House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

Memorandum submitted by Kaye Wellings, London School of Hygiene and Tropical Medicine (SH 154)

CAMPAIGNS USING PAID FOR MASS MEDIA

By "mass media" we mean any communication which reaches large heterogeneous sections of the population, through TV or radio broadcasting, print media such as newspapers and magazines, posters and leaflets. Mass media interventions are "broad spectrum" interventions, as distinct from "narrow gauge" interventions which are tailored to individuals or small groups and generally consist of more personalised communication.

The AIDS Campaigns

The advent of the AIDS epidemic saw the use of the mass media in health promotion on a scale unprecedented in the sphere of public health. The AIDS campaigns of the 1980s and early 1990s were effectively the first attempts in this country (and indeed in Europe as a whole), to use the mass media in the context of sexual health campaigns. Apart from PSAs and posters directed at servicemen seen to be at risk of contracting an STI during the Second World War, there were few instances of use before the 1980s.

The nature of the epidemic, and the behaviours implicated in HIV transmission, presented particular challenges for mass media work. Difficult messages had to be transmitted, to wide audiences, using images generally regarded as more appropriate to private than public domains.

Nevertheless, the AIDS campaigns made a major impact on the UK public, achieving levels of awareness previously only seen in relation to anti-smoking advertisements. What they did less well was to provide information on how risk could be avoided, and create the conditions under which public awareness might be sustained.

More Recent Sexual Health Campaigns

Since the high profile television AIDS advertisements of the last decade, radio and the print media have been used to transmit sexual health messages. Examples include the Chlamydia awareness campaigns (using the characters "Chlem" and "Lydia"), and safe sex campaigns promoting condom use.

Most recently, radio and magazine advertisements have been used in the Government's Teenage Pregnancy Strategy. Since teenage conception rates are closely associated with deprivation levels, the aim here has been to reach young people in lower socio-economic groups.

GETTING THE MESSAGE

Which Messages to Choose

In relation to the prevention of both sexually transmitted infection and unplanned conception, there is a variety of messages from which to choose in the context of prevention. These include abstinence, monogamy, restrictions in numbers of sexual partners, and condom use. On scientific grounds, the condom message makes better preventive sense; since a monogamous relationship with a partner already infected with HIV will not lessen the risk of infection. However, there has often been resistance on moral grounds, to an exclusive condom message. Health educators believe careful selection from a hierarchy of messages to be the most effective strategy in "engaging" the largest number of young people. In relation to drug use and HIV, this would look like this:

— Don't use drugs;

— If you have started to use drugs, try to stop;

— If you can't stop using drugs immediately, protect against risks—don't inject;

— If you are currently injecting drugs, don't share needles; and

— If you can't avoid sharing needles, clean them between use.

These are clearly specialised and targeted messages. The message to clean needles would not be appropriate in a wide circulation young people's magazine any more than the "Don't start using drugs" would be in a drop-in centre for drug users. Careful targeting of messages at the right level enhances their uptake. In the case of sexual activity, we might advise young people:

— Don't have sex before the time which is right for you and you feel ready;

— If you are already sexually active, keep to one partner or avoid penetrative sex; and

— If you have had more than one sexual partner, or you think your partner might have done so, use condoms.

Should the Abstinence Message be used in Mass Media Campaigns?

Abstinence campaigns have been launched, mostly in the United States, using slogans such as "Pet your date, not your pet" to convey the "Just say No" message. Evidence of their effect is inconclusive. They have been shown to have had some effect on behaviour in some instances, but not in others.

The "Just Say No" message is problematic because, unlike drinking, smoking and using drugs, sexual activity is something that virtually everyone embarks upon sooner or later. The important questions for young people then are not "if" but "when" and "who with". These are complex issues for the mass media to deal with, and are probably best addressed using personal communication (there is good evidence that first experience of sex is more likely to be protected and less likely to be regretted than when it is with a regular partner than when it is with a casual partner).

