Margaret Gerteis

Matthew Hodges

James Mulligan

Mathematica Policy Research, Inc.

955 Massachusetts Avenue

Suite 801

Cambridge, MA 02139

MedPAC

601 New Jersey Avenue, NW

Suite 9000

Washington, DC 20001

(202) 220-3700

Fax: (202) 220-3759

www.medpac.gov

•

•

The views expressed in this report

are those of the authors.

No endorsement by MedPAC

is intended or should be inferred.

Engaging Consumers:

What Can Be Learned

from Public Health

A study conducted by staff from 

Mathematica Policy Research, Inc. for the

Medicare Payment Advisory Commission

July 2008 • No. 08–6

Consumer Education

Programs?
Contract No.: RFP03-06-MedPAC/E4034941 

MPR Reference No.: 6384-400

Engaging Consumers: 

What Can Be Learned 

from Public Health 

Consumer Education 

Programs? 

Final Report

March 6, 2008 

Margaret Gerteis 

Matthew Hodges 

James Mulligan 

Submitted to: 

Medicare Payment Advisory Commission 

601 New Jersey Avenue, N.W. 

Suite 9000 

Washington, DC 20001-2021 

Project Officer: 

 Joan Sokolovsky 

Submitted by: 

Mathematica Policy Research, Inc. 

955 Massachusetts Ave., Suite 801 

Cambridge, MA 02139 

Telephone: (617) 491-7900 

Facsimile: (617) 491-8044 

Project Director: 

Margaret Gerteis
This page has been left blank for double-sided copying 
 

C ONTENTS

Chapter Page 

 EXECUTIVE SUMMARY ............................................................................................... vii

I INTRODUCTION ..............................................................................................................1 

II RESEARCH APPROACH ..................................................................................................3 

III THEORY-DRIVEN COMPONENTS OF PUBLIC HEALTH CAMPAIGNS .................7 

IV ELEMENTS OF CAMPAIGN SUCCESS........................................................................ 11 

MAKING IT PERSONAL.................................................................................................. 11 

 UNDERSTANDING MULTIPLE INFLUENCES ON INDIVIDUAL BEHAVIOR ............. 12 

 REACHING PEOPLE WHERE THEY LIVE AND WORK .............................................. 13 

 MAKING THE MESSAGE ACTIONABLE....................................................................... 14 

 USING MEDIA STRATEGICALLY .................................................................................. 15 

V CHALLENGES OF PUBLIC HEALTH CONSUMER EDUCATION PROGRAMS .... 17 

DEMONSTRATING EFFECTIVENESS............................................................................ 17 

GETTING/STAYING ON THE PUBLIC AGENDA ........................................................ 18 

LEVERAGING LIMITED RESOURCES ........................................................................... 19 

INFORMING VERSUS MOTIVATING VERSUS MANIPULATING BEHAVIOR............. 20 
Contents 

iv 

Chapter Page 

VI IMPLICATIONS FOR MEDICARE................................................................................ 23 

IS THE MEDICARE POPULATION DIFFERENT?.......................................................... 23 

WHAT DO WE WANT TO ACCOMPLISH BY ENGAGING MEDICARE 

 CONSUMERS?.................................................................................................................. 24 

DO WE WANT TO MOTIVATE CONSUMERS OR INFORM THEIR BEHAVIOR?....... 25 

 APPENDIX A: REFERENCES

 APPENDIX B: SEARCH TERMS USED FOR LITERATURE REVIEW

 APPENDIX C: PROGRAMS SELECTED FOR REVIEW

 APPENDIX D: INTERVIEW RESPONDENTS AND GUIDES
T ABLES

Table Page 

II.1 RANGE OF SUGGESTED TOPICS, BEHAVIORS, AND MOTIVATIONAL

 CONSIDERATIONS............................................................................................................ 4 

B.1 SEARCH TERMS USED TO IDENTIFY PUBLIC HEALTH CAMPAIGNS IN 

 SELECTED TOPIC AREAS ............................................................................................ B-1 

C.1 PUBLIC HEALTH CONSUMER EDUCATION PROGRAMS SELECTED FOR

 REVIEW, BY TYPE OF BEHAVIOR TARGETED ......................................................... C-1 
This page has been left blank for double-sided copying 
E XECUTIVE S UMMARY

he Medicare Payment Advisory Commission recognizes the importance of engaging 

consumers in the movement to promote greater quality and efficiency in the 

healthcare system. In this project, MedPAC contracted with Mathematica Policy 

Research, Inc. (MPR) to explore what can be learned from other public health campaigns in 

other arenas about strategies for engaging consumers and influencing their behavior. 

RESEARCH APPROACH AND CAMPAIGNS SELECTED FOR REVIEW

Drawing on a limited review of the literature and key informant interviews, and focusing 

on selected campaigns that have demonstrated an effect on consumer behavior, MPR set out 

to identify strategies associated with success and explore their potential application to 

Medicare. 

We selected a mix of public health topics reflecting different types of motivational 

challenges, including changing individual risk behaviors, promoting participation in mass 

screening, targeting individual behaviors that affect the well-being of the larger community, 

and health care purchasing or choice decisions. We then reviewed the literature and selected 

10 programs or campaigns to explore further: 

• 2 sun-protection campaigns (Choose Your Cover and the Falmouth Safe Skin 

Project) 

• 2 cancer screening programs (Screen for Life and the Georgia Cancer 

Awareness and Education Campaign) 

• 2 programs promoting fitness and weight loss through walking (Canada on the 

Move and Wheeling Walks) 

• 2 programs targeting inappropriate antibiotic use (the Wisconsin Antibiotic 

Resistance Network and the Campaign to Prevent Antimicrobial Resistance in 

Healthcare Settings) 

• 1 anti-littering campaign (Keep American Beautiful) 

T
viii 

Executive Summary 

• 1 program promoting informed and shared clinical decision-making (Health 

Dialog) 

We identified key informants who could speak to the design, implementation, and 

outcomes of these programs or who had expertise in related areas of public health 

promotion, communication, or health decision-making and conducted one-hour interviews 

with 19 respondents. 

ELEMENTS OF CAMPAIGN SUCCESS

Across all of the programs reviewed, we found broad agreement that success was 

dependent on a program’s ability to accomplish the following: 

• Make it personal 

Target audiences may be defined in terms of demographic or risk groups, but 

effective campaign messages have to appeal to individuals. This entails 

segmenting audiences, framing messages, and communicating risk in a way that 

conveys to consumers how the message relates to them personally. Making it 

personal can be especially challenging in campaigns that focus on the public 

good rather than individual health. 

• Understand and address multiple influences on individual behavior 

Although all campaigns aim ultimately to influence individual behavior, 

effecting change requires recognizing and addressing multiple levels of influence 

on individual behavior – including personal health beliefs and attitudes; 

interpersonal relationships; the larger community environment (including policy, 

infrastructure, and the regulatory environment); and social and cultural norms. 

Addressing all levels of influence cannot be achieved in a single program or 

campaign. The long-term success of campaigns against smoking or drunk 

driving reflect multiple efforts targeting many different levels of influence over 

several decades. 

• Reach people where they live and work 

The most effective campaigns reach people in the environments where the 

targeted behaviors and the influences on those behaviors take place. The natural 

social groupings in which people carry out their everyday lives are most readily 

identified at the community level, and these groups, in turn, can be the vehicles 

for reaching and influencing individuals. Given limited resources, campaigns 

will have more impact if they go for more intense “dosage” with these groups, 

rather than attempting to reach a broader audience through more diffuse 

efforts. 
 ix 

 Executive Summary 

• Make it actionable 

Effective campaigns suggest or provide specific, positive follow-up action(s) for 

people to take. They avoid preaching, or telling people what not to do. Actions 

have to be accessible, do-able. Taking action at the community level also 

enhances commitment and learning. 

• Use media strategically 

Media campaigns by themselves do not determine campaign effectiveness. 

Mass media campaigns may reinforce campaign messages or raise public 

awareness but have limited impact when used alone. Effective campaigns use 

print, broadcast, and other mass communications, advertising, news, and 

entertainment media strategically to reach target audiences where they live and 

work. “Earned” media attention (news or feature stories and entertainment 

programming) may be more effective than paid advertising, but it is harder to 

“earn” or influence. Free public service announcements may have limited utility. 

CHALLENGES OF PUBLIC HEALTH CONSUMER EDUCATION PROGRAMS

Our research also highlighted the challenges common to public health consumer 

education programs: 

• Demonstrating effectiveness 

The evidence base for public health campaign effectiveness is limited, because 

behavior change takes time and sustained effort on many fronts. Formal 

evaluation is expensive, and much evidence is anecdotal. Most evaluations that 

do exist focus on interim and short-term measures (reach, “dosage,” awareness) 

rather than behavioral outcomes. Distinguishing impacts of discrete campaigns 

from secular trends is also difficult. 

Although evidence from controlled trials suggests that informed decisionmaking can prevent the overuse of treatment options of uncertain benefit to 

patients, patient decision tools to facilitate shared decision-making are not 

widely used, in practice. 

• Getting/staying on the public agenda 

There are any number of legitimate issues of public/public health concern 

competing for resources (money, champions) and/or target audience attention 

at any given time. Limited windows of opportunity make sustained effort 

difficult, and most campaigns and/or issues have a relatively short “shelf life.” 

However, changing social norms and entrenched behaviors requires a sustained 

effort on many different fronts over many years, as the history of anti-smoking 

initiatives and campaigns to reduce drunk driving attests. 
x 

Executive Summary 

• Leveraging limited resources 

The high costs of designing and implementing consumer campaigns and limited 

resources dictate finding ways to leverage efforts – for example, through 

partnerships with commercial enterprises, pro bono contributions (including 

PSAs), and voluntary alliances. However, the interests of commercial or 

voluntary partners may not be consistent with those of the campaign, making it 

difficult to maintain effective control over campaign messages or strategies. 

• Informing vs. motivating vs. manipulating behavior 

The principles guiding informed (or shared) decision making recognize that in 

many clinical decision-making situations there is no strong, evidence-based, or 

preferred course of action. Shared decision-making protocols are therefore 

designed to inform patients about the risks and benefits associated with 

alternatives and help them understand how their personal preferences and 

values play into the decision. 

Most public health campaigns, however, seek less to inform consumers than to 

influence their behavior in a preferred direction. This entails conveying 

information in a way that gets their attention and motivates them to take action. 

When public health advocacy or promotional campaigns lead consumers to 

have a distorted sense of their personal risks or benefits, however, such 

strategies may raise ethical questions about the distinction between motivating 

and manipulating behavior. 

IMPLICATIONS FOR MEDICARE

• There may be characteristics unique to the over-65 population that would 

shape the approach of campaigns targeting Medicare beneficiaries. However, 

the behaviors and characteristics of older age groups are changing, and 

commonly-held assumptions may not hold. Program design should be 

informed by research about the specific audiences and behaviors targeted. 

• We need to more clearly define the objectives and the desired behavioral 

outcomes of engaging consumers in efforts to bring higher quality and greater 

efficiency to the healthcare system. Consumers have not come to the table 

around these issues, because the issues have not been framed in terms they 

perceive to be either personally relevant or actionable. In practice, consumer 

choice may be limited, variations in quality may not be apparent, information 

may be conflicting or confusing, and the relevance of quality information to 

personal health care decisions may not be obvious. 

• Creating a better, more efficient health care system may require asking 

individuals to forego unnecessary high-cost health services. However, the 

prevailing cultural norm is that more health care and more high-cost 
 xi 

 Executive Summary 

technology is better. Changing social norms around the use of health resources 

for the common good will require a multifaceted and sustained effort for many 

years to come. We need to explore examples from other areas of public life 

that provide better models for appealing to individuals’ interests in the welfare 

of the larger community or their legacy to future generations. 

• We need to determine whether the preponderance of evidence that bears on 

questions of quality and efficiency in health care is strong enough to warrant 

motivating consumers toward preferred choices, or whether the objective 

should be to inform their decisions in a more value-neutral way. 

• To help Medicare beneficiaries make informed decisions regarding their health 

care, we need to learn from other fields about ways to translate complex 

population-based statistics and communicate risk in ways that make the 

information both understandable and personally relevant. 
This page has been left blank for double-sided copying 
C HAPTER I 

I NTRODUCTION

he voice of the consumer has been notably absent from much of the public debate 

on health care policy—a debate dominated and shaped by health care purchasers, 

providers, and other professional stakeholders. Yet there is a growing sense in policy 

circles that the movement to promote quality and efficiency will not gain serious momentum 

until health care consumers—the end users and ultimate beneficiaries of the system—are 

actively engaged in the effort. Nor, amid the growing burden of chronic illness, will the 

health of the population improve significantly until we develop models that actively involve 

people in managing their own health care. 

Recognizing that these issues are of vital concern to the Medicare population, the 

Medicare Payment Advisory Commission (MedPAC)—an independent Congressional 

agency charged with advising the U.S. Congress on a broad range of issues affecting the 

Medicare program—wishes to explore ways to engage consumers more effectively. As a 

start, MedPAC hopes to learn from public health and related consumer campaigns in other 

arenas. The small project whose findings are reported here, undertaken by Mathematica 

Policy Research, Inc. (MPR), under contract to MedPAC, is a step in that direction. 

