Project acronym: / MAX
Project title: / Successful Travel Awareness Campaigns and Mobility Management Strategies
Integrated Project
6.2 Sustainable Development
1.6.2 Sustainable Surface Transport Objective
3.1.1.1.3 Advancing Knowledge on innovative measures in urban transport
Title of Report:
What can we learn from health promotion campaigns? What can be applied to sustainable transport campaigns?
Period covered: / Date of preparation:
Start date of project: / 1 Oct. 2006 / Duration:
Version: / Final
Prepared by: / WHO
Checked by:
Verified by:
Status:
Dissemination level: / Public
Project co-funded by the European Commission within the Sixth Framework Programme (2002-2008)
MAX - introduction
MAX ran from 2006 to 2009 and was the largest research project on Mobility Management within the EU’s sixth framework programme. The MAX consortium, of 28 partners, served to extend, standardise and improve Mobility Management – it did so in the fields of quality management, campaigns, evaluation, modelling and land use planning. Much of the work was directly endorsed by the European Platform on Mobility Management (EPOMM) and continues to be supported by EPOMM – in order to provide truly Europe-wide expansion, standardisation and dissemination of Mobility Management.
The work has resulted in several products and services that can be downloaded via www.epomm.org.
For more information, please visit www.epomm.org or www.max-success.eu
Max PartnersAustrian Mobility Research, FGM-AMOR
(project leader) – Austria / Mobiel 21 – Belgium
ILS Institut für Landes- und
Stadtentwicklungsforschung gGmbH – Germany / Eric N. Schreffler, Transportation Consultant – USA
Equipo de Tecnicos en Transporte y Territorio,
ETT – Spain / FIT Consulting – Italy
Lyle Bailie International Limited – United Kingdom / synergo – Switzerland
Timo Finke Consult Aachen – Germany / Traject – Belgium
Austrian Standards Institute – Austria / Trivector – Sweden
Universities
University of Piraeus Research Centre – Greece / University of Maribor, Faculty of Civil
Engineering – Slovenia
Cracow University of Technology – Poland / Aristotle University of Thessaloniki – Greece
University of Lyon – CNRS-LET – France / Edinburgh Napier University – United Kingdom
University of Central Lancashire – United Kingdom / Otto-von-Guericke-University of Magdeburg – Germany
University of Giessen, Institute for applied and
empirical social research – Germany / Vilnius Gedimas Technical
University – Lithuania
Demonstrators
Almada Municipal Energy Agency,
AGENEAL – Portugal / Almada Municipality – Portugal
Lazio Transport Company COTRAL – Italy / Kortrijk Municipality – Belgium
Tallinn Municipality – Estonia / Munich Municipality – Germany
Table of Contents
1 Introduction 5
1.1 The use of campaigns in health promotion 5
1.2 Mass media campaigns 6
1.3 Criticisms of health promotion campaigns 6
1.4 Focus on physical activity 6
2 Reviews 8
2.1 Systematic review of physical activity campaigns 8
2.1.1 Introduction 8
2.1.2 Search and inclusion criteria 8
2.1.3 Description of campaigns 10
2.1.4 Campaign impacts 10
2.1.5 Physical Activity levels 10
2.1.6 Discussion 11
2.2 Review of selected international experiences 12
2.2.1 Overview of findings 12
2.2.2 Use of media campaigns: Canada 13
2.2.3 Use of media campaigns: Finland 14
2.2.4 Use of media campaigns: England’s Active for LIFE campaign 14
2.3 US Community Guide 16
2.4 UK review of social marketing 16
2.4.1 Methods 17
3 Discussion 18
3.1 Promoting physical activity and promoting sustainable transport: the similarities 18
3.2 Promoting physical activity and promoting sustainable transport: the differences 18
4 Summary of Recommendations 19
5 Appendix one 20
6 Appendix two 21
7 References 22
page 3 / 23
1 Introduction
1.1 The use of campaigns in health promotion
The public health community has grappled with the utility (or otherwise) of the health promotion campaign for many years. Even back in the early 1700s, media approaches to health promotion were being used, with the Reverend Cotton Mather’s campaign to promote inoculation for smallpox in the US (Noar 2006), while in the UK early efforts tended to focus either on announcing outbreaks of infectious diseases, or making general pleas for healthy behaviours (see Fig 1.)
