident among LSS teens, who were not targeted and had very low levels of marijuana use. Palmgreen, Lorch, Stephenson, Hoyle, and Donohew (2007) provided further evidence of the effectiveness of HSV PSAs on HSS youths’ drug use in another study that examined effects of the ‘‘Marijuana Initiative’’ put into effect in 2002 as part of the Office of National Drug Control Policy’s National Youth Anti-Drug Media Campaign. The marijuana initiative was developed and launched after evaluations of the initial campaign were showing it to be ineffective. The new PSAs were designed to follow the principles of HSV message design much more closely. Modeling the design of their 2001 study, Palmgreen and colleagues collected data from 100 randomly selected adolescents in Lexington and Knoxville monthly over a 48-month period that included the first 6 months of the marijuana initiative. Again, interrupted time-series analyses showed that the new HSV PSAs were effective in reversing the upward developmental trend in 30-day marijuana use and reducing positive marijuana attitudes and beliefs among HSS teens. Consistent with the 2001 study, there was no discernible impact on LSS given their low levels of marijuana use.
SENTAR All of this research built to and supported an approach used to guide the design of a number of health communication campaigns for at-risk audiences. This approach, called SENTAR (for SENsation seeking TARgeting; Palmgreen & Donohew, 2003, 2010), is summarized by the following principles: Use the sensation-seeking trait as a major audience segmentation variable Design HSV prevention messages to reach HSS . Conduct formative research with members of the HSS target audience . Place prevention messages in high sensation value contexts . .
As the Office of National Drug Control Policy study previously described indicates, ‘‘SENTAR has evolved beyond the sphere of scientific research to guide policy and large-scale prevention interventions’’ (Palmgreen & Donohew, 2010, p. 609). In 2007, the Society for Prevention Research presented the University of Kentucky SENTAR research group with the Prevention Science Award. The award recognizes a large body of research that has used scientific methods to test preventive interventions or policies.
The Role of Theory Thus far, we have been arguing for the importance of evaluation in health communication campaign research. Equally important is theory. Without theory, a researcher has little to guide the design of messages, the implementation of the campaign, or, for that matter, the campaign’s evaluation. As da Vinci argued, ‘‘He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast.’’ The activation theory of information exposure guided message design and dissemination for the program of research reviewed in this article. It, along with other theoretical models, also provides direction for future research. For example, even with the success of campaigns based on SENTAR principles, there is much more we need to know about how MSV affects target audiences. We see at least two pressing theoretical questions facing MSV research. The first is related to message targeting and the extent to which messages that vary in sensation value are necessary to reach target audiences; the second is related to message
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processing and the extent to which HSV features that function to attract attention may also function as distractors and inhibit message processing. According to theory, HSV messages should appeal to HSS audiences but not LSS audiences, whereas LSV messages should appeal to LSS but not HSS. A number of early studies supported this contention (e.g., Everett & Palmgreen, 1995; Palmgreen et al., 1991). However, some later studies began to suggest that while HSV messages are necessary to reach HSS youth, LSS youth may find HSV messages just as appealing as LSV messages (Helme, Donohew, Baier, & Zittleman, 2007; Lorch et al., 1994). This lack of differentiation among LSS youth may reflect the changing nature of the media landscape, in which so many of the messages targeting adolescents are HSV that it is difficult to find something low in sensation value; in other words, LSS youth may have become habituated to HSV messages. The empirical question, then, becomes whether HSS youth also have become habituated and therefore need something even higher in sensation value to attract and hold their attention. Although the bounds of ethics and decency may prevent us from exploring the upper end of the MSV continuum, the empirical question remains. A more pressing question may be how HSV actually functions to influence the persuasion process. As mentioned earlier, according to the activation theory of information exposure, message features act as a source of stimulation that can help audience members meet their optimal level of arousal; therefore, effectively targeted messages can attract and hold the attention of a target audience. Attention is just the first step of the persuasion process, however. Some theoretical perspectives suggest that HSV features may compromise message processing, acting as distractors that would impede the ability to centrally process message arguments (the elaboration likelihood model [ELM]; Petty & Cacioppo, 1986) or as drains on limited cognitive resources that would reduce the ability to encode and store message arguments (Lang, 2000). For example, Kang, Cappella, and Fishbein (2006) found as part of a secondary analysis of 60 antimarijuana PSAs that for high-risk adolescents, MSV served as a distractor of attention. In this study, one sample of adolescents provided assessments of argument quality, which was determined by adolescents’ ratings of a number of argument characteristics such as convincingness, believability, and importance; a second sample of adolescents provided data on perceived PSA effectiveness, liking, and thought listing (which has the longest standing tradition as a measure of