Health-related consumer education is a vast field, but this project has a modest goal: by 

drawing on a limited review of the literature and key informant interviews, and by focusing 

on campaigns that have demonstrated an effect on consumer behavior, to help MedPAC 

begin to frame the salient questions. 

The project addresses the following research questions: 

• What types of campaigns or programs are most relevant to MedPAC’s interests? 

• Which campaigns or programs have produced results? 

• What strategies do successful programs employ? 

• What outcomes have they been able to achieve? 

T
2 

Chapter I: Introduction 

• To what extent can successful strategies be applied to campaigns or programs 

targeting Medicare beneficiaries? 

We first provide an overview of our research approach (Chapter II), and then, to create 

a context for our discussion, a brief description of the theory-driven components of public 

health campaigns (Chapter III). Chapter IV focuses on key findings from our research, 

beginning with a discussion of common elements that we identified of campaign success. 

Chapter V describes briefly the challenges common to all the programs and campaigns we 

studied. We conclude in Chapter VI by reflecting on what our findings imply for Medicare 

and by recommending avenues for further research. 
C HAPTER II 

R ESEARCH A PPROACH

iven the vast literature and the broad range of consumer campaigns that might be 

explored for this project, the first task of the research team was to define the range 

of topics to pursue. At the outset, the MedPAC project officer advised the MPR 

team that MedPAC’s primary interest is in learning from experience with public health 

consumer education programs, rather than from health care quality reporting initiatives or 

consumer education in other areas (such as financial planning). The team also chose early 

on not to explore some of the more dramatic long-term successes in changing health 

behavior (such as those aimed at smoking or drinking and driving), both because they have 

already been studied and written about extensively and because teasing out the differential 

effects of multifaceted campaigns waged over several decades would be well beyond the 

scope of this project. 

To frame the discussion and further refine the scope of work, we identified five 

varieties of behavior typically targeted in public health campaigns: (1) individual risk 

behaviors (such as those involving smoking, diet/exercise, and sun exposure), (2) 

participation in mass screening or immunization (such as cancer screening and flu shots), (3) 

recognizing symptoms and getting timely care for emergent conditions (such as heart attack 

and stroke), (4) individual behaviors that have consequences for the health or well-being of 

the larger community (such as littering, antibiotic use, and organ donation), and (5) health 

care purchasing or choice decisions (such as shared or informed clinical decision-making and 

value-based purchasing). Although every public health-related consumer campaign aims to 

influence individual behavior in some way to enhance the public good, we reasoned that 

motivational considerations would vary in interesting ways, depending on the type of 

behavior targeted and people’s perceptions of the risks and benefits associated with taking 

action. For these reasons, we recommended selecting a mix of topics reflecting different 

types of motivational challenges. Table II.1 summarizes the topics selected, examples of 

programs of potential interest to the research team, and the motivational considerations 

associated with each.1

 

 1 At the project officer’s recommendation, the research team elected, for this project, not to include 

campaigns that focused on care for emergent conditions. 

G 
4 

Chapter II: Research Approach 

Table II.1. Range of Suggested Topics, Behaviors, and Motivational Considerations 

Examples of 

Targeted Behaviors Desired Impact Who Benefits 

Motivational 

Considerations 

1. Individual Risk Behaviors 

• Smoking 

• Obesity 

• Physical activity 

• Drunk driving 

• Sun exposure 

Changing current 

ongoing/lifestyle behavior 

to reduce risk of bad 

outcomes or enhance the 

probability of good 

outcomes downstream 

Long-term benefits may 

or may not accrue to 

individuals taking action 

Mortality, morbidity in 

general population is 

reduced 

Gratification or perceived 

benefits of current 

behavior versus cost of 

behavior change 

Perceived costs and 

benefits of downstream 

outcomes 

2. Participation in Mass Screening/Immunization 

• Mammography 

• Cervical cancer 

screening 

• Colorectal 

cancer 

screening 

• PSA testing 

• Immunization 

Episodic use of 

healthcare, in the absence 

of symptoms, for 

prevention or early 

detection of disease 

For screening, long-term 

benefits accrue to 

individuals found to have 

early, treatable diseases 

For immunization, 

benefits accrue to 

individuals who may 

otherwise have gotten 

sick 

Mortality, morbidity in 

general population is 

reduced 

Perceived risk of disease 

versus inconvenience 

and/or discomfort 

associated with 

screening and 

immunization 

Anxiety about negative 

outcomes versus 

reassurance of positive 

outcomes 

Uncertain outcomes 

(false positives/ 

negatives) 

Perceived benefit of early 

detection and treatment 

3. Individual Behaviors That Have Social Consequences 

• Littering 

• Antibiotic use 

• Name brand 

versus generic 

drug use 

• Organ donation 

Changing individual 

behaviors for greater 

social good 

Promoting more efficient 

use of resources 

Costs, but no benefits, 

may accrue to individuals 

taking action 

General health and 

welfare of society is 

enhanced 

Perceived self-interest 

versus altruism 

Perceived cost/benefit to 

society 

4. Health Care Purchasing/Choice Decisions 

• Shared or 

informed clinical 

decision making 

• Medical errors 

Involving patients in selfmanagement, clinical 

decision-making, and care 

Patients’ values reflected 

in clinical decisions 

Society benefits from 

reduction in unwarranted 

variations in clinical 

practice 

Perception of and desire 

for choice or control 

Perceived costs/benefits 

of and personal stake in 

alternatives 
 5 

 Chapter II: Research Approach 

We next searched the literature to review the evidence base for campaign effectiveness 

and to identify specific campaigns of interest. Through the multi-database search engines 

OVID and EBSCOhost, we used the MEDLINE, Academic Search Premier, and EconLit 

databases to identify relevant journal articles in the peer-reviewed literature. We also 

searched the web to identify campaigns undetected by the electronic databases. A list of our 

references and sources is in Appendix A; examples of search terms we used for database 

queries are in Appendix B. 

In reviewing this literature, we looked in particular for programs or campaigns that (1) 

targeted adult consumers (or consumers and health care providers); (2) included a mass 

communications media component; (3) had demonstrated some degree of success 

(preferably through rigorous evaluation); and (4) were recent enough that information about 

key features of program design and implementation would be reasonably accessible to the 

research team. On the basis of this review, we identified 10 campaigns or programs that we 

thought warranted further exploration: 

1. Screen for Life. A national campaign sponsored by the Centers for Disease 

Control and Prevention (CDC) to promote screening for colorectal cancer. 

2. Falmouth Safe Skin Project. A three-year skin cancer prevention program based in 

Falmouth, Massachusetts, to promote sun protection. 

3. Georgia Cancer Awareness and Education Campaign. A statewide cancer awareness and 

education effort in Georgia with an initial focus on promoting awareness of and 

screenings for breast and cervical cancer. 

4. Wisconsin Antibiotic Resistance Network (WARN). A statewide campaign 

promoting the judicious use of antibiotics by clinicians and consumers in 

Wisconsin. 

5. Choose Your Cover. A national skin cancer prevention campaign sponsored by the 

CDC. 

6. Canada on the Move. A public-private partnership of the Canadian Institutes of 

Health Research (CIHR) and Kellogg Canada to promote walking and physical 

activity with the aid of pedometers. 

7. Keep America Beautiful. A nationwide nonprofit organization that sponsors 

ongoing efforts to combat littering by promoting cleanup, recycling, and 

beautification. 

8. Wheeling Walks. A Wheeling, West Virginia-based campaign to promote 

moderate daily physical activity, with emphasis on walking. 

9. Health Dialog. A for-profit organization that provides personalized health 

coaching services to identified populations to help them understand their 

medical issues and become more engaged in managing their health care. 
6 

Chapter II: Research Approach 

10. Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. An effort targeting 

clinicians, including doctors and nurses, with evidence-based strategies to 

prevent and control antimicrobial resistance in health care settings. 

Detailed information about each of these campaigns can be found in Appendix Table C.1. 

Through our review of the literature and subsequent referrals, we also identified two 

broad categories of key informants: (1) those who could shed light on the design, 

implementation, and outcomes of specific programs or campaigns of interest; and (2) those 

with broader expertise in related areas of public health promotion, communication, or health 

decision-making. We then conducted one-hour semistructured interviews with 19 

respondents. At least two members of the research team participated in all interviews, with 

one taking written notes. Interview protocols and a list of respondents are in Appendix D. 

Once interviews were completed, members of the research team reviewed all notes and met 

to identify key themes as well as areas of divergence. 

In the chapters that follow, we summarize the principal findings from this research. 
C HAPTER III 

T HEORY - D RIVEN C OMPONENTS OF 

P UBLIC H EALTH C AMPAIGNS

he design and development of most public health consumer education campaigns 

derive from two main sources of influence: public health and social marketing.1

Public health approaches (most notably in the programs associated with the CDC 

and the National Institutes of Health), drawing on scientific, epidemiologic models of 

disease, emphasize the importance of research to identify populations “at risk,” the use of 

evidence-based intervention strategies well-grounded in theory, and a “social-ecological” 

perspective that recognizes multiple environmental, social, and individual influences on 

behavior. Research and evaluation figure heavily in public health approaches, as does the 

language of medicine (“risk,” “risk group,” “dosage,” “boosters,” and so on). 

Social marketing, as the name implies, applies the pragmatic principles of product 

marketing to the advancement of social causes. The language of social marketing similarly 

reflects its commercial origins: “product,” “consumer,” “market,” “target audience,” 

“demographic” (as a noun), “campaign reach.” Borrowing from marketing lingo, the 

principles of social marketing are often described in terms of the “four P’s”: 

1. Product: Does the product (that is, whatever is being promoted) meet a 

recognized consumer need? 

2. Place: Is the product accessible to the consumer? 

3. Price: Is the cost of the product worth the benefit to the consumer?

4. Promotion: Does the consumer know about the product?

 1 For a detailed but user-friendly summary of the theoretical foundations of public health campaigns, see 

the National Cancer Institute publication “Theory at a Glance” at [www.nci.nih.gov/PDF/481f5d53-63df41bc-bfaf-5aa48ee1da4d/TAAG3.pdf]. 

T
8 

Chapter III: Theory-Driven Components of Public Health Campaigns 

In practice, a program or campaign often combines public health and social marketing 

approaches. For example, public health principles drive the formative research, the strategy 

development, and the evaluation design, while social marketing principles drive the design, 

the market and consumer research, and the implementation of the campaign itself. 

Feeding into these approaches are numerous theories, derived from many different 

areas of empirical research, about individual health beliefs, behavior, behavioral change, 

social and environmental influences, innovation diffusion, and communication theory. 

Exploration of all these is well beyond the scope of this project, but here we highlight two 

that are often referenced in public health consumer education campaigns. 

In their “transtheoretical model” of behavior change (based initially on research about 

addictive behaviors), James Prochaska and colleagues have identified successive stages that 

people typically go through in the process of change, from pre-contemplation (when there is no 

intent to change) to contemplation to preparation to action and, finally, to maintenance (when the 

new behavior is on its way to becoming habitual). The application of this model to health 

promotion and consumer education suggests that messages be tailored to people’s stage of 

change, as they wrestle with the costs and benefits of taking action at various points along 

the continuum. In the pre-contemplation and early contemplation stages, Prochaska 

emphasizes, people tend to overestimate the costs and underestimate the benefits of 

initiating action, and informational messages may be designed to shift that balance. In later 

stages, once they have made the initial decision to change, they need help dealing with 

practical barriers and maintaining momentum in the face of setbacks (Prochaska et al. 2002). 

Everett Rogers’ work on the diffusion of innovations through social networks has also 

influenced the way public health and social marketing professionals think about the way new 

behaviors spread in a population and the implications for identifying and segmenting target 

audiences. Rogers’ model of diffusion suggests that the personality characteristics and 

communication networks of the innovators and early adopters of a new practice are very 

different from those of later adopters. The former are more amenable to adopting a new 

practice based on their own judgment of the evidence supporting it and less constrained by 

social norms. Rogers observes that people in the innovator and early-adopter groups also 

tend to have greater access to communication channels and, as trusted and credible sources, 

are more likely to become the opinion leaders who can influence others to adopt the practice. 

By contrast, those who fall in the late majority or laggard categories are more influenced by the 

subjective experience of their peers, conveyed through interpersonal networks, and are 

unlikely to adopt a new practice until it is well established in their peer network (Rogers 

1995). 

Although the emphasis varies from campaign to campaign (depending in part on who is 

involved and from what professional background), the union of public health and social 

marketing approaches has created a fairly consistent set of iterative activities typically 

involved in the development and execution of campaigns: 

1. Identifying target populations: the people whose behavior you want to change or 

influence (such as identified risk groups) 
 9 

Chapter III: Theory-Driven Components of Public Health Campaigns 

2. Identifying target audiences for the campaign, which may be either those whose 

behavior you want to change or the people who influence them 

3. Conducting (formative) research to understand what influences target audience 

behavior 

4. Developing campaign strategies to reach these audiences and influence their behavior 

5. Developing and testing campaign messages and program materials 

6. Carrying out programs, interventions, and/or communication campaigns 

7. Evaluating the effectiveness of program/campaign components and of the campaign 

overall 

Research plays an important role throughout the process. Depending on project 

budgets, this may include epidemiologic and market research to identify target populations 

and audiences, focus group research to explore their social environment and the influences 

on target audience behavior, consumer testing of campaign messages and materials to ensure 

that they resonate with the target audience and convey the messages as intended, media 

tracking to assess the “reach” of the campaign, and evaluation research to assess its 

effectiveness. 
This page has been left blank for double-sided copying 
C HAPTER IV 

E LEMENTS OF C AMPAIGN S UCCESS

n this chapter, we examine the factors that appeared to drive success across the 

programs we reviewed. These focus on making the campaign personally relevant to 

members of the target audience, understanding multiple influences on individual 

behavior, reaching people where they live and work, devising campaign messages that spur 

action, and using media strategically. 