Messages which stress readiness are likely to have considerable effect on lowering the rate of under-age sex. 50 per cent of young women who have intercourse before the age of 16 believe, in retrospect, that the event occurred too early for them. We do not fully understand why young people have sex at a time which is not right for them, but peer pressure and media influence, absence of self esteem and lack of the skills to assert one's own needs may be implicated, and these are all issues which can be at least raised in the mass media.

TARGETING MASS MEDIA CAMPAIGNS

Mass media interventions can be targeted. By choosing the right medium, it is possible to reach specific sections of the population.

Can Mass Media Campaigns Reach Black and Minority Ethnic (BME) Groups?

— BME groups may not identify or be reached by targeted approaches, but they are likely to be at least occasional users of the mass media and can be reached through dedicated broadcasting channels and print media.

— Many of the issues associated with ethnicity cross over with those relating to socio-economic inequality and deprivation. Including BME groups within the audience therefore may be a question of ensuring that the media used are those accessed by the appropriate groups (see Teenage Pregnancy Strategy campaigns, above).

— Efforts to target directly must address the tackle the tension between tokenism (for example, including one black face in a crowd) and scape-goating (for example, showing a black Afro-Caribbean family in an HIV prevention advertisement could appear to suggest that black Africans were disproportionately responsible for the spread of HIV.

How Are Young People Best Reached?

Young women's magazines are an obvious medium, but young men can also be reached through special interest magazines. Radio channels whose audience is predominately young people are another option. Young people have been reached by both these means in the campaigns mounted in the context of the Teenage Pregnancy Strategy. The Strategy also uses a dedicated website entitled RUThinking, The evaluation of the Teenage Pregnancy Strategy shows this campaign to have been effective in reaching more disadvantaged and less well educated young people.

— Spontaneous awareness of advertising is high (over three in five recognise a press or radio advertisement);

— Recognition is strong among boys;

— More than half believe the majority of young people have had sex before 16 (in reality only a third have done so—a key campaign message); and

— Despite the high profile of the advertisement dubbed by the press the "Virgin" campaign, the message most commonly recalled is to use contraception.

MOTIVATING BEHAVIOUR CHANGE

The Use of Fear

Advertising relies on the use of emotions to motivate behaviour change; the two most commonly used in this context being fear and humour. Early AIDS campaigns in this country used death-related images rather than life enhancing ones, the now familiar tombstones and lilies. Although the UK examples have been widely cited as the prime illustrative examples of the use of fear, they were not unique in Europe in this respect. Other countries also used fear to motivate. In the Netherlands, for example, rows of candles were progressively snuffed out as the question "who will be next" was posed, and a promiscuous bee flying around too many flowers met a premature end.

"Shock Horror" campaigns are effective in raising awareness, but they are difficult to follow up and sometimes have unintended consequences. In the UK, attendances at clinics for HIV testing increased by more than 300 per cent over the initial period of most intensive AIDS campaigning, in 1986-87—the increase being mainly made up of the "worried well". For this reason, the use of radio and press seems to be more effective than television in achieving sustained public awareness among the general population and avoiding the peaks and trough of public concern.

The evidence is that fear "works" in motivating changes in public attitudes and behaviour when:

— the threat is seen to be real and not imaginary, and;

— people are told about, and provided with, the means by which they might protect themselves.

In the earliest AIDS ads, the threat was presented as on a scale which far outreached the public imagination, partly because of the long lead time between infection and AIDS-related illness. Furthermore, the earliest advertisements were vague about how the public could protect themselves, encouraging them rather to "read this leaflet when it arrives". Health educational messages most likely to meet with compliance are those which provide advice on preventive action.

The Use of Humour

As an alternative, in many countries of the world, humour has been effectively used to convey messages related to sexual health. The use of cartoons permits otherwise offensive images to be presented, while a more jokey treatment of issues enables messages to be conveyed without fear of sounding didactic. Some of the most effective campaigns in Europe, for example, the Swiss AIDS campaigns, have made lavish use of irony.

How do we compare with other European Countries?