message processing). Trained coders coded the PSAs for MSV using a slightly modified version of the Morgan and colleagues (2003) classification system. Analysis of variance results showed a three-way interaction between MSV, argument quality, and risk of marijuana use, indicating that among at-risk youth, perceptions of HSV PSA persuasiveness were lower when argument quality was high and higher when argument quality was low. Such an interaction is taken as evidence of peripheral processing, suggesting that HSV was a distractor. (In the experimental setting, PSAs did not have to compete with other stimuli for attention.) Other research, however, suggests that HSV messages actually facilitate processing. Niederdeppe (2005) conducted a study to investigate how specific features related to MSV might be related to message processing. He first coded PSAs used in the Florida ‘‘truth’’ antitobacco media campaign for a variety of MSV features. Then, using data from the Florida Anti-tobacco Media Evaluation surveys, he created a measure of cognitive processing based on the extent to which adolescents thought about, talked about, and liked the PSAs. He found that among older teens (16–18 years), unrelated cuts, intense images, and a ‘‘second-half punch’’ were related to increased cognitive processing. An additive three-item index consisting of these features was related to increased cognitive processing among both older and younger (12–15 years) teens. He suggested that the concept of syntactic
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indeterminacy (Messaris, 1997) may explain the increased processing effects. Syntactic indeterminacy notes that visual images lack the syntax found in text; therefore, audiences must put forth more effort into decoding the meaning of visual images. HSV messages that have a greater number of unrelated cuts increase the amount of cognitive resources needed to make sense of the imagery, which in turn enhances overall message processing. The question of whether HSV promotes or inhibits central processing (and under what conditions it may do so) remains an open one. Even if HSV functions to inhibit central processing, though, such an effect may actually be beneficial for an at-risk audience. Stephenson and Palmgreen (2001) investigated the influence of PMSV and personal involvement with marijuana on cognitive (central), narrative (attention to character and story details), and sensory (attention to audio and video features) processing of antimarijuana PSAs. In this study, 386 students in 9th through 12th grade watched three of six PSAs, all of which had narrative structure and varied on sensation value elements. Students completed the PMSV scale for each PSA and a measure of personal involvement with marijuana, and they completed closed-ended measures for amount and valence of cognitive processing, narrative processing, and sensory processing. Results showed less cognitive processing and more negative cognitive processing among students more personally involved with marijuana and by HSS more so than LSS; HSS also were more involved with marijuana than LSS, a result that is not surprising but is important for targeting. Most important for message design was the finding that higher PMSV facilitated message processing among both HSS and LSS. In other words, higher PMSV facilitated promessage processing and inhibited the negative effects of personal involvement with marijuana for both HSS and LSS. The results of four other studies (including three campaign studies) reported above (Palmgreen et al., 1991, 1995, 2001, 2007) also provide evidence of the positive persuasive effects of HSV messages on HSS audiences. The results of these and other studies on the effects of MSV=PMSV on message processing are complex, and they are complicated by substantial differences in methodologies across the studies. A more thorough understanding of the impact of MSV on message processing and persuasion is of crucial theoretical importance, however, and therefore warrants continued attention by researchers interested in campaign research and drug abuse prevention.
Concluding Thoughts As research in health communication campaigns moves forward, researchers must be mindful of the central role of evaluation in understanding campaign effects and advancing their effectiveness. They must also be mindful of the extremely complex and ever-evolving media landscape. In the past few decades, the landscape has evolved from one of primarily print, radio, and television to a heavily Internet-based, interactive, multimedia free-for-all. This evolution has profound implications for message design. While it may increase flexibility in terms of message design and dissemination, it also introduces constraints in terms of platform and channel. We also must recognize that campaigns do not operate in a vacuum. Indeed, there is a multitude of environmental factors that can influence campaign effects. As Hornik and Yanovitzky (2003) observed, ‘‘A . . . typical campaign may depend on operating through multiple channels, diffusion of messages repeatedly over time, and supportive actions from institutions and social networks’’ (p. 212). Evaluation researchers should be mindful of this. Evaluation researchers also should be mindful of sound reporting standards when they publish their studies (Harrington & Noar, 2012). Reports should clearly specify the theory or theories that informed the study and all relevant aspects of
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formative, process, and outcome evaluation (see also APA Publications and Communications Board Working Group on Journal Article Reporting Standards, 2008). Following sound reporting standards will more effectively convey results of evaluation research, will facilitate replication and synthesis, and in turn will help to promote a cumulative science of health promotion and disease prevention research.
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