MAKING IT PERSONAL

Most health communications experts emphasize that consumers will not pay attention 

to a campaign message unless they understand how it relates to them personally. Public health 

professionals may define risk populations in epidemiologic terms, but effective campaigns 

must appeal to the individuals in the target audience, not to demographic groups. As one 

interview respondent noted, this entails communicating in terms of “you,” rather than 

“people like you.” Indeed, people may resist campaign messages that refer to the health 

risks of their demographic group and thus seem to be stigmatizing or stereotyping. 

Engaging consumers personally also requires translating information about population-based 

risks and benefits in terms that help consumers understand their personal stake in the 

matter. The best-designed campaigns know their target audiences well, segment them (as 

much as possible), and refine campaign messages to resonate with their personal perceptions 

and experiences. 

In this project, the most personalized approach we encountered to health 

communication was Health Dialog’s program of shared decision-making, which provides 

personalized health coaching services to help people understand their medical issues and 

become more engaged in managing their health care. Health Dialog provides clients with 

first-person video narratives of people from different walks of life who faced similar 

decisions about their medical care (such as about elective surgery or alternative therapies), 

decision aids that help clients understand the relative risks of alternatives in personal terms, 

and one-on-one health coaching. 

Tailoring information to this degree is not possible for most public health campaigns, 

but some of the same principles were at work elsewhere. When Katie Couric became a 

national spokesperson for colon cancer awareness after her husband died of the disease, her 

I 
12 

Chapter IV: Elements of Campaign Success 

celebrity status certainly helped draw attention to the issue. But the real upsurge in 

colonoscopy rates, dubbed by some the “Katie Couric effect,” came when she underwent 

the procedure on the Today show in 2000, helping millions of viewers understand in personal 

terms what the procedure involved and what it might be like for them (Cram et al. 2003). 

However, crafting messages that help consumers understand their personal stake in the 

matter can be particularly challenging in campaigns that focus more on the greater public 

good than on individual health. WARN used a variety of methods to reach both physicians 

and consumers (including parents of small children) with messages about the uses and 

misuses of antibiotics and the dangers of antibiotic resistance. The challenge they faced, 

however, was in finding ways to convey this information in a way that made members of 

both audiences feel personally affected. As the campaign’s sponsors observed, many 

physicians resisted changing their own prescribing patterns for fear of losing patients and 

argued that it would have no effect on overall antibiotic use, in any case, since patients would 

simply go elsewhere for the prescriptions they wanted. And selling overworked mothers on 

the idea that they should avoid giving antibiotics to their toddlers with ear infections for the 

sake of the common good was an uphill battle. 

Keep America Beautiful is another campaign that has, for more than 50 years, sought to 

change individual behavior for the public good through its anti-littering advertising. The 

program’s mass media efforts have brought attention to highway litter through catchy 

slogans (“Every Litter Bit Hurts”) and powerful visual images (such as the “crying Indian” 

ads of the 1970s). The appeal of the campaign, however, lies not so much in its ability to 

convince people that not littering is in their personal self-interest as in the opportunities it 

has created to engage people personally in community group volunteer efforts (highway 

cleanup, tree-planting, recycling). 

UNDERSTANDING MULTIPLE INFLUENCES ON INDIVIDUAL BEHAVIOR

Although all campaigns aim ultimately to influence individual behavior, effecting change 

requires recognizing and addressing many levels of influence on behavior (or what public 

health professionals sometimes refer to as multiple levels of the social ecology), including 

personal health beliefs and attitudes, interpersonal relationships, the larger community 

environment (including policy, infrastructure, and the regulatory environment), and social 

and cultural norms (Green and Kreuter 1999; U.S. Department of Health and Human 

Services 2005). Over its 30-year history, for example, the anti-drunk-driving movement has 

addressed, at various times, several levels: personal health beliefs, by educating the public about 

the relationship between blood alcohol levels and physical impairment; interpersonal 

relationships, through bystander interventions, such as “Friends Don’t Let Friends Drive 

Drunk,” and designated-driver campaigns; the community environment, through server liability 

laws, highway sobriety checkpoints, law enforcement, and raising the drinking age; and 

cultural norms, by working with the entertainment industry to change images of normative 

social drinking behavior (Harvard School of Public Health 2007). 

Clearly, addressing all (or even just the most important) levels of influence cannot be 

achieved in a single program or campaign. Those reviewed for this project recognized their 
 13 

 Chapter IV: Elements of Campaign Success 

limitations, but their research-based strategies also reflected an understanding of the social 

dynamics at work. For example, both the CDC’s Choose Your Cover and the Falmouth 

Safe Skin Project sought to influence sun-protection behavior through family relationships, 

by engaging parents in protecting their children, and by enlisting the support of the 

community. The challenge they faced in getting their messages across, however, was the 

persistence of both personal health beliefs and cultural norms that equated suntans with 

health and beauty. One mother who participated in a focus group told CDC researchers that 

she and her children had an ongoing contest to see who could get darkest the fastest, even 

though she was presumably aware of the long-term dangers of excessive sun exposure. 

Persistent cultural beliefs, reinforced by mass media images, were a far more powerful 

influence than the campaign’s messages. 

In its efforts to promote judicious use of antibiotics, WARN also sought to appeal to 

multiple levels of influence, by working with parents of small children, physicians, and day 

care providers. However, day care centers would not allow sick children to return unless 

they were on an active antibiotic regimen—a policy whose underlying message to parents 

and providers undermined the message of the campaign. The program sponsors also 

concluded that individual physicians were unlikely to change their behavior until a “critical 

mass” of their peers did the same. Similar reasoning led the CDC’s Campaign to Prevent 

Antimicrobial Resistance in Healthcare Settings to partner with professional societies in an 

effort to bring the influence of peer networks and opinion leaders to bear on health care 

providers. 

The natural social groupings in which people carry out their everyday lives are most 

readily identified at the community level, and these groups, in turn, can be the vehicles for 

reaching and influencing individuals in the target audience. Involving representatives of such 

groups in the formative design stages of a campaign can help establish buy-in. For example, 

the sponsors of Wheeling Walks credited the success of its effort to promote physical 

activity in large part to the way it organized its approach to planning. Instead of designing a 

campaign for a community, Wheeling Walks solicited input from a wide range of participants 

to craft a campaign congruent with the values and interests of the groups it sought to reach. 

REACHING PEOPLE WHERE THEY LIVE AND WORK

Public health educators also recognize that people are most receptive to campaign 

messages that reach them at the point of decision-making, in the environments where the 

targeted behaviors take place and are influenced. Although sponsors may face political 

pressure to make the most of limited campaign budgets by waging broad-based 

communication efforts that reach large numbers of people, most public health professionals 

agree that campaigns have more impact on behavior if they seek depth—and intense 

“dosage”—rather than breadth. 

Thus the campaigns we reviewed that had a community-level component were generally 

seen as more promising and effective than those that relied on mass communication. For 

example, the Falmouth Safe Skin Project targeted a seaside community in the summer to 

reach people at the time and place they were most likely to experience excessive exposure to 
14 

Chapter IV: Elements of Campaign Success 

the sun. The project included many different components, including a mass communication 

campaign, with promotional materials distributed throughout the community. However, its 

greatest success was in engaging the parents of newborns in hospital nurseries, where sun 

protection training was integrated into pre-existing instructional sessions demonstrating 

infant bathing techniques. Because the nursery experience was so successful in achieving 

results with little inconvenience to staff or parents, program sponsors report that if they had 

to do the campaign again, given limited budgets, they would go for greater depth through a 

similar intervention rather than attempting to reach a broader audience through more diffuse 

efforts. 

Starting as a community-based intervention, WARN tried similarly to reach physicians 

where they lived and worked, using one-on-one “academic detailing” approaches (similar to 

those used by drug companies) and small-group continuing education programs for 

physicians. Although the sponsors continue to believe that this is probably the best way to 

reach physicians, they had to abandon the approach when the only available sources of 

funding required statewide educational campaigns. Without the financial resources of a large 

pharmaceutical company, academic detailing was too expensive to implement statewide. 

Health Dialog reports that they are most successful in engaging clients who are facing a 

critical, and imminent, medical decision (such as regarding elective surgery or cancer 

therapy). With a strategy similar to academic detailing, Health Dialog uses sophisticated 

analytics to identify clients likely to fit this description. The health coaches then send 

decision tools and informational material to clients’ homes and reach out to them by 

telephone. 

MAKING THE MESSAGE ACTIONABLE

Most people resist messages that preach (or tell them what not to do). Health 

communications experts agree that, after getting the audience’s attention, the most effective 

campaign messages are those that include specific—and positive—follow-up actions for 

people to take. Action reinforces learning and moves people a step further on a path toward 

change, even if the step is small. However, the action steps must be both accessible to the 

consumer and doable. 

Canada on the Move, a public-private partnership between CIHR and Kellogg Canada, 

began as a Kellogg’s Special K promotion that included packaging free pedometers in cereal 

boxes. Kellogg’s marketing department initially developed simple, and memorable, 1-2-3 

messages for the campaign, urging people (1) to wear their Special K pedometer, (2) to “add 

2,000 steps” to their everyday activities, and (3) to eat healthy foods (like Special K). To 

make the campaign more consistent with CIHR’s public health research agenda, the 

messages developed for Canada on the Move eliminated references to Special K and revised 

the third message to tap into Canadians’ support for research, urging them to “donate” their 

steps to health research by visiting a web site specifically designed to track participant 

progress. The messages were clear and explicit, and the free pedometers and sponsored 

website helped make them doable. 
 15 

 Chapter IV: Elements of Campaign Success 

The CDC deliberately chose Choose Your Cover as its campaign slogan, in lieu of the 

stay-out-of-the-sun-altogether message favored by some “hard-line” professionals, because 

its research showed that the adolescents it targeted would not consider taking such an 

austere approach to sun protection. The campaign’s messages went on to suggest alternative 

ways to cover up (wearing protective clothing, using sun block, staying in the shade), leaving 

the choice up to the individual. When research also showed that teenage boys resisted 

wearing sun block because it smelled like perfume, the program’s sponsors urged the 

manufacturers to come up with an unscented product that could appeal to that group. 

Keep America Beautiful is best known as a nationwide mass media campaign, but its 

real action message is not to stop littering, but to become involved in the community-level 

efforts the program promotes. Program sponsors point out that people will not make a 

lifetime commitment to cleaning up other people’s trash, but they will spend a couple of 

hours volunteering—and this creates valuable hands-on communal “teaching moments” in 

which to educate people about the contributing causes and the magnitude of the littering 

problem, without preaching at them. 

USING MEDIA STRATEGICALLY

Because they deliver messages to large numbers of people, mass media campaigns are 

often attractive to funding organizations or sponsors of public health consumer education 

campaigns. However, isolated mass media efforts do not make a campaign effective. They 

might raise public awareness or reinforce messages delivered by other means, but most 

respondents agree that they have limited impact on target audiences when used alone. 

The real power of the media lies in the ability to reach defined audience segments in the 

various venues where they live and work, as part of a multifaceted strategic approach. At the 

community level, for example, some communications experts suggest that newspapers or 

local television news broadcasts are good ways to reach older people, while radio is more 

effective with younger people and ethnic or linguistic minorities. Transit ads and billboards 

can also be used to reach specific neighborhoods. Mass circulation magazines can be useful 

in targeting broadly defined demographic groups at the national level. The web, of course, 

has rapidly become a powerful mechanism for reaching and mobilizing young people, in 

their own personal space and across broad geographic boundaries. 

Marketing specialists distinguish between pro bono, paid, and “earned” media coverage. 

Media outlets are often willing to place pro bono public service announcements for public 

health campaigns, but sponsors have little control over when, where, or how often such ads 

are placed or aired. Purchased advertising allows more control over content and placement 

of messages, but limited budgets still may not permit the equivalent of prime-time (or frontpage) coverage. Target audiences may also be skeptical of paid advertising, knowing that it is 

trying to sell them on something. For these reasons, “earned” media coverage—voluntary 

reporting on an issue in news or features stories—is often seen as more valuable, since it 

sends the message from a neutral party that the topic warrants interest and attention. 

However, earned media may be hard to get (given competing newsworthy stories), and 

reporters may not frame the issues as campaign sponsors would hope. Public health 
16 

Chapter IV: Elements of Campaign Success 

professionals have been especially interested in tapping the potential of the entertainment 

media to shape social norms or model behavior. Although they have met with some limited 

success in a few areas (anti-drunk driving, safe sex), this has proven to be the most difficult 

media attention to earn. 