As the graphs below show, there are not major differences between the sexual behaviour of young people in this country compared with those in other European countries. As a result, we have to look for other possible causes of the unfavourable rates of teenage conception in this country.

Teenage conception rates are linked to deprivation and one possible explanation is that the gap between rich and poor is larger in the UK compared to other European countries. A study carried out by the Alan Guttmacher Institute attributes the higher conception rates in the US and the UK to confusing treatment of sex in this country, with salacious and titillating images in the mass media combined with a silence around the serious treatment of sex.

ACTUAL AND LEGAL AGE AT FIRST INTERCOURSE FOR MEN AND WOMEN BORN 1967-71, FOR SELECTED EUROPEAN COUNTRIES

	% s.i. before 16		Median age		Age of sexual
	men	women	men	women	consent
Belgium	15	9	18.1	18.7	16
Denmark	27	32	17.5	17.0	15
Finland	20	18	18.0	18.0	16
France	22	13	17.7	18.3	15
Germany	15	18	17.7	17.7	16
GB	25	16	17.1	17.4	16
Greece	27	5	17.5	19.0	15
Iceland	38	22	16.8	16.9	16
Netherlands	17	12	18.3	18.3	16
Norway	19	22	18.3	17.6	16
Portugal	30	7	17.1	19.9	16
Switzerland	12	9	18.1	18.4	16

Source:

Hubert M et al. (1998) Sexual Behaviour and HIV/AIDS in Europe, UCL Press, London.

Kane R and Wellings K (1999) Reducing the rate of teenage conceptions; An international review of the evidence: data from Europe, HEA, London.

Countries in which AIDS public education maintained a constant presence and a continuous flow, eg Switzerland, saw more consistent increases in condom usage than did those countries in which campaigns have been characterised more by peaks and troughs of campaign activity, eg the UK. In those countries in which campaigns transmitted a single, simple message to use condoms, condom use increased dramatically. In Switzerland, for example, the proportion of young people who reported using a condom consistently increased from less than 10 per cent in 1987 to nearly 70 per cent in 1993.

By contrast, the evidence is that little success was achieved in persuading people to limit their numbers of partners or to restrict them to one. The proportion reporting more than one partner in the past year remained remarkably static, irrespective of country.

RISK BEHAVIOURS FOR SELECTED EUROPEAN COUNTRIES

	5+ partners last year		Paid for sex	Lifetime partners
	men	women	men	men	women
Belgium	3.2	0.5	—	—	—
Finland	7.0	3.3	—	15	6
France	2.0	0.4	1.1	12	4
Germany	2.0	0.2	4.8	—	—
GB	25	—	—	12	4
Netherlands	4.6	0.7	2.8	20	6
Norway	3.6	1.5	1.8	12	6
Portugal	5.1	0.4	5.4	—	—
Spain	6.6	3.2	11.0	10	5
Switzerland	—	—	—	12	5

Source:

Hubert M et al. (1998) Sexual Behaviour and HIV/AIDS in Europe, UCL Press, London.

Kane R and Wellings K (1999) Reducing the rate of teenage conceptions; international review of the evidence: data from Europe, HEA, London.

THE EVIDENCE

It is difficult to gauge the effectiveness of mass media campaigns since by design and definition they reach everyone. This means that the gold standard in terms of evaluation—the randomised controlled trial (RCT) cannot be used to evaluate them. The RCT requires that people can be randomly allocated to separate groups, so that the only difference between them is that one group is exposed to the intervention, and the other is not. The difference between the two groups is then examined.

A major challenge is that of attributing outcome to intervention, ensuring that the observed effects are truly the outcome of public education campaigns and not the result of heightened awareness of the issues by other means.

Mass media interventions are effective in raising awareness, but there are some doubts over their capacity to produce changes in behaviour. The largest gains in this respect are likely to be achieved by face-to-face communication and counselling, when messages can be tailored to the specific needs of individuals.

The use of the mass media can however help to:

Reach a wide variety of people:

Legitimate action at other levels:

Raise the issue on the public agenda:

November 2002



© Parliamentary copyright 2003	Prepared 11 June 2003