NINDS: Stroke Proceedings: Maibach

Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

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Lessons for Success in Public Education Campaigns

Edward W. Maibach, Ph.D., M.P.H.
Porter Novelli, Washington, DC

This paper will outline five lessons for success gleaned from previous public health education campaigns.

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• Lesson 1: Public Education Works
• Lesson 2: Big, Comprehensive Programs are Most Effective
• Lesson 3: "General Population" Isn't a Valid Definition of our Target Audience
• Lesson 4: Education ¹ Motivation ¹ Behavior Change
• Lesson 5: Effective Education is Both Theory- and Audience-Driven

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Lesson 1: Public Education Works

It is commonly said that we can't change behavior, but this is simply not true. Evidence for this can be seen in a number of large-scale behavior changes witnessed over the past quarter century. One important example is the 50% reduction in smoking in this country. Another example is the rise in the use of automobile seat belts and child safety seats; over the past 20 years there have been dramatic improvements in the use of these safety devices. Utilization of mammography screening tests is a third important example. Between 1987 and 1992, the percentage of women over the age of 40 who received annual mammograms rose from 17 to 44%. This is an impressive change in behavior over a relatively brief period of time.

Other examples include reducing dietary fat and increasing the consumption of high-fiber foods. Unfortunately these trends seemed to have peaked in 1989 or so, but Americans are still eating a much healthier diet than was the case 15 or 20 years ago.

Condom use among male adolescents has increased dramatically in this country, from less than 15% in the pre-AIDS era to 50-60% in the current era. This change took place among a population that many believed would be extremely difficult to reach and influence.

A final example is the reduction in the incidence of sudden infant death syndrome (SIDS), a result of the successful public education campaign encouraging parents of newborns to turn babies on their backs to sleep. The lower incidence of SIDS is especially notable in Australia and New Zealand, although we are making a great deal of progress in this country as well.

Each of these are compelling examples of the fact that public education works. While it is certainly true that noneducational factors such as increased availability and decreased cost (in the case of mammography) and changes in public policy (in the case of seat belts) also play a role, the evidence is clear that the public can be educated effectively, and that behavior change does, in many instances, follow.

It is important to note, however, that public education tends to work slowly. In most of the examples cited above, changes occurred over a decade or more. And progress in getting stroke victims into emergency departments rapidly will also take time. It is simply unrealistic to expect overnight changes in behavior of this type. In addition, not all health behaviors are equally amenable to change or equally responsive to public health intervention efforts. For example, compare the differences in public behavior concerning SIDS and AIDS. SIDS-related behavior change has occurred very rapidly, and with a minimal level of educational intervention. In contrast, the behaviors we are promoting for AIDS prevention are complicated: they take place in highly emotionally charged situations and there are many social norms surrounding the behaviors. Preventing SIDS is vastly simpler.

Our national experience in promoting early response to acute myocardial infarction (AMI) may provide some indication of how long it will take to change behaviors related to rapid stroke response. The symptoms of AMI are more dramatic, and easier to communicate, than are symptoms of stroke. Unfortunately, overcoming that communication challenge is likely to slow down the rate of behavior change.

Finally, some behaviors or "offers" are easier to promote than others. Fortunately, the offer concerning rapid treatment of stroke is becoming more attractive all the time. Now that we know there are proven means of preventing some of the most feared consequences of stroke--such as long-term disability--the offer to seek medical help quickly will become far more attractive to the average American.

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Lesson 2: Big, Comprehensive Programs are Most Effective

Effective public education campaigns include the largest number of information vehicles possible. The combination of print, broadcast, national and local news media, public service announcements, paid advertising, aggressive public relations efforts, dramatic depictions in the entertainment media, and collaborations with community leaders, retailers, care providers, and health plans will work better than smaller efforts focused on only several of these information outlets. The information environment today is highly cluttered. Only large, multidimensional programs have the capacity to rise above the clutter to convey our messages and successfully bring about behavior change. Each and every instance of communication can have a small effect, but the totality of myriad efforts generated in the public, private, and voluntary sectors will produce results and make a difference in the way the public responds to stroke.

