PSAs are effective strategies to spread public health warnings. Dr Nandita Murukutla, VP Global Policy & Research, Country Director-India, Vital Strategies, in an interaction with Viveka Roychowdhury, explains how the ‘TB-Cough’ PSA launched by The Ministry of Health and Family Welfare (MoH&FW) on this year’s World No Tobacco Day, was developed and implemented with technical support from Vital Strategies
What are the strategies to gauge the effectiveness and impact of Public Service Announcements (PSAs) like the ‘TB-Cough’ film launched by MoH&FW, Government of India?
These Public Service Announcements (PSAs) are pre-tested among representative focus groups to gauge their effectiveness. The key messages must be understandable and memorable, with the effect of changing the viewer’s knowledge and attitudes about the harms of tobacco. This research also seeks to identify any potential for improvement, so the PSA can be amended to ensure maximal effectiveness when it airs.
‘TB Cough’ was very highly rated in a rigorous message testing exercise, where 20 focus group discussions (with 10-12 respondents in each group) evaluated 16 different PSAs. These PSAs included warning messages about smokeless tobacco, bidi and cigarettes, and second hand smoke exposure, as well as TB and tobacco.
Further analysis can be conducted to help evaluate the campaign’s impact. Typically, this is undertaken through a nationally-representative household survey of tobacco users, conducted by a reputable research agency. The best time to run the evaluation is soon after the campaign ends, and ask respondents questions about topics including whether they recall the campaign and what they think about tobacco use after viewing the campaign.
What have been the most effective PSAs in India and globally? How did these help shape public health policy?
Studies published to date show that PSAs can be highly effective in communicating the serious health harms of tobacco use and in prompting intention to quit and quit attempts across high-, medium- and low- income countries. They are an integral part of the W (Warn) in the WHO MPOWER framework of proven, cost effective interventions to reduce tobacco use.
Evidence from more than four decades of tobacco control mass media social marketing campaigns in High Income Countries (HICs) shows that strong graphic messages that evoke negative emotions are consistently best at delivering attitudinal and behaviour change. The public is more likely to recall these PSAs, think about them, and discuss them with others (National Cancer Institute, 2008). They can also help to shape public health policy, as they can build support for policy change, prompt behavioural change, and influence social norms around tobacco use ( http://dx.doi.org/10.1080/10810730.2011.601395 ).
The ‘Ten Country Study’
In Low and Middle Income Countries (LMICs), including India, the ‘Ten country study’ (Wakefield M, Bayly M, Durkin S, et al. Tobacco Control (2011) https://www.ncbi.nlm.nih.gov/pubmed/21994276) found that three PSAs, featuring graphic images of the serious health harms of smoking, performed consistently highly across all countries. Two of these ads showed diseased human tissue or body parts, and a third used a disgust-provoking metaphor to illustrate how tar accumulates in smokers’ lungs.
These PSAs elicited high levels of message acceptance and personalised perceived effectiveness (‘I understand this message and feel it applies to me’) and consistently high levels of discomfort (which is effective in encouraging behaviour change) among a sample of young adult smokers in different countries.
In comparison, a different PSA called Bubblewrap was used to illustrate smoking-related emphysema. This PSA did not achieve consistent results across different countries partly because the bubblewrap metaphor is complex and the PSA did not generate feelings of discomfort in the viewer.
PSAs that feature the experiences of real victims of tobacco can be highly effective, but a PSA featuring the personal testimonial of a female smoker with lung cancer (Zita) also elicited a variable response – scoring highly in Mexico, the Philippines and India, but lower in Bangladesh, Russia and Indonesia. One of the issues with this PSA is that in some countries, the lack of explicit references to smoking impeded comprehension.
The Ten Country Study suggests that what worked best in HICS also will work best in LMICs. Using graphic imagery to communicate the serious harms of smoking and provide reasons to quit can generate universally high understanding and engagement. These PSAs often employ imagery that viewers can relate to, no matter where they live, as internal body parts look the same in every country. This also means they can be easily adapted for broadcast in different countries, as many do not feature actors. Findings from recent anti-smoking mass media reviews also indicate that these types of ads perform well across a range of demographic and socioeconomic population groups. Disgust is a universal response, and fear can be a strong motivator for behaviour change, if used correctly.