To the extent that their limited budgets would allow, most of the campaigns and 

programs we reviewed tried to make strategic use of media rather than rely on mass 

communication campaigns alone. Keep America Beautiful, for example, began appropriately 

enough by using highway billboards to deliver its anti-littering messages to drivers, but its 

media strategy has evolved as the characteristics of its target audiences have changed, and it 

now uses the web to reach out to younger generations. In its Choose Your Cover campaign, 

the CDC partnered with Seventeen magazine to help deliver its message to teenage girls, and 

with the Weather Channel to reinforce messages about the hazards of spending summer 

days in the sun. 
C HAPTER V 

C HALLENGES OF P UBLIC H EALTH 

C ONSUMER E DUCATION P ROGRAMS

ome of the most compelling themes to emerge from our research highlight the 

challenges common to all the public health consumer education programs we 

reviewed, and we would be remiss not to mention these in our discussion of key 

findings. In this chapter, we address the key challenges we identified: demonstrating 

effectiveness; getting (and staying) on the public agenda; leveraging limited resources; and 

weighing the distinctions between informing, motivating, and manipulating behavior. 

DEMONSTRATING EFFECTIVENESS

First, we must acknowledge that the evidence base for campaign effectiveness is limited. 

As we searched the literature for successful programs, we found few that had been formally 

evaluated and fewer still that could demonstrate an impact on behavior. This cursory 

impression, based on our limited review, is supported by rigorous reviews and meta-analyses 

by other researchers (Snyder et al. 2004; van Sluijs 2007; Saraiya et al. 2004; Cavill and 

Bauman 2004). 

This paucity of evidence reflects the challenges that even well-designed campaigns face 

in generating hard evidence of effectiveness. Behavioral change takes time, but few 

campaigns have the resources to sustain a long-term effort or to evaluate more than shortterm outcomes. Distinguishing discrete campaign effects from secular influences on 

behavior is also difficult, since campaigns almost never take place in controlled or isolated 

environments. For these reasons, evaluations more often focus on the performance of the 

campaign itself (such as the depth and breadth of audience exposure to campaign messages) 

or on short-term impacts on audience perceptions, awareness, or attitudes. Only rarely are 

campaigns able to conduct follow-up studies to determine whether short-term impacts 

persist or lead to changes in behavior. 

Although for this study we deliberately selected programs that included fairly rigorous 

evaluations in their design, they were similarly challenged to demonstrate hard outcomes 

with lasting effects. For example, the government cosponsors of Canada on the Move 

recognized that Kellogg Canada’s distribution of pedometers in cereal boxes created a rare 

opportunity to conduct a “natural experiment” in mass communication about the health 

S 
18 

Chapter V: Challenges of Public Health Consumer Education Programs 

benefits of walking. Through its government-funded evaluation, Canada on the Move was 

able to show that it had attracted the attention of a large segment of the Canadian 

population, that pedometer ownership increased, and that awareness of the campaign was 

associated with pedometer use (Craig et al. 2006). Nonetheless, the short time frame and 

limited budget for evaluation did not permit researchers to determine whether the campaign 

had had an impact on long-term outcomes related to walking behavior, fitness, or weight 

loss. 

WARN faced similar challenges. A federally funded initiative designed to educate 

physicians and the public about drug resistance while promoting the judicious use of 

antimicrobial drugs, WARN used a natural experimental design to evaluate its efforts, 

selecting Minnesota as the “control” comparison group to its “treatment” efforts in 

Wisconsin. Although the research team found that antimicrobial prescribing in Wisconsin 

declined more than 20 percent between 1998 and 2003, that reduction was not significantly 

different from comparable declines in the control state of Minnesota (Belongia et al. 2005). 

Demonstrating the effectiveness of shared or informed decision-making is also difficult, 

in part because of the challenges of determining what constitutes a “good” decision when 

outcomes are uncertain—a point we address further below (Holmes-Rovner et al., 2007; 

O’Connor et al. 2003, 2004; Politi et al. 2007). Several randomized controlled studies have 

shown that people who more accurately understand the probabilities of outcomes associated 

with specific procedures (such as elective surgery and cancer screening) are more likely to 

decide against them (Ward 1999; Sarfati et al. 1998; Schwartz et al. 1999; Halvorson et al. 

2007; Edwards et al. 2001, 2003; O’Connor et al. 2004). However, the evidence also 

suggests that efforts to engage consumers in using decision aids or otherwise participating in 

shared decision-making have had limited success (O’Connor et al. 2004). One study found 

wide variation in the extent to which people want to be involved in decisions about their 

care, with older people, in particular, less inclined to participate actively (Levinson et al. 

2005). 

GETTING/STAYING ON THE PUBLIC AGENDA

At a given moment, any number of legitimate concerns compete for public attention 

and limited public health resources. In what one group of health communications 

researchers described as “marketing health in a crowded media world,” advocates and 

advocacy organizations try to bring their issues to the fore by whatever means they can: by 

soliciting celebrity endorsements, by taking advantage of events in the news to draw 

attention to a particular problem, or by framing messages in a way that raises public alarm 

(Randolph and Viswanath 2004). Meanwhile, public priorities and attention can and do shift 

often and quickly, creating limited windows of opportunity in which to take action. 

Changing social norms and entrenched behaviors requires a sustained effort on many 

different fronts over many years, as the long-term success of anti-smoking initiatives and 

campaigns to reduce the incidence of drunk driving clearly attests. The experience of these 

initiatives underscores the fact that progress requires a continuously renewed commitment, 
 19 

 Chapter V: Challenges of Public Health Consumer Education Programs 

and a substantial amount of resources, before a “tipping point” is reached. Yet most issues 

and campaigns have a short “shelf life” that makes sustained effort difficult. 

Keep America Beautiful has been able to maintain momentum behind its anti-littering 

campaigns for more than 50 years, in part because it has been able, at critical junctures, to 

realign its core messages with larger social phenomena that resonate with broad sectors of 

the American public, from the “See the USA” ethos of the post-World War II era 

(commensurate with the proliferation of automobiles and federal highway development) to 

the environmental movement of the 1970s to more recent interests in recycling and 

minimizing the “carbon footprint.” 

Yet several of the other programs we studied acknowledged that both their life span and 

their effectiveness were limited by competing and shifting priorities. For example, the 

programs promoting sun protection arose from the CDC’s search for “low-hanging fruit” in 

cancer prevention in the 1990s: skin cancer was commonly diagnosed, most forms were 

eminently preventable, and the means for preventing them (avoiding excessive sun exposure 

in children and adolescents) seemed straightforward and accessible. In spite of broad 

professional consensus on these issues, efforts to get cooperative support for the campaign 

among health care providers and schools were largely unsuccessful amid competing (and 

more compelling) concerns about other adolescent risks, like unprotected sex and substance 

abuse. 

Similarly, WARN was unable to secure discretionary state funding to support even a 

modest continuation of its campaign to promote more judicious antibiotic use after federal 

money ran out, because those who made the funding decisions had other more immediate 

public health priorities, such as improving children’s access to dental care. This experience 

in particular suggests the importance of having champions with influence over the 

distribution of resources who can help sustain momentum behind public health campaigns 

that seek to enhance the public good over the long term, even though benefits may not 

accrue to individuals in the near term. 

LEVERAGING LIMITED RESOURCES

The expenses associated with the development, implementation, and evaluation of welldesigned consumer education campaigns and the limited availability of funding to support 

such efforts often dictate the need to leverage resources, wherever possible, through 

partnerships with commercial endeavors, pro bono contributions, and voluntary alliances. 

Most of our respondents agreed that such partnerships are critical and have the potential to 

expand a program’s reach or effectiveness well beyond what it would otherwise be. 

However, they can sometimes make it difficult for program sponsors to maintain control 

over campaign messages or strategies. 

The common interest of CIHR and Kellogg Canada in delivering messages about diet 

and exercise led them to join forces in an unprecedented public-private partnership for 

Canada on the Move. Kellogg’s resources and promotional ability could reach far more 

people than government funding alone. However, CIHR worried initially that its association 
20 

Chapter V: Challenges of Public Health Consumer Education Programs 

would be seen as product endorsement and that its credibility would be undermined by 

association with a manufacturer of high-sugar cereals popular with children. On the advice 

of independent consultants, it addressed this concern by separating the launch of the 

campaign from the launch of the cereal and appealing to the Canadian public for support for 

health research. 

The CDC’s Choose Your Cover sun protection campaign targeted adolescents with the 

practical message about the need to cover up during peak midday hours, after research 

showed that this audience would not respond well to stronger admonitions. The campaign 

was able to stretch its limited budget by enlisting pro bono support from Seventeen magazine 

and the Weather Channel in spreading its message. Ironically, however, it faced opposition 

from a vocal professional group with whom it had hoped to partner, which insisted that the 

message be Do not go outside during these hours. 

INFORMING VERSUS MOTIVATING VERSUS MANIPULATING BEHAVIOR

Virtually everyone agrees that information alone does not change behavior. Because 

most public health campaigns do seek to influence behavior, however, they must convey 

information in a way that gets consumers’ attention and motivates them to take action. In 

this connection, both the literature and the experts we interviewed emphasize the 

importance of message “framing” in motivating behavior. Numerous studies, for example, 

have explored how “loss framing” (that is, stressing the risk of dire outcomes) and “gain 

framing” (emphasizing the benefits or the chances of good outcomes) influence behavior, 

depending on people’s emotional response to the perceived risks and benefits associated 

with the behaviors and the uncertain outcomes (Kahneman and Tversky 1984; Rothman and 

Salovey 1997). Under some circumstances, appeals to fear have also been shown to be 

effective in arousing people to take action (although if overdone they can prompt people to 

block the messages altogether). 

However, a number of other research findings raise questions about whether the way 

information is presented perhaps unintentionally manipulates behavior by creating distorted 

perceptions. For example, awareness campaigns have helped move breast cancer to the 

forefront of the public agenda, likely contributing to increased use of mammograms over the 

past 20 years. Yet several recent studies suggest that these campaigns have led many women 

to assume that their personal breast cancer risk is far higher than it really is. The women in 

one study were relieved to learn that their actual risk was much lower (Fagerlin et al. 2005; 

Boyles 2005). Framing the odds in terms of survival rather than mortality also makes 

patients more likely to give their “informed consent” for risky procedures (and vice versa) 

(McNeil et al. 1982). Patients who consent to participate in phase I clinical trials also tend to 

have an exaggerated sense of the potential benefits of the untested treatments, compared to 

their physicians and to patients who decline (Weinfert et al. 2003; Merapol et al. 2003). 

In contrast to the behavioral objectives of most public health campaigns, the aim of 

informed decision-making is not to persuade consumers to take a particular course of action, 

but rather to help them incorporate accurate information about the risks and benefits of 

alternatives into their decisions. And studies of informed decision-making have shown that 
 21 

 Chapter V: Challenges of Public Health Consumer Education Programs 

people who more accurately understand the risks and benefits of specific procedures (such 

as elective surgery and cancer screening) are actually more likely to forgo them (Ward 1999; 

Sarfati et al. 1998; Schwartz et al. 1999; Halvorson et al. 2007; Edwards et al. 2001, 2003; 

O’Connor et al. 2004). 

Studies such as these raise a fundamental ethical question about public health consumer 

education programs that is not often acknowledged: Is it justifiable to exaggerate risks or 

benefits in order to motivate people to take a preferred course of action? 

Health Dialog seeks to sort out questions about informing versus motivating versus 

manipulating health-related decisions in its approach to communication with clients. Health 

Dialog makes a clear distinction between situations where there is a strong, evidence-based, 

preferred behavior or treatment and those where there is not. In the former case (for 

example, diet and weight management in diabetes control), the health coach’s job is frankly 

motivational. This may require rectifying misperceptions or informational deficits on the 

client’s part, but more often the barriers clients face are emotional and practical (not 

informational), and the coach’ job is to help clients develop appropriate strategies, given 

their stage of readiness. However, in cases where the evidence is equivocal (for example, 

PSA screening) or where there are many different options with equivalent outcomes (for 

example, in early-stage breast cancer treatment), the coach’s job is not to influence decisions 

but to remain neutral, to give clients accurate and unbiased information about the risks and 

benefits of various options, to help them recognize how their personal preferences and 

values play into the decision, and to coach them to advocate for themselves within the health 

care system once they have made their decision. 
This page has been left blank for double-sided copying 
C HAPTER VI 

I MPLICATIONS FOR M EDICARE

ne of the research team’s charges in undertaking this project was to consider how 

our findings might apply to Medicare and to programs or campaigns targeting 

Medicare beneficiaries. In this chapter, we address these questions (1) by 

considering ways the Medicare population might be different from other audiences typically 

targeted in consumer public health education campaigns, (2) by reflecting on what Medicare 

wants to accomplish by engaging consumers, and (3) by returning to the question raised at 

the end of the previous chapter about the distinction between motivating and informing 

behavior. 

IS THE MEDICARE POPULATION DIFFERENT? 