Figure 1 - Red Cross campaign from the 1930s
The theoretical basis for the use of campaigns in health promotion is relatively straightforward: that influencing population-level thinking and social norms around a health issue will require interventions that can reach large numbers of people at relatively low cost, and are likely to influence community beliefs. This has led public health agencies to consider the relevance of mass media campaigns and social marketing techniques to influence community understanding and beliefs on topics such as smoking, healthy eating, safe sex or immunisation. These are considered essential first steps in developing integrated, sustained approaches to encouraging healthy behaviour. (McGuire, 1984; Hornik, 2002). Many health campaigns have aimed to influence health-related social norms through the use of persuasive communications, targeting whole populations, using organised mass media (Flora, 2000). Campaigns of this sort have changed the social climate around tobacco use (particularly smoking near children or in public places), and have influenced community beliefs and attitudes towards immunisation or seat-belt use (Smith, 2002). Indeed this objective of changing social norms through persuasive communication aimed at a broad target audience has also been a common theme in many transport campaigns.
It is useful to distinguish this type of mass media activity, which targets whole populations with messages around a health topic, from the type of communication techniques used by health practitioners at a small group or one-to-one level. A review of mediated interventions for physical activity (Marcus et al., 1998) found that a range of different communication approaches had been tried, including use of broadcast media, print and, more recently electronic media and the internet. They found that interventions using print and/or telephone were found to be effective in changing behaviour in the short-term. Studies in which there was more contact and interventions tailored to the target audience produced greater change.
1.2 Mass media campaigns
In this paper, our focus is less on the use of communication skills in group or one to one counselling, and more on the role of campaigns that aim to communicate universal messages about a health topic and aim to make a change at a population level. Snyder and Hamilton (2004) conducted one of the first meta-analyses of the health mass media campaign literature. Overall, they found the average campaign changed the behaviour of about 8% of the population in the expected, positive direction, and that:
· success varied with different behaviours, with seatbelt, oral health, and alcohol campaigns being the most successful;
· greater effects were found for campaigns focused on adoption of new behaviours as compared with prevention or cessation of problem behaviours; and
· greater effects were found in campaigns with greater reach/exposure.
In addition, the strongest campaign effects were found with regard to campaigns that had a law enforcement aspect, such as seatbelt campaigns. When these enforcement campaigns are removed from the analysis, the overall effect of campaigns on behaviour drops considerably (to r = .05).
Legislation has also been seen to be particularly important in the issue of tobacco control, where taxation, pack-side messages and now the use of bans on smoking in public places has made a considerable contribution to the reduction of smoking prevalence in many countries. However, there are still many issues that can be applied from successes in tobacco control to other aspects of public health such as physical activity promotion – or indeed to sustainable transport. Green et al (2006) point out a wide range of issues that can be directly applied from tobacco control to physical activity promotion (see appendix). For example the tobacco control movement attributes some of its success to the strategy of engaging other sectors including education, industry, workplaces, and restaurants. A parallel approach in physical activity promotion would involve engagement of diverse sectors such as recreation, parks, sport and urban planning in helping to shape the environment for physical activity. Another example is the smoking lobby’s use of multiple-level strategies of intervention. This approach has also found resonance in the physical activity community where there is evidence that approaches that combine activity at a variety of levels – from interpersonal interventions in primary care through to community and legislative and environmental change – are more effective (Sallis et al 1998).
1.3 Criticisms of health promotion campaigns
So if health promotion campaigns are generally thought to be a useful component of a public health approach, why are they not used more universally? It is worth looking briefly at the main objections to the use of campaigns and social marketing in public health. The first main criticism is that campaigns are an inefficient public health approach, as they are very expensive to do well, and are limited in their effectiveness in achieving measurable levels of behaviour change. The second issue is that of the ‘nanny state’: that campaigns often involve some agency – usually a government or its agency – telling people how they should behave. This is sometimes seen to be counter-productive, as people in democratic countries do not respond well to being ‘nannied’ (King’s Fund, 2005). We will revisit these two objections in the discussion section below.