India’s experience
The Government of India launched a national television and radio mass media campaign, Mukesh, featuring a smokeless tobacco victim. It ran for six weeks during November and December 2009. The campaign affected smokeless tobacco users as intended: 63 per cent of smokeless-only users and 72 per cent of dual users (i.e, those who consumed both smoking and smokeless forms of tobacco) recalled seeing the PSA, primarily on television. The vast majority (over 70 per cent) of those aware of the campaign said that it made them stop and think, was relevant to their lives and provided new information. 75 per cent of smokeless-only users and 77 per cent of dual users said that it made them feel concerned about their habit. Campaign awareness was associated with better knowledge, more negative attitudes towards smokeless tobacco and an increase in quitting intentions and behaviours among smokeless tobacco users.
What are the most important components of such PSAs, in terms of designing content, reach etc?
Vital Strategies adopts a best-practice, strategic and evidence-based approach to health communications, based on proven theories and models of communication and behaviour change. We advocate a “breakthrough” model which begins with strategic planning, formative research and behaviour analysis, followed by communication planning, implementation, monitoring, and evaluation. When applied effectively and within the appropriate context, strategic communications can be a powerful tool for achieving changes in social norms around tobacco use. The costs, time and effort involved in producing a new mass media campaign can seem formidable, so Vital Strategies encourages governments to adapt existing, proven, effective PSAs to enable them to implement campaigns more rapidly and cost-efficiently. The savings made on production costs and time mean more resources can be concentrated on media placement, to achieve the greatest possible reach.
A recent paper analysing Vital Strategies’ use of “Raw and Real” campaigns that feature real tobacco victims (Tahir Turk et. Al, Tobacco Control, July 2016. http://tobaccocontrol.bmj.com/content/early/2016/07/18/tobaccocontrol-2016-052968) confirms that messages developed and used effectively in HICs can be successfully translated and adapted for use in LMICs, but that more localised, culturally sensitive approaches are also required. Personal testimonial PSAs that are culturally appropriate (like Sunita) and employ emotional appeals, graphic disease depictions and other effective techniques, are highly cost-effective and increase the campaign’s efficiency in terms of target audience recall and other metrics.
What is Vital Strategies’ involvement in such projects?
Vital Strategies – an NGO headquartered in New York City (US), with a regional office in New Delhi (India) – is one of the five global partner organisations in the Bloomberg Initiative to Reduce Tobacco Use, which includes the World Health Organisation and the Centers for Disease Control and Prevention. The Initiative assists countries (including India) that have the highest burden of tobacco use, working with governments and civil society to help them reduce their country’s burden of tobacco-related disease through the implementation of proven policies and programmes. Vital Strategies’ team of strategic health communication and policy advocacy experts provides technical assistance to governments around the world, enabling them to implement cost-effective, best practice social marketing campaigns. These campaigns support policy change as well as tobacco cessation efforts, mainly using well-tested, proven graphic imagery and highly emotive PSAs to communicate the health harms of tobacco.
We use an evidence-based, strategic health communication programming model. Our approach is iterative, collaborative and audience-focussed, using insights from stakeholders and research findings to inform decisions about the best ways to effect behaviour change. We employ a comprehensive range of processes including identifying problems and populations at most risk, defining the programme’s behavioural objectives, identifying an overall strategic approach, articulating key messages, media production (development of PSAs), message-testing, selecting communication tools and channels, and post-campaign evaluation. In addition, we have built a multi-language online resource of low-cost and no-cost PSAs, health warnings and supportive materials (at http://www.mediabeacon.org/tobacco-control/) to enable governments to more rapidly and cost-effectively select and adapt proven, impactful campaigns.
In India, Vital Strategies has supported the MoH&FW, Government of India (GOI), in the design and implementation of 15 national tobacco control communication campaigns. Vital Strategies also helps the MOHFW to amplify its messages through earned media activity and social media campaigns that run in parallel with the mass media campaigns. In addition, Vital Strategies assists the state governments in implementing state-wide tobacco control mass media campaigns.
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