The first question that comes to mind when considering the implications of this 

research to Medicare is whether any characteristics unique to the Medicare population would 

shape the approach to campaigns that target this population. While the principles identified 

in Chapter IV would apply regardless of the population (for example, the need to make 

campaign messages personal and actionable, to focus on multiple levels of influence, and to 

use media strategically) our interviews revealed several common assumptions about this agedefined demographic group that may shape campaign strategies. For example, one 

respondent noted that older age groups do not respond well to humorous appeals. Some 

communications researchers have found that people over 65 are reached best through 

newspapers, daytime television, and local news broadcasts, and many note that seniors make 

little use of computers or the web. Several respondents also cited research showing that 

older consumers are more deferential to their physicians than younger ones and less inclined 

to take an active part in health care decision-making. Others observed that older people in 

particular have trouble sorting through complex information about the risks and benefits of 

alternative courses of action. 

Yet evidence also suggests that the behaviors and characteristics of older age groups 

may be changing and that some commonly held assumptions do not necessarily hold. 

Computer and web use is rapidly increasing among older people, for example, and will 

continue to do so as baby boomers age. Based on their health coaching experience, Health 

Dialog staff also report that older people, far from deferring to their physicians, are often 

most interested in discussing treatment alternatives, because they are more likely than 

O 
24 

Chapter VI: Implications for Medicare 

younger people to have had negative health care experiences at some point. Regardless of 

their personal opinions about these questions, all our respondents agreed that prior 

assumptions about any demographic group often turn out to be wrong, and all stressed the 

importance of conducting research on the target audience when designing a program. 

In sum, rather than making assumptions about the Medicare population, we need to 

inform our communication or educational campaigns through research into the specific 

perceptions, attitudes, and behaviors we wish to address. 

WHAT DO WE WANT TO ACCOMPLISH BY ENGAGING MEDICARE CONSUMERS? 

We began this project by identifying several different kinds of behaviors that public 

health consumer education programs typically seek to influence, the objectives they seek to 

achieve, and the different motivational considerations associated with each (Table II.1). As 

we understand it, what prompted MedPAC to launch this project is the conviction that 

consumers (who have heretofore been mostly absent from policy discussions) need to 

become active partners in efforts to bring higher quality and greater efficiency to the health 

care system and to become active participants in their own health care. What are the desired 

behavioral outcomes of engaging consumers in these endeavors, and what are the associated 

motivational considerations? How do our research findings bear on these questions? 

One of the biggest challenges is that these objectives have not been well defined in 

public policy circles. If the aim is to inform consumer choice, the presumption is that 

consumers do have choices, perceive consequences to those choices, understand the 

information reported and its relevance to their needs, and see meaningful differences in 

performance. In practice, however, none of this may be true: choice might be limited or 

nonexistent; variations in quality may not be apparent; information may be conflicting, 

confusing, or highly technical; and the relevance of information to personal health care 

decisions may not be obvious (Gerteis et al. 2004). In sum, consumers have not come to the 

table for discussions of quality and efficiency, because the issues have not been framed in 

terms that are either personally relevant or conducive to action. 

In many respects, these issues, as well as those in other areas of public policy interest 

(such as health information technology), are similar to those faced by the programs targeting 

littering and antibiotic use: that is, the objective of creating a better, more efficient health 

care system has more to do with the promotion of the greater public good than with the 

health or well-being of any individual. Just as people are asked to sacrifice some degree of 

convenience or personal comfort for the greater good by abstaining from littering or 

antibiotic use, so will they be asked to forgo some high-tech or high-cost health care services 

in the interest of creating a more judicious and efficient health care system. Indeed, one of 

the biggest obstacles to getting consumers to consider lower-tech treatment alternatives in 

shared decision-making protocols, according to spokespersons for Health Dialog, is the 

prevailing cultural norm, reinforced by the media, that more—more health care, more highcost technology—is better. 
 25 

 Chapter VI: Implications for Medicare 

How, then, do we engage consumers in conversations that say less may be better? 

Several respondents observed that the individualism of Americans, in contrast to their 

Canadian or European counterparts, makes them less responsive to appeals based on the 

interest of the larger community. But others suggested that appealing to their patriotism or 

to the need to conserve resources for children and grandchildren may resonate, especially, 

with older Americans. The programs we reviewed for this research helped identify some of 

the factors that contribute to (or limit) the success of public health consumer education 

campaigns. But we need to explore other examples, from other areas of public life, that 

provide better models for engaging people in the pursuit of the common good. There are, 

however, no simple solutions. Changing social norms around the use of health resources for 

the sake of the common good—if that is our aim—will require a multifaceted and sustained 

effort for many years to come. 

DO WE WANT TO MOTIVATE CONSUMERS OR INFORM THEIR BEHAVIOR? 

Our research raised questions about the distinctions between informing, motivating, and 

manipulating consumer behavior, as well as about the circumstances that may justify 

different approaches. As we think through what Medicare wants to accomplish by engaging 

consumers and how it should do so, it is worthwhile to ask whether our aim ought to be to 

motivate or to inform. Does the preponderance of evidence we bring to bear on questions 

of quality and efficiency, for example, indicate that some health care providers are clearly 

better than others? If it does, then the objective may well be to move consumers toward 

those providers, just as public health campaigns seek to move them toward evidence-based 

healthy behaviors. While this will still require sustained effort on many different fronts, our 

review of public health consumer education programs suggests some of the principles that 

should guide such efforts. 

If, on the other hand, the evidence is mixed, inconsistent, or inconclusive—as often 

seems to be the case with existing measures of quality and efficiency—then the challenge is 

to engage consumers with the information in a way that allows them to understand the 

uncertainties, weigh the costs and benefits of alternatives, and make an informed decision 

consistent with their own needs and values (Politi et al. 2007). As several of our interview 

respondents observed, this is an especially difficult task, given limited proficiency with the 

language of mathematics and statistics throughout the population. We also need to learn 

from other fields how to convey information about probabilities, risks, and benefits in a 

value-neutral way and translate complex statistics into terms that consumers can understand. 
This page has been left blank for double-sided copying 
A PPENDIX A 

R EFERENCES
This page has been left blank for double-sided copying 
R EFERENCES

Beaudoin, C.E., C. Fernandez, J.L. Wall, and T.A. Farley. "Promoting Healthy Eating and 

Physical Activity: Short-Term Effects of a Mass Media Campaign." American Journal of 

Preventive Medicine, vol. 32, no. 3, March 2007, pp. 217-223. 

Beeker, C., J.M. Kraft, B.G. Southwell, and C.M. Jorgensen. "Colorectal Cancer Screening in 

Older Men and Women: Qualitative Research Findings and Implications for 

Intervention." Journal of Community Health, vol. 25, no. 3, June 2000, pp. 263-278. 

Belongia, E.A., M.J. Knobloch, B.A. Kieke, J.P. Davis, C. Janette, and R.E. Besser. "Impact 

of Statewide Program to Promote Appropriate Antimicrobial Drug Use." Emerging 

Infectious Diseases, vol. 11, no. 6, June 2005, pp. 912-920. 

Belongia, E.A., B.J. Sullivan, P.H. Chyou, E. Madagame, K.D. Reed, and B. Schwartz. "A 

Community Intervention Trial to Promote Judicious Antibiotic use and Reduce 

Penicillin-Resistant Streptococcus Pneumoniae Carriage in Children." Pediatrics, 

vol. 108, no. 3, September 2001, pp. 575-583. 

Benjes, L.S., D.R. Brooks, Z. Zhang, L. Livstone, L. Sayers, C. Powers, D.R. Miller, T. 

Heeren, and A.C. Geller. "Changing Patterns of Sun Protection Between the First and 

Second Summers for Very Young Children." Archives of Dermatology, vol. 140, no. 8, 

August 2004, pp. 925-930. 

Boyles, Salynn. “Breast Cancer Risk: Perception vs. Reality.” WebMD Medical News. 

Available at [http://www.webmd.com/breast-cancer/news/20050608/breast-cancerrisk-perception-vs-reality]. June 8, 2005. 

Brinsley, K., R. Sinkowitz-Cochran, and D. Cardo. "An Assessment of Issues Surrounding 

Implementation of the Campaign to Prevent Antimicrobial Resistance in Healthcare 

Settings." American Journal of Infection Control, vol. 33, no. 7, September 2005, pp. 402-

409. 
A-2 

References 

Brinsley, K., A. Srinivasan, R. Sinkowitz-Cochran, R. Lawton, R. McIntyre, G. Kravitz, B. 

Burke, R. Shadowen, and D. Cardo. "Implementation of the Campaign to Prevent 

Antimicrobial Resistance in Healthcare Settings: 12 Steps to Prevent Antimicrobial 

Resistance among Hospitalized Adults--Experiences from 3 Institutions." American 

Journal of Infection Control, vol. 33, no. 1, February 2005, pp. 53-54. 

Brinsley, K.J., R.L. Sinkowitz-Cochran, and D.M. Cardo. "Assessing Motivation for 

Physicians to Prevent Antimicrobial Resistance in Hospitalized Children using the 

Health Belief Model as a Framework." American Journal of Infection Control, vol. 33, no. 3, 

April 2005, pp. 175-181. 

Briss, P., B. Rimer, B. Reilley, R.C. Coates, N.C. Lee, P. Mullen, P. Corso, A.B. Hutchinson, 

R. Hiatt, J. Kerner, P. George, C. White, N. Gandhi, M. Saraiya, R. Breslow, G. Isham, 

S.M. Teutsch, A.R. Hinman, and R. Lawrence. "Promoting Informed Decisions about 

Cancer Screening in Communities and Healthcare Systems." American Journal of Preventive 

Medicine, vol. 26, no. 1, January 2004, pp. 67-80. 

Cameron, R., A. Bauman, and A. Rose. "Innovations in Population Intervention Research 

Capacity: The Contributions of Canada on the Move." Canadian Journal of Public Health, 

vol. 97, suppl. 1, March-April 2006, pp. S5-S9. 

Catalano, R., L. Winett, L. Wallack, and W. Satariano. "Evaluating a Campaign to Detect 

Early Stage Breast Tumors in the United States." European Journal of Epidemiology, vol. 18, 

no. 6, 2003, pp. 545-550. 

Cavill, N. and A. Bauman. "Changing the Way People Think about Health-Enhancing 

Physical Activity: Do Mass Media Campaigns have a Role?" Journal of Sports Sciences, 

vol. 22, no. 8, August 2004, pp. 771-790. 

Chattopadhyay, Sajal K., PhD, and Carande-Kulis, Vilma G., PhD. "Economics of 

Prevention: The Public Health Research Agenda." Journal of Public Health Management and 

Practice, vol. 10, no. 5, 2004, pp. 467-471. 

Cosgrove, S.E., A. Patel, X. Song, R.E. Miller, K. Speck, A. Banowetz, R. Hadler, R.L. 

Sinkowitz-Cochran, D.M. Cardo, and A. Srinivasan. "Impact of Different Methods of 

Feedback to Clinicians After Postprescription Antimicrobial Review Based on the 

Centers for Disease Control and Prevention's 12 Steps to Prevent Antimicrobial 

Resistance among Hospitalized Adults." Infection Control and Hospital Epidemiology, 

vol. 28, no. 6, June 2007, pp. 641-646. 

Coughlin, S.S., M.E. Costanza, M.E. Fernandez, K. Glanz, J.W. Lee, S.A. Smith, L. Stroud, I. 

Tessaro, J.M. Westfall, J.L. Weissfeld, and D.S. Blumenthal. "CDC-Funded Intervention 

Research Aimed at Promoting Colorectal Cancer Screening in Communities." Cancer, 

vol. 107, no. 5, September 2006, pp. 1196-1204. 
 A-3 

 References 

Craig, C.L., S.E. Cragg, C. Tudor-Locke, and A. Bauman. "Proximal Impact of Canada on 

the Move: The Relationship of Campaign Awareness to Pedometer Ownership and 

Use." Canadian Journal of Public Health, vol. 97, suppl. 1, 2006, pp. S21-S27. 

Craig, C.L., C. Tudor-Locke, and A. Bauman. "Twelve-Month Effects of Canada on the 

Move: A Population-Wide Campaign to Promote Pedometer use and Walking." Health 

Education Research, vol. 22, no. 3, June 2007, pp. 406-413. 

Cram, P., A.M. Fendrick, J. Inadomi, M.E. Cowen, D. Carpenter, and S. Vijan. "The Impact 

of a Celebrity Promotional Campaign on the use of Colon Cancer Screening: The Katie 

Couric Effect." Archives of Internal Medicine, vol. 163, no. 13, 2003, pp. 1601-1605. 

Dietrich, A.J., A.L. Olson, C.H. Sox, M. Stevens, T.D. Tosteson, T. Ahles, C.W. Winchell, J. 

Grant-Petersson, D.W. Collison, and R. Sanson-Fisher. "A Community-Based 

Randomized Trial Encouraging Sun Protection for Children." Pediatrics, vol. 102, no. 6, 

December 1998, E64. Available at [ www.pediatrics.org/cgi/content/full/102/6/e64]. 

Dietz, W.H. "Canada on the Move: A Novel Effort to Increase Physical Activity among 

Canadians." Canadian Journal of Public Health, vol. 97, suppl. 1, March-April 2006, pp. S3-

S4. 