1.4 Focus on physical activity
It is beyond the scope of this paper to review all health promotion topics and apply the learning to sustainable transport campaigns. There are likely to be many health topics – such as safe sex promotion or campaigns against illegal drug use – for which there are few parallels with the behaviour change processes needed to lead to transport modal shift. This paper will therefore focus on what has been learned from the many campaigns that have focused on the promotion of physical activity including cycling and walking, as there are many direct parallels. Firstly, most transport campaigns include some degree of promotion of cycling and walking, making this almost a ‘meeting point’ between the areas of health and transport. A lot of campaigns for sustainable transport use the message that cycling and walking are healthier options in order to decrease car use. Additionally, when encouraging people to use other modes (trains and buses) it is argued that this involves a walk to either a station or bus stop – rather than a door-to-door trip in a car, thus increasing physical activity.
In the remainder of this paper we will also draw out some of the learning from one of the international campaign approaches that we explore in more detail in the accompanying case study of the Finnish Fit for Life campaign.
In the next section we will draw on a number of reviews of physical activity promotion that have been published. We will deliberately draw on a variety of sources of literature, from published systematic reviews to articles in the ‘grey’ literature on approaches taken overseas. The aim is to draw out the collective learning that can be applied to sustainable transport campaigns in section 4.
2 Reviews
2.1 Systematic review of physical activity campaigns
2.1.1 Introduction
One of the most comprehensive reviews of the role of physical activity campaigns in recent years was conducted by Cavill and Bauman in 2004.
They defined campaigns as:
‘purposive attempts to inform, persuade, and motivate a population (or sub-group of a population) using organised communication activities through specific channels, with or without other supportive community activities.’ (Rice and Atkin, 2000).
Such campaigns are typically (though not exclusively) run by public agencies for social rather than commercial benefit; tend to be run for a defined time period; and are often not reported in the scientific literature.
2.1.2 Search and inclusion criteria
In order to influence the cascade of variables [shown in figure 2];
campaigns had to employ at least a pre-post design using retrieve information about as many campaigns as possible, the authors searched relevant databases of the peer-reviewed literature in English. They found fifteen individual campaigns that satisfied the inclusion criteria:
· The campaign had to have at least one media element with mass reach;
· The campaign had to use the media in a purposive and organised manner population samples to measure changes brought about as a result of the campaign (in physical activity or in any of the antecedent variables.);
· The campaign had to contain a clear physical activity mass media component.
The reviewers used an adapted model to describe the ‘step-wise’ process that occurs during media campaigns. This is shown in figure 2, and is adapted from McGuire’s Hierarchy of change in response to a communication process (McGuire, 1984; Rice and Atkin, 2000). They note that behaviour change is neither a likely nor a necessary early outcome of mass media campaigns. Rather, a valid outcome is a positive change in any of the antecedent variables, such as beliefs, social norms or intention. This is slightly at odds with the traditional notions of social marketing (Maibach et al, 2002) which tends to focus on behaviour as an outcome. However, the more usual public health communications framework, which includes assessing shorter term mass media initiatives, should emphasise the proximal over the distal variables (in Figure 2) in assessing campaign effects, and campaigns should thus aim to influence antecendent variables in a step wise process . To illustrate this in the context of a public transport campaign, this would mean collecting data (perhaps from a user survey) on such issues as whether people had seen the campaign (awareness); whether it seemed relevant to them (salience); whether they think they wanted to try switching to public transport (intention); and finally whether they had done so and for how often and how long etc (behaviour). This is shown for physical activity in Figure 2.
Figure 2 - Levels of impact of physical activity promoting mass communications campaigns
2.1.3 Description of campaigns
The fifteen campaigns reviewed employed a diverse set of mass media and communications strategies including paid TV commercials, public service announcements and radio and newspaper advertising as well as the full range of unpaid media publicity techniques. These targeted whole populations or defined sub groups. Some of the campaigns had integrated media communications with other community-based activities such as support and self-help groups, counselling, screening and education, community events, and walking trails (Kahn et al., 2002); while others were classified as ‘media only’ approaches.