Successful educational campaigns are typically multisectorial. The government cannot do it alone. Nor can industry or nongovernmental organizations. Only when we achieve synergy among organizations from multiple sectors will we really start to see change.

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Lesson 3: "General Population" Isn't a Valid Definition of our Target Audience

Who do we need to reach to make a difference in the treatment of acute stroke? Unfortunately, even though we may need to reach everyone, we cannot simply educate the "general population." Different groups of people have different educational needs. We must segment the diverse general population into smaller, more homogeneous audiences. By tailoring our message to these different groups, in a manner that reflects their unique view of the world, we are more likely to succeed in delivering educational messages they will respond to.

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Lesson 4: Education ¹ Motivation ¹ Behavior Change

The fact that education does not necessarily lead to motivation, and that motivation does not necessarily lead to behavior change, poses a quandary. How are we to carry out our mission if one element doesn't necessarily lead to the other? Health educators have long discussed the discontinuity between knowledge, attitude, and behavior change (the "KAB fallacy"). I suggest that we reframe the problem. Instead of thinking about knowledge, attitude, and behavior change, I suggest thinking in terms of education, motivation, and behavior change. Unfortunately, just thinking about the problem of changing behavior differently does not necessarily make the basic task any easier. It is still the case that we can educate a population and they may fail to change their behavior. We can even succeed at motivating a population and they may still fail to change their behavior. But I believe that by thinking more clearly about these discrete subtasks within the overall educational process we can start to make some concrete headway.

Education occurs when clear, simple messages are repeated often in many different venues. The communication challenges at this stage are to develop those clear, simple messages, and to ensure that the messages reach members of the audience with sufficient frequency and from a sufficient number of credible sources.

Motivation occurs when the perceived benefits of a behavior clearly outweigh the perceived costs. There are always costs associated with behavior change and sometimes there are benefits. Often, people simply don't see or understand that the cost/benefit ratio is desirable for them or in their best interest. Our challenge is to communicate about the behavior such that the perceived benefits are clearly understood to outweigh the perceived costs.

Behavior change is more likely to occur with education, motivation, and ability. By ability, I mean the acquisition of the skills--cognitive, physical, and social--that a person needs to make a particular behavior change. This will be a great challenge when the goal is getting people to come to emergency departments as soon as they recognize they are having a stroke. High-risk individuals (whose numbers are growing) and their family members and co-workers simply do not yet have the cognitive skills to make the proper conclusions about seeking treatment. Moreover, there are powerful social forces at play that cause people to avoid rapid responses. Part of our communication challenge will be learning how to simplify the cognitive and social skills and how to communicate them clearly and repeatedly.

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Lesson 5: Effective Education is Both Theory- and Audience-Driven

Effective education is driven by both behavioral theory and good marketing research. Behavioral scientists have given us an important head start through the development of theories about behavior, motivation, education, and behavior change. We need to draw on specific relevant theories to guide us through different parts of the problem--including the knowledge-gain problem, the persuasion and motivation problem, and the behavior-change problem. Appropriate behavioral theories can provide critical insight into how to conduct an insightful "educational diagnosis" and how to structure potentially effective "educational" programs.

Good marketing research allows educational planners to "get into the minds" of target audience members. By understanding how audience members think and feel, educational planners can develop programs that specifically respond to the audience's unique perspective, thereby enhancing the odds of successful communication. Audience input, through focus groups, in-depth interviews, surveys, and a variety of other means, is the most powerful resource available to the program planner.

In summary, in an ideal world a stroke education campaign would involve the efforts of many different sectors of our society--governments and not-for-profit organizations, industry, and a broad spectrum of private sector concerns. It would target specific audiences and tailor efforts to their specific needs. And it would deliver education based both on behavioral theory and on what is in the minds of our target audience. This is the only formula for success that we have. It is not simple work, and it is certainly not quick work, but if we follow these basic principles, we will achieve incremental gains each step of the way and are certain to create a meaningful impact in the long run.

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Last Edited: July 01, 1999

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892