Dunn, A.L. and S.N. Blair. "Translating Evidenced-Based Physical Activity Interventions 

into Practice. the 2010 Challenge." American Journal of Preventive Medicine, vol. 22, no. 4, 

May 2002, pp. 8-9. 

Edwards, A., G. Elwin, J. Covey, E. Matthews, and R. Pill. “Presenting Risk Information – 

A Review of the Effects of ‘Framing’ and Other Manipulations on Patient Outcomes.” 

Journal of Health Communication, vol. 6, 2001, pp. 61-82. 

Edwards, Adrian, Silvana Unigwe, Glyn Elwyn, and Kerenza Hood. “Effects of 

Communicating Individual Risks in Screening Programmes: Cochrane Systematic 

Review.” British Medical Journal, vol. 327, September 27, 2003, pp. 703-709. 

Fagerlin, Angela, Brian J. Zikmund-Fisher, and Peter A. Ubel. “How Making a Risk 

Estimate Can Change the Feel of that Risk: Shifting Attitudes.” Patient Education and 

Counseling, vol. 57, no. 3, June 2005, pp. 294-299. 

Farrelly, M.C., K.C. Davis, M.L. Haviland, P. Messeri, and C.G. Healton. "Evidence of a 

Dose-Response Relationship between ‘Truth’ Antismoking Ads and Youth Smoking 

Prevalence." American Journal of Public Health, vol. 95, no. 3, March 2005, pp. 425-431. 

Faulkner, G. and S.J. Finlay. "Canada on the Move: An Intensive Media Analysis from 

Inception to Reception." Canadian Journal of Public Health, vol. 97, suppl. 1, March-April 

2006, pp. S16-S20. 

Fishbein, M. "Developing Effective Behavior Change Interventions: Some Lessons Learned 

from Behavioral Research." NIDA Research Monograph, vol. 155, 1995, pp. 246-261. 
A-4 

References 

Geller, A.C., L. Sayers, H.K. Koh, D.R. Miller, L. Steinberg Benjes, and M. Crosier Wood. 

"The New Moms Project: Educating Mothers about Sun Protection in Newborn 

Nurseries." Pediatric Dermatology, vol. 16, no. 3, May 1999, pp. 198-200. 

Gerteis, Margaret, Christopher Koepke, Rosemary Lee, Phyllis Nagy, Fiona Smith, Alyson E. 

M. Ward, and Jessie Gerteis. “Social Marketing Challenges of Reporting Nursing Home 

and Home Health Quality Measures to Inform Consumer Choice: A Report on 

Formative Research.” Paper presented at the American Public Health Association 

132nd Annual Meeting, Washington, DC, November 9, 2004. 

Giblin, T.B., R.L. Sinkowitz-Cochran, P.L. Harris, S. Jacobs, K. Liberatore, M.A. 

Palfreyman, E.I. Harrison, and D.M. Cardo. "Clinicians' Perceptions of the Problem of 

Antimicrobial Resistance in Health Care Facilities." Archives of Internal Medicine, vol. 164, 

no. 15, 2004, pp. 1662-1668. 

Green, Lawrence W., and Marshall W. Kreuter. Health Promotion Planning: An Educational and 

Ecological Approach, 3rd ed. New York: McGraw-Hill, 1999. 

Halvorson, Peder A., Randi Selmer, and Ivar Sønbø Kristiansen. “Different Ways to 

Describe the Benefits of Risk-Reducing Treatments; a Randomized Trial.” Annals of 

Internal Medicine, vol. 146, no. 12, 2007, pp. 848-856. 

Harvard School of Public Health, Center for Health Communication. “The Harvard 

Alcohol Project’s Designated Driver Campaign.” Cambridge, MA: President and 

Fellows of Harvard College, 2007. 

Hill, D. "Skin Cancer Prevention: A Commentary." American Journal of Preventive Medicine, 

vol. 27, no. 5, December 2004, pp. 482-483. 

Holmes-Rovner, M., W.L. Nelson, M. Pignone, G. Elwyn, D.R. Rovner, A.M. O’Connor, A. 

Coulter, R. Correa-de-Araujo. “Are Patient Decision Aids the Best Way to Improve 

Clinical Decision Making? Report of the International Patient Decision Aid Standards 

(IPDAS) Symposium.” Medical Decision Making, vol. 27, No. 5, September – October 

2007, pp. 599-608. 

Institute of Medicine. Promoting Health: Strategies from Social and Behavioral Research. Edited by 

Brian D. Smedley and S. Leonard Syme. Washington, DC: National Academies Press, 

2000. 

Jorgensen, C.M., C.A. Gelb, T.L. Merritt, and L.C. Seeff. "Observations from the CDC: 

CDC's Screen for Life: A National Colorectal Cancer Action Campaign." Journal of 

Womens Health and Gender-Based Medicine, vol. 10, no. 5, June 2001, pp. 417-422. 

Jorgensen, C.M., J. Wayman, C. Green, and C.A. Gelb. "Using Health Communications for 

Primary Prevention of Skin Cancer: CDC's Choose Your Cover Campaign." Journal of 

Womens Health and Gender-Based Medicine, vol. 9, no. 5, June 2000, pp. 471-475. 
 A-5 

 References 

Kahn, E.B., L.T. Ramsey, R.C. Brownson, G.W. Heath, E.H. Howze, K.E. Powell, E.J. 

Stone, M.W. Rajab, and P. Corso. "The Effectiveness of Interventions to Increase 

Physical Activity. A Systematic Review." American Journal of Preventive Medicine, vol. 22, 

no. 4, May 2002, pp. 73-107. 

Kahneman, Daniel, and Amos Tversky. “Choices, Values, and Frames.” American 

Psychologist, vol. 39, 1984, pp. 341-350. 

Kaplan, R.M. "Shared Medical Decision Making. A New Tool for Preventive Medicine." 

American Journal of Preventive Medicine, vol. 26, no. 1, January 2004, pp. 81-83. 

Katz, D.L., M. O'Connell, M.C. Yeh, H. Nawaz, V. Njike, L.M. Anderson, S. Cory, and W. 

Dietz. "Public Health Strategies for Preventing and Controlling Overweight and Obesity 

in School and Worksite Settings: A Report on Recommendations of the Task Force on 

Community Preventive Services." Morbidity and Mortality Weekly Report: Recommendations 

and Reports, vol. 54, no. RR-10, October 2005, pp. 1-12. 

Kiang, K.M., B.A. Kieke, K. Como-Sabetti, R. Lynfield, R.E. Besser, and E.A. Belongia. 

"Clinician Knowledge and Beliefs After Statewide Program to Promote Appropriate 

Antimicrobial Drug Use." Emerging Infectious Diseases, vol. 11, no. 6, June 2005, pp. 904-

911. 

Koh, H.K. and A.C. Geller. "Skin Cancer Prevention Comes of Age." American Journal of 

Preventive Medicine, vol. 27, no. 5, December 2004, pp. 484-485. 

Levinson, W., A. Kao, A. Kuby, and R.A. Thisted. “Not All Patients Want to Participate in 

Decision Making. A National Study of Public Preferences.” Journal of General Internal 

Medicine, vol. 20, no. 6, June 2005, pp. 531-535. 

McCaul, K.D. and K.S. Wold. "The Effects of Mailed Reminders and Tailored Messages on 

Mammography Screening." Journal of Community Health, vol. 27, no. 3, June 2002, 

pp. 181-190. 

McCaul, Kevin D., Kim Jacobson, and Beverly Martinson. "The Effects of a State-Wide 

Media Campaign on Mammography Screening." Journal of Applied Social Psychology,

vol. 28, no. 6, 1998, pp. 504-515. 

McKenzie-Mohr, Doug, and William Smith. Fostering Sustainable Behavior: an Introduction to 

Community-Based Social Marketing. Gabriola Island, British Columbia: New Society 

Publishers, 1999. 

McNeil, B.J., S.G. Pauker, H.C. Sox, Jr., and A. Tversky. “On the Elicitation of Preferences 

for Alternative Therapies.” New England Journal of Medicine, vol. 306, 1982, pp. 1259-

1262. 
A-6 

References 

Merapol, Neal J., Kevin P. Weinfurt, Caroline B. Burnett, Andrew Balshem, Al B. Benson 

III, Liana Castel, Sandra Corbett, Michael Diefenbach, Darrell Gaskin, Yun Li, Sharon 

Manne, John Marshall, Julia H. Rowland, Elyse Slater, Daniel P. Sulmasy, David Van 

Echo, Shakira Washington, and Kevin A. Schulman. “Perceptions of Patients and 

Physicians Regarding Phase I Cancer Clinical Trials: Implications for Physician-Patient 

Communication.” Journal of Clinical Oncology, vol. 21, no. 13, July 1, 2003, pp. 2589-2596. 

Miles, A., L. Rapoport, J. Wardle, T. Afuape, and M. Duman. "Using the Mass-Media to 

Target Obesity: An Analysis of the Characteristics and Reported Behaviour Change of 

Participants in the BBC's 'Fighting Fat, Fighting Fit' Campaign." Health Education 

Research, vol. 16, no. 3, June 2001, pp. 357-372. 

Miller, D.R., A.C. Geller, M.C. Wood, R.A. Lew, and H.K. Koh. "The Falmouth Safe Skin 

Project: Evaluation of a Community Program to Promote Sun Protection in Youth." 

Health Education & Behavior, vol. 26, no. 3, June 1999, pp. 369-384. 

O’Connor, Annette, France Légaré, Dawn Stacey. “Risk Communication in Practice: The 

Contribution of Decision Aids.” British Medical Journal, vol. 327, 27 September 2003, 

pp. 736-737. 

O’Connor, Annette, Hilary A. Llewellyn-Thomas, and Ann Barry Flood. “Modifying 

Unwarranted Variations in Health Care: Shared Decision-Making Using Patient 

Decision Aids.” Health Affairs, Web Exclusive, 7 October 2004, DOI 

10.1377/hlthaff.var.63, VAR-63 – VAR-72. 

Olson, A.L., C. Gaffney, P. Starr, J.J. Gibson, B.F. Cole, and A.J. Dietrich. "SunSafe in the 

Middle School Years: A Community-Wide Intervention to Change Early-Adolescent 

Sun Protection." Pediatrics, vol. 119, no. 1, January 2007, pp. e247-e256. 

Parker, D.M. "Georgia's Cancer Awareness and Education Campaign: Combining Public 

Health Models and Private Sector Communications Strategies." Preventing Chronic 

Disease, vol. 1, no. 3, July 2004. Available at [www.cdc.gov/pcd/issues/ 

2004/jul/04_0030.htm]. 

Perz, J.F., A.S. Craig, C.S. Coffey, D.M. Jorgensen, E. Mitchel, S. Hall, W. Schaffner, and 

M.R. Griffin. "Changes in Antibiotic Prescribing for Children After a Community-Wide 

Campaign." Journal of the American Medical Association, vol. 287, no. 23, 2002, pp. 3103-

3109. 

Peterson, M., A. Abraham, and A. Waterfield. "Marketing Physical Activity: Lessons Learned 

from a Statewide Media Campaign." Health Promotion Practice, vol. 6, no. 4, October 

2005, pp. 437-446. 

Plotnikoff, R.C., J.C. Spence, L.S. Tavares, L.S. Rovniak, A. Bauman, S.A. Lear, and L. 

McCargar. "Characteristics of Participants Visiting the Canada on the Move Website." 

Canadian Journal of Public Health, vol. 97, suppl. 1, 2006, pp. S28-S35. 
 A-7 

 References 

Politi, Mary C., Paul K. J. Han, and Nananda F. Col. “Communicating the Uncertainty of 

Harms and Benefits of Medical Interventions.” Medical Decision Making, vol. 27, 

September – October 2007, pp. 681-695. 

Prochaska, James O., Colleen A. Redding, and Kerry E. Evers. “The Transtheoretical Model 

of Stages of Change.” In Health Behavior and Health Education Research: Theory, Research, 

and Practice, 3rd ed. Edited by Karen Glanz, Barbara K. Rimer, and Francis Marcus 

Lewis. San Francisco: Joseey-Bass Publications, Inc., 2002. 

Randolph, W. and K. Viswanath. "Lessons Learned from Public Health Mass Media 

Campaigns: Marketing Health in a Crowded Media World." Annual Review of Public 

Health, vol. 25, 2004, pp. 419-437. 

Reger, B., L. Cooper, S. Booth-Butterfield, H. Smith, A. Bauman, M. Wootan, S. 

Middlestadt, B. Marcus, and F. Greer. "Wheeling Walks: A Community Campaign 

Using Paid Media to Encourage Walking among Sedentary Older Adults." Preventive 

Medicine, vol. 35, no. 3, September 2002, pp. 285-292. 

Reger-Nash, B., A. Bauman, S. Booth-Butterfield, L. Cooper, H. Smith, T. Chey, and K.J. 

Simon. "Wheeling Walks: Evaluation of a Media-Based Community Intervention." 

Family & Community Health, vol. 28, no. 1, 2005, pp. 64-78. 

Renger, R., V. Steinfelt, and S. Lazarus. "Assessing the Effectiveness of a Community-Based 

Media Campaign Targeting Physical Inactivity." Family & Community Health, vol. 25, 

no. 3, October 2002, pp. 18-30. 

Rogers, Everett M. Diffusion of Innovations, 4th ed. New York: The Free Press, 1995. 

Rose, A. and D. Finegood. "Postscript: Learning from the Experience of Developing and 

Running Canada on the Move." Canadian Journal of Public Health, vol. 97, suppl. 1, 2006, 

pp. S41-S42. 

Rothman, A.J. and P. Salovey. "Shaping Perceptions to Motivate Healthy Behavior: The 

Role of Message Framing." Psychological Bulletin, vol. 121, no. 1, January 1997, pp. 3-19. 

Samuels, S.E. "Project LEAN--Lessons Learned from a National Social Marketing 

Campaign." Public Health Reports, vol. 108, no. 1, 1993, pp. 45-53. 

Saraiya, M., K. Glanz, P.A. Briss, P. Nichols, C. White, D. Das, S.J. Smith, B. Tannor, A.B. 

Hutchinson, K.M. Wilson, N. Gandhi, N.C. Lee, B. Rimer, R.C. Coates, J.F. Kerner, 

R.A. Hiatt, P. Buffler, and P. Rochester. "Interventions to Prevent Skin Cancer by 

Reducing Exposure to Ultraviolet Radiation: A Systematic Review." American Journal of 

Preventive Medicine, vol. 27, no. 5, December 2004, pp. 422-466. 

Sarfarti, D., P. Howden-Chapman, A. Woodward, and C. Salmond. “Does the Frame Affect 

the Picture? A Study Into How Attitudes to Screening for Cancer are Affected by the 

Way Benefits are Expressed.” Journal of Medical Screening, vol. 5, no. 3, 1998, pp. 137-140. 
A-8 

References 

Schneider, T.R., P. Salovey, A.M. Apanovitch, J. Pizarro, D. McCarthy, J. Zullo, and A.J. 

Rothman. "The Effects of Message Framing and Ethnic Targeting on Mammography 

use among Low-Income Women." Health Psychology, vol. 20, no. 4, July 2001, pp. 256-

266. 

Schwartz, Marc D., Barbara K. Rimer, Mary Daly, Colleen Sands, and Caryn Lerman. “A 

Randomized Trial of Breast Cancer Risk Counseling: The Impact on Self-Reported 

Mammography Use.” American Journal of Public Health, vol. 89, no. 6, June 1999, 

pp. 924-926. 

Sheridan, S.L., R.P. Harris, and S.H. Woolf. "Shared Decision Making about Screening and 

Chemoprevention. a Suggested Approach from the U.S. Preventive Services Task 

Force." American Journal of Preventive Medicine, vol. 26, no. 1, January 2004, pp. 56-66. 

Smith, B.J., C. Ferguson, J. McKenzie, A. Bauman, and P. Vita. "Impacts from Repeated 

Mass Media Campaigns to Promote Sun Protection in Australia." Health Promotion 

International, vol. 17, no. 1, March 2002, pp. 51-60. 

Snyder, Leslie B., Mark A. Hamilton, Elizabeth W. Mitchell, James Kiwanuka-Tondo, Fran 

Fleming-Milici, and Dwayne Proctor. “A Meta-Analysis of the Effect of Mediated 

Health Communication Campaigns on Behavior Change in the United States.” Journal of 

Health Communication, vol. 9, no. 71, 2004, pp. 71-96. 

Spence, J.C., R.C. Plotnikoff, L.S. Rovniak, K.A. Martin, W. Rodgers, and S. A. Lear. 

"Perceived Neighbourhood Correlates of Walking among Participants Visiting the 

Canada on the Move Website." Canadian Journal of Public Health, vol. 97, suppl. 1, 2006, 

pp. S36-S40. 

Stephenson, J. "CDC Campaign Targets Antimicrobial Resistance in Hospitals." Journal of the 

American Medical Association, vol. 287, no. 18, 2002, pp. 2351-2352. 

Stone, E.G., S.C. Morton, M.E. Hulscher, M.A. Maglione, E.A. Roth, J.M. Grimshaw, B.S. 

Mittman, L.V. Rubenstein, L.Z. Rubenstein, and P.G. Shekelle. "Interventions that 

Increase use of Adult Immunization and Cancer Screening Services: A Meta-Analysis." 

Annals of Internal Medicine, vol. 136, no. 9, 2002, pp. 641-651. 

Thackeray, R., B.L. Neiger, and C.L. Hanson. "Developing a Promotional Strategy: 

Important Questions for Social Marketing." Health Promotion Practice, vol. 8, no. 4, 

October 2007, pp. 332-336. 

Thornton, Hazel. “Patients’ Understanding of Risk.” British Medical Journal, vol. 327, 

September 27, 2003, pp. 693-694. 

Tudor-Locke, C., S.B. Sisson, S.M. Lee, C.L. Craig, R.C. Plotnikoff, and A. Bauman. 

"Evaluation of Quality of Commercial Pedometers." Canadian Journal of Public Health, 

vol. 97, suppl. 1, 2006, pp. S10-S15. 
 A-9 

 References 

U.S. Department of Health and Human Services, National Institutes of Health, National 

Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice, 2nd ed. NIH 

Publication No. 05-3896. September, 2005. 

van Sluijs, Esther M.F., Alison M. McMinn, and Simon J. Griffin. “Effectiveness of 

Interventions to Promote Physical Activity in Children and Adolescents; Systematic 

Review of Controlled Trials.” British Medical Journal, vol. 335, 2007, pp. 703-707. 

Wandersman, A. and P. Florin. "Community Interventions and Effective Prevention." 

American Psychologist, vol. 58, no. 6-7, 2003, pp. 441-448. 

Ward, J. “Population-Based Mammographic Screening: Does ‘Informed Choice’ Require 

Any Less than Full Disclosure to Individuals of Benefits, Harms, Limitations and 

Consequences?” Australian and New Zealand Journal of Public Health, vol. 23, no. 3, 

June 1999, pp. 301-304. 

Weinfurt, Kevin P., Liana D. Castel, Yun Li, Daniel P. Sulmasy, Andrew M. Balshem, Al B. 

Benson, III, Caroline B. Burnett; Darrell J. Gaskin, John L. Marshall, Elyse F. Slater, 

Kevin A. Schulman, and Neal J. Meropol. “The Correlation Between Patient 

Characteristics and Expectations of Benefit from Phase I Clinical Trials.” Cancer, 

vol. 98, no. 1, May 23, 2003, pp. 166-175. 

Wellman, N.S., B. Kamp, N.J. Kirk-Sanchez, and P.M. Johnson. "Eat Better & Move More: 

A Community-Based Program Designed to Improve Diets and Increase Physical 

Activity among Older Americans." American Journal of Public Health, vol. 97, no. 4, 

April 2007, pp. 710-717. 

Williams, G.A., R.R. Abbott, and D.K. Taylor. "Using Focus Group Methodology to 

Develop Breast Cancer Screening Programs that Recruit African American Women." 

Journal of Community Health, vol. 22, no. 1, February 1997, pp. 45-56. 

Williams, Ted. "The Metamorphosis of Keep America Beautiful." Audubon, vol. 92, no. 2, 

1990, pp. 124-34. 

Wray, R.J., K. Jupka, and C. Ludwig-Bell. "A Community-Wide Media Campaign to 

Promote Walking in a Missouri Town." Preventing Chronic Disease, vol. 2, no. 4, October 

2005. Available at [www.cdc.gov/pcd/issues/2005/oct/05_0010.htm]. 

Zaza, S., R.S. Lawrence, C.S. Mahan, M. Fullilove, D. Fleming, G.J. Isham, and M. 

Pappaioanou. "Scope and Organization of the Guide to Community Preventive 

Services. the Task Force on Community Preventive Services." American Journal of 

Preventive Medicine, vol. 18, no. 1, suppl., January 2000, pp. 27-34. 
This page has been left blank for double-sided copying 
A PPENDIX B 

S EARCH T ERMS USED FOR L ITERATURE 

R EVIEW
This page has been left blank for double-sided copying 
Table B.1. Search Terms Used to Identify Public Health Campaigns in Selected Topic Areas 

OVID MEDLINE 

• Sun exposure 

“sun exposure” OR “sun protection” OR “skin cancer” 

campaign OR intervention 

“pubic health” OR “health education” 

behavior adj4 change 

evaluat$ OR success$ 

• Antibiotic use 

antimicrobial OR antibiotic 

prescri$ OR use or usage 

campaign OR intervention 

“public health” OR “health education” 

behavior adj4 change 

evaluat$ OR success$ 

patient OR clinician OR physician 

• Mammography 

breast adj4 cancer 

mammography 

“breast cancer” AND screen$ 

campaign OR intervention 

“public health” OR “health education” 

behavior adj4 change 

evaluat$ OR success$ 

woman$ or women$ AND health 

EBSCOhost (Academic Search Premier and EconLit) 

• Sun exposure 

“sun exposure” OR “sun protection” OR “skin cancer” 

campaign OR intervention 

“pubic health” OR “health education” 

behavior N4 change 

evaluat* OR success* 

• Antibiotic use 

antimicrobial OR antibiotic 

prescri* OR use or usage 

campaign OR intervention 

“public health” OR “health education” 

behavior N4 change 

evaluat* OR success* 

patient OR clinician OR physician 

• Mammography 

breast N4 cancer 

mammography 

“breast cancer” AND screen* 

campaign OR intervention 

“public health” OR “health education” 

behavior N4 change 

evaluat* OR success* 

woman* or women* AND health 
This page has been left blank for double-sided copying 
A PPENDIX C 

P ROGRAMS S ELECTED FOR R EVIEW
This page has been left blank for double-sided copying 
Table C.1. Public Health Consumer Education Programs Selected for Review, by Type of Behavior Targeted 

Program (Duration) 

Goals/Targeted 

Behaviors 

Target 

Audience(s) 

Communication 

Methods/Strategies

Messages/ 

Information Conveyed

Evaluation 

Measures 

1. Individual Risk Behaviors 

Canada on the Move (2003-2004) 

Walking, physical activity, pedometer use 

Adult Canadians 

Mass education supported by distribution of pedometers, interactive website 

Promoted message of undertaking 30 minutes of moderateintensity activity most days of the week 

Survey data 

Icioacwp

Wheeling Walks (2001-2002) 

Walking, physical activity 

Sedentary and insufficiently active adults aged 50-65 years 

Mass education promoted by mass communications, media events, and local interventions 

Promoted behavior change with simple, focused message emphasizing self-efficacy 

Survey data 

Ssoac

Falmouth Safe Skin Project (1995-1997) 

Sun protection 

Parents, children age 13 and younger, and caregivers 

Mass education, community activism, and behavioral interventions 

Promoted continuous use of sunscreen, as well as hat and shirt use, outdoors to help prevent skin cancer 

Survey data 

Iobptopd

Choose Your Cover (1998-2003) 

Sun protection Adolescents, young adults 

Mass education and supported by mass communications and media outreach 

Promoted messages highlighting harmful effects of UV radiation as well as measures to prevent skin cancer, including seeking shade, covering up exposed skin, and applying sunscreen 

Survey data, media tracking 
Program 

(Duration) 

Goals/Targeted 

Behaviors 

Target 

Audience(s) 

Communication 

Methods/Strategies

Messages/ 

Information Conveyed

Evaluation 

Measures 

2. Participation in Mass Screening 

Georgia Cancer Awareness and Education Campaign (2002-2003) 

In 2002: Screening education regarding breast and cervical cancer 

Georgia residents (focus groups and surveys helped determine specific target audiences) 

Mass education, public service announcements, grassroots community outreach 

Cancer prevention and detection message was augmented by education regarding the importance of proper nutrition, exercise, and healthy lifestyles 

Survey data 

Scachma

Screen for Life (1999-2007) 

Greater awareness of and screening for colorectal cancer 

General public, adults aged 50 and older 

Mass education, public service announcements 

Key facts regarding those at risk, prevention, detection, and treatment 

Survey data, media tracking 

3. Individual Behaviors that Have Social Consequences 

Keep America Beautiful (1953 - present) 

Preventing littering, reducing waste, beautification 

General public 

Mass education promoted by mass communications and partnerships 

Various messages regarding littering and conservation with intent to change attitudes and behaviors 

N/A 

Wisconsin Antibiotic Resistance Network (1999-2003) 

Education about drug resistance and judicious antimicrobial drug use 

Primary campaign physicians, general public 

Mass education supported by mass communications, local interventions 

Various messages promoting judicious use and prescribing of antimicrobial drugs 

Survey data 

Dpaisd

Appendix C: Programs Selected for Review

Table C.1 (continued) 
Program 

(Duration) 

Goals/Targeted 

Behaviors 

Target 

Audience(s) 

Communication 

Methods/Strategies

Messages/ 

Information Conveyed

Evaluation 

Measures 

3. Individual Behaviors that Have Social Consequences (continued)

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings (2002-present) 

Appropriate use of antimicrobials 

Clinicians, including doctors, nurses, and other hospital staff 

Dissemination of evidence-based strategies through educational tools and materials 

Use of 12-step recommendations as well as four basic strategies regarding diagnosis and treatment of infections, wise use of antimicrobials, prevention of infections, and prevention of transmission of infections 

Survey data, focus group 

Ipporprspmi

4. Health Care Purchasing/Choice Decisions 

Health Dialog (1997 – present) 

Seeks to engage consumers/ patients in decisions about undergoing diagnostic and therapeutic procedures 

Health care consumers at point of decisionmaking 

One-on-one telephone consultation supported by video media and written materials 

Conveys risks and benefits of alternative procedures in a value-neutral way 

N/A 

Appendix C: Programs Selected for Review

Table C.1 (continued) 
This page has been left blank for double-sided copying 
A PPENDIX D 

I NTERVIEW R ESPONDENTS AND G UIDES
This page has been left blank for double-sided copying 
L IST OF I NTERVIEW R ESPONDENTS

CAMPAIGN-AFFILIATED INTERVIEW RESPONDENTS 

Screen for Life and Choose Your Cover

Cynthia Jorgensen, DrPH 

Centers for Disease Control and Prevention 

Atlanta, GA 

Falmouth Safe Skin Project

Alan Geller, RN, MPH 

Boston University School of Medicine 

Boston, MA 

Georgia Cancer Awareness and Education Campaign

Kimberly Redding, MD, MPH 

Georgia Department of Human Resources, Division of Public Health 

Atlanta, GA 

Wisconsin Antibiotic Resistance Network

Edward Belongia, MD 

Mary Jo Knobloch, MPH 

Marshfield Clinic Research Foundation 

Marshfield, WI 

Canada on the Move

Diane Finegood, PhD 

Canadian Institutes of Health Research, Institute of Nutrition, Metabolism and Diabetes 

Ottawa, Ontario, Canada 

Keep America Beautiful

Robert Wallace, MA 

Keep America Beautiful 

Washington, DC 
D.2 

List of Interview Respondents 

Wheeling Walks

William Reger-Nash, EdD 

West Virginia University 

Morgantown, WV 

Health Dialog Shared Decision-Making Program

David Wennberg, MD, MPH 

David Veroff, MPP 

Mary Jane Favazza, MBA 

Health Dialog 

Boston, MA 

 

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Kristin Brinsley-Rainisch, MPH 

Ronda Sinkowitz-Cochran, MPH 

Centers for Disease Control and Prevention 

Atlanta, GA 

RESEARCH EXPERT INTERVIEW RESPONDENTS 

Tamera Schneider, PhD 

Wright State University 

Dayton, OH 

Kasisomayajula Viswanath, PhD 

Harvard School of Public Health 

Boston, MA 

David Buller, PhD 

Klein Buendel 

Golden, CO 

Steven Coughlin, PhD, MPH 

Judith Lee, PhD 

Centers for Disease Control and Prevention 

Atlanta, GA
6384 – STUDY OF PUBLIC HEALTH CONSUMER EDUCATION PROGRAMS 

Final Interview Protocols

I. Introduction and Project Background (5 minutes) 

 Hello, this is ______________ from Mathematica Policy Research. We scheduled this 

time to talk with you about your [experience with/observations of] the [campaign name]. Is this 

still a good time for you? Are there any particular time constraints we should know about before 

we start? 

 As I said, my name is ________________, and I’m a [title] here at MPR, and I’m joined 

by ______________, [title]. The two of us are working with _________________, [title and, if 

Margaret, explanation of her role as Project Director]. 

 Let me tell you a little bit about the purpose of this project and what we’d like to talk to 

you about today. The Medicare Payment Advisory Commission also known as MedPAC (a 

congressional advisory body), is interested in understanding how public health campaigns affect 

public behavior regarding health issues. In particular, they are interested in understanding how 

information is best communicated, and the factors that lead consumers to take action or change 

behavior. This information, which we are researching on behalf of MedPAC, will inform other 

efforts to improve health or engage consumers in promoting quality and efficiency in health 

care. To that end, we are focusing on a few selected campaigns that have demonstrated success. 

After our research is completed, we will be providing a final report summarizing our 

findings to MedPAC. This study will, in turn, be incorporated into MedPAC's annual June report 

to Congress covering a variety of topics related to improvement in cost, quality, and access to 

health care. Please be assured that we will respect anything you wish kept confidential. 

 During this interview, I’ll be asking most of the questions. ____________ from MPR 

will be mostly listening and taking notes, or following up on some points that I may have missed. 

[IF MEDPAC PERSON IS SITTING IN] ___________ from MedPAC is also on the line and 

may have some follow-up questions for you. 

Do you have any questions before we start?

II. Campaign/Program Origins and Goals (10 minutes) 

1. To get us started, please provide a brief overview of the history and original impetus for 

the campaign/program. Also, what was your role in developing and implementing the 

campaign/program? 

1a. Probe: who sponsored it? how long did it last?

2. What were its overall objectives? What outcomes did it hope to achieve?
III. Campaign/Program Design (5 minutes) 

I’d like to focus in now on the design of the program. 

1. Who were the target audiences? Why were these audiences selected? 

1a. Probe: were multiple audiences targeted? was the focus on health provider, ,as 

well as consumers, or both 

1b. Probe: was there a geographic focus or other ways in which the scope of the 

program was limited or targeted?

2. How was the campaign/program designed to achieve its objectives? What were its 

principal strategies? 

2a. Probe: was any formative research (such as focus groups and surveys) used in the 

design? 

2b. Probe: at what level the campaign focus on: individual attitudes, behaviors, 

beliefs? interpersonal relationships? institutional structures, policies? community or 

social norms? 

3. Did the campaign/program seek primarily to convey information or to influence behavior 

or both? What behavior(s) did the campaign intend to influence? 

IV. Information and Communications (10 minutes) 

1. What were the core messages that the campaign/program sought to communicate? How 

were these messages selected? How were they framed? 

[Note: “framing” refers to the use of a specific message design to ensure its success; for 

example, the use of gain-framed messages (such as good health) for promoting prevention 

and the use of loss-framed messages (such as mortality) for promoting early detection.] 

1a. Probe: how did audience demographics affect messaging? 

1b. Probe: were messages pre-tested using focus groups or surveys? 

2. How did the campaign/program communicate with target audiences? What tools or 

media were used? 

2a. Probe: were communications strategies a function of available resources? 

2b. Probe: were public service announcements used? If so, did they help? 

3. What sources did the campaign/program draw on for technical or other information it 

provided? 

3a. Probe: was there ever a concern about the technical complexity or ambiguity of 

the information used or conveyed in the campaign? 

V. Campaign Implementation (5 minutes) 

1. How was the campaign implemented? What partners or stakeholders were involved? 
2. Apart from communication campaigns, were there any interventions [e.g., local 

outreach/education, medical interventions, etc.] used to augment campaign goals? 

2a. Probe: did the campaign have any inherent risks or potential negatives? (e.g., 

false positives from screening campaigns) 

VI. Outcomes (10 minutes) 

1. What were the outcomes of the program/campaign? Did it accomplish its objectives? 

2. Was the program/campaign evaluated? How rigorous was the evaluation and what were 

the key evaluation components? 

2a. Probe: Was data collected before and after the campaign? Was data 

collected on a control or comparison group? 

3. How was success measured or assessed? 

4. Were process analyses used or midcourse corrections implemented?

5. Did the campaign/program raise awareness? Increase knowledge? Change behavior? 

5a. Probe: is there evidence to suggest that the campaign has had enduring effects? That 

effects were transitory? 

6. What factors led to action or behavior change? Did any specific incentives play a role? 

7. Were there other factors, apart from the campaign/program, that may have influenced 

outcomes, in your view? 

VII. Other Questions and Conclusion (15 minutes) 

1. Overall, what were the most successful aspects of the campaign/program? What were the 

least successful? 

1a. Probe: were there any unintended consequences? 

2. What would you do differently, if you were to be involved in another, similar 

campaign/program? 

3. Are there any other campaign “best practices” not discussed that we should know about? 

3a. Probe [where appropriate]: is there anything about the campaign specific to 

older (over-65) or disabled populations that we should know? 

4. Are you aware of similar campaigns/programs that were successful in (1) effectively 

communicating information and messages and (2) getting those targeted to take action? 

Thank you very much for your help today. Good bye. 
1 

6384 – STUDY OF PUBLIC HEALTH CONSUMER EDUCATION PROGRAMS 

Draft Interview Protocols 

“Big Picture” Researchers

I. Introduction and Project Background (5 minutes) 

 Hello, this is ______________ from Mathematica Policy Research. We scheduled this 

time to talk with you about your [experience with/observations of] the [campaign name]. Is this 

still a good time for you? Are there any particular time constraints we should know about before 

we start? 

 As I said, my name is ________________, and I’m a [title] here at MPR, and I’m joined 

by ______________, [title]. The two of us are working with _________________, [title and, if 

Margaret, explanation of her role as Project Director]. 

 Let me tell you a little bit about the purpose of this project and what we’d like to talk to 

you about today. The Medicare Payment Advisory Commission also known as MedPAC (a 

congressional advisory body), is interested in understanding how public health campaigns affect 

public behavior regarding health issues. In particular, they are interested in understanding how 

information is best communicated, and the factors that lead consumers to take action or change 

behavior. This information, which we are researching on behalf of MedPAC, will inform efforts 

to improve health or engage consumers in promoting quality and efficiency in health care. To 

that end, we are focusing on focusing on a few selected campaigns that have demonstrated 

success. We are also interviewing a few people who, like you, have broader research experience 

in this area. 

After our research is completed, we will be providing a final report summarizing our 

findings to MedPAC. This study will, in turn, be incorporated into MedPAC's annual June report 

to Congress covering a variety of topics related to improvement in cost, quality, and access to 

health care. Please be assured that we will respect anything you wish kept confidential. 

 During this interview, I’ll be asking most of the questions. ____________ from MPR 

will be mostly listening and taking notes, or following up on some points that I may have missed. 

[IF MEDPAC PERSON IS SITTING IN] ___________ from MedPAC is also on the line and 

may have some follow-up questions for you. 

Do you have any questions before we start?

II. Background and Research Area of Expertise (10 minutes) 

1. To get us started, please tell us a little bit about your background and your research 

interests. 

2. How would you describe your research approach. Is it mostly theoretical? 

Experimental? Empirical? A combination? 
2 

2a. Probe: What particular research questions have you explored? What are you 

involved in now? 

2b. Probe: [If empirical] What kinds of campaigns have you been involved in or 

studied? 

III. Overview: What Makes Campaigns Effective

Let’s start at the 50,000-foot level. 

1. Based on your experience, what would you say are the most important factors that 

determine a campaign’s effectiveness? 

2. One of the things we’re interested in is how strategies may vary, depending on the kinds of 

behavior that you’re trying to influence. For example, we are looking at some campaigns 

that target individual risk behaviors and some that target behaviors that have broader social 

consequences. What are your thoughts about this? 

2a. Probe: What are the important distinctions among types of campaigns, in your 

view? 

2b. Probe: Are there some principles that apply across the spectrum, or are 

campaigns idiosyncratic? 

IV. Target Audiences 

1. How do you decide whom to target in public health campaigns? What are the most 

important criteria to consider? 

1a. Probe: Do you focus on populations most at risk? Low-hanging fruit – i.e., 

people who are most receptive, or most ready to change? Populations who are most 

likely to influence others? 

2. How does choice of target audience vary with campaign strategies? For example, does it 

make a difference if you’re trying to influence individual behavior or change social norms? 

V. Message Development and Framing 

1. How does message framing/messaging affect health-related behaviors, in your view? How 

does it affect individuals’ motivation to take action?

2. Do different audiences respond differently to messages, in your experience? Are some 

types of messages more effective with some audiences? 

2a. Probe: How does age, gender, or race affect audiences’ responses? 

2b. Probe: [Given MedPAC’s interest in the Medicare population] Is there anything 

specific to communicating with the over-65 population that we should know about? 

2c. Probe: How do you determine what approaches will work with different 

audiences? (e.g., formative research; message testing) 
3 

VI. Communicating Risk 

We are also interested in the difference (or the trade-off) between communicating to 

influence behavior and communicating to convey information. 

1. In your experience, how important is it to convey information about the risks and benefits 

of behaviors as part of a public health campaign? 

1a. Probe: Is it more important to motivate behavior or to convey information 

accurately? 

2b. Probe: Are there ethical concerns about exaggerating risks in order to motivate 

behavior? Are there, potentially, unintended negative consequences of doing so? 

2. If the evidence around risks and benefits of behaviors is technically complex or 

ambiguous, how does this affect campaign messaging? 

2a. Probe: Are there ways of framing risks and benefits that make the information more 

understandable to consumers? 

VII. Campaign Implementation/Channels of Communication 

1. In your experience, are some channels of communication more effective than others? How 

do effective channels of communication relate to campaign strategies? 

1a. Probe: What is the value of mass communication versus face-to-face interactions? 

2. What makes for successful mass communication campaigns? 

2a. Probe: What is the value of earned versus paid media coverage? Of PSAs? 

2b. Probe: How important is breadth versus depth in determining the effectiveness of the 

campaign’s reach? 

VIII. Outcomes

1. How do you determine whether a campaign is successful? 

2. In your experience, are there examples of campaigns that have demonstrated sustained 

long-term results, or are most campaigns evaluated in terms of their short-term impacts? 

3. What contributes to sustained impact, in your view? 

IX. Wrap–Up 

1. Are there any other important issues that we haven’t touched on?