Challenging Dogma - Spring 2011

Sunday, May 15, 2011

Have Knowledge, Will Behave? The ‘Learn The Signs. Act Early’ Campaign – Andrew Well

It is estimated that 16.8% of children have a developmental disability in the United States (1). Developmental disabilities have substantial consequences in both health and social outcomes. Children with these disabilities have 1.5 times more doctors visits, 3.5 times more hospital inpatient days, 2 times the number of school days missed, and 2.5 times the likelihood of repeating a grade when compared to children without these disorders (1). These disabilities include Cerebral Palsy, Learning Disabilities, Autism Spectrum Disorders (ASD), and others.

The prevalence of ASD in the population is 12.6 to 40 per 10,000 (2). The American Academy of Pediatrics recommends all children should be screened for ASD at 18 months of age (3). Identification and commencement of interventions before the age of 3 years has shown the greatest impact on improving the outcomes of developmental disabilities (4). However, despite the recommended screening and efficacy of early intervention, the mean age for initial evaluation for ASD is 48 months and the mean age at initial diagnosis is 61 months (5).

With this disparity in mind, the Centers for Disease Control and Prevention (CDC) launched the ‘Learn the Signs. Act Early’ campaign nationally in 2004. This campaign targeted three populations, parents, healthcare professionals, and early educators (6). The goal for the campaign was to close the time gap by educating these populations to identify delays earlier and react more quickly.

Learn the Signs. Act Early Campaign

The main thrust of the media campaign consisted of a public service announcement television ad, a radio ad, and print advertisements. These advertisements were produced in both English and Spanish (7). These media efforts were targeted at the parent audience (6). Parents, healthcare providers, and early educators were all targeted to receive resource kits that included facts on anticipated developmental milestones and what to do if there is a concern about development (6). The campaign also partnered with other organizations and corporations to further its message. For parents, the campaign partnered with,, Lysol, and Autism advocacy groups (6). Professional groups, such as the American Academy of Pediatrics and the National Association of Child Care Providers, were partnered with to reach health care professionals and early educators (6).

Prior to developing campaign materials, the CDC preformed formative research. These activities included focus groups and analysis of relevant available surveys of parents, healthcare providers, and early educators (6). The CDC also utilized social marketing principles to determine target audiences (6). Social marketing involves three steps:

1. Segment the market using relevant factors

2. Evaluate each segment

3. Choose one or more markets for targeting during the campaign (8)

Formative Research Results

Surveys of parents found that 63% did not know what behaviors suggested a child may have autism and 57% did not know the best time to seek help for concerns (6). Physicians reported poor resources to be able to identify autism with less than half reporting proper resources to educate parents about developmental milestones (6). Only 27% of physicians reported that they believed physicians as a whole were well informed about developmental disorders (6). Early educators reported a general lack of knowledge of developmental milestones and a lack of resources to properly evaluate children and discuss concerns with parents (6).

Taking into consideration the data available, the CDC decided to use the Transtheoretical Model as the frame for the ‘Learn the Signs. Act Early’ Campaign (6). The Transtheoretical Model contains five steps:

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance (9)

This model postulates that an individual will work their way through each step of the model to alter a behavior and maintain the altered behavior. An individual can move forward and backward through the model. In other words, the model allows for regression of an individual. The model is designed to promote the evaluation of where an individual is currently in the model and target interventions to allow them to move forward through the steps.

Campaign Results

After the campaign had run for three years (2004-2007) new survey data was analyzed to determine the effectiveness of the campaign. The results in 2007 indicate a small number of statistically significant changes. However, while these changes reached statistical significance, they were only minor in their impact clinically. Only 34% of parents reported having heard of the campaign. Parents who knew the behavior most associated with autism increased from 37% to 52% and 42% answered ‘don’t know’ down from 57%. Sixty-six percent of parents reported looking for developmental milestones up from 51% and 42% endorsed that before two years of age was the opportune time for intervention, up from 22% (6).

Only 43% of pediatricians reported having heard of the campaign. A large increase was seen in physicians reporting adequate resources to educate parents (77% vs. 29%). Fewer physicians would advocate a ‘wait and see’ policy (19% vs. 30%). Those who were aware of the campaign were slightly more likely to evaluate for developmental delays regularly (71% vs. 61%), were more confident in discussing developmental milestones with parents (84% vs. 74%), and were more likely to be aware of resources available and treatment options (87% vs. 70%) (6).

No systematic evaluation had been performed to elucidate results in the early educator population.

Learn the Signs. Act Early Critique

As is clearly shown above, the campaign was mostly ineffectual particularly in changing parental behavior. The CDC included a few good aspects into the campaign; however, these were overshadowed by large failings in the theoretical design and implementation of the campaign. The CDC was insightful in using social marketing theory to attempt to develop their campaign. The overarching theoretical failure is utilizing the Transtheoretical Model. This model is developed to be used to assess and describe an individual (10). Applying this model to evaluate a population is difficult. This application, negates one of the strengths of the model which is an individualized intervention based on the individual characteristics. In determining a population intervention based on this idea already alienates a large portion of the population that is not currently in the stage of the Transtheoretical Model being targeted. Also, there is a fundamental flaw in the theory, which is assuming people act and think rationally and that all people must proceed through the steps in order to achieve success. The Transtheoretical Model has been shown to have no efficacy in smoking cessation (11-13), pregnancy and sexually transmitted infection prevention (14), and dietary intervention (15). Aside from these theoretical shortcomings, three implementation problems are described below.

One-Size Fits All – Critique #1

The first implementation problem was a one size fits all advertising campaign. There was really only one television commercial, one radio commercial, and one print ad, which were distributed in English and Spanish (7). These commercials did not have a breath of cultures encompassed into the campaign. It has been shown that individuals respond stronger to interventions that are specifically tailored to them (16). A study on a tailored intervention to reduce individuals dietary fat intake showed that those who received the tailored intervention information were more likely to remember receiving the information 4 months later, 72.9% vs. 33.3%, compared to a group that received information that was generic and not tailored (17). Those in the tailored intervention were more likely to have read the entire information sheet, 71.7% vs. 55.7% (17). The tailored group also had a greater response to the message decreasing their daily dietary fat intake more than the non-tailored group (17).

The impact of tailoring can be seen on functional MRI (fMRI) images. In a study on smoking cessation, smokers were shown three types of messages while their brain activity was being monitored by fMRI. The messages included an instructional or information based message, a motivational message and a personalized message (18). Each of the three messages showed activation in different portions of the brain. The instructional message activated the rules processing portion, the motivational message activated the anticipated reward processing regions, and the personalized message activated the self-related processing regions (18). Furthermore, it has been shown that increased activation of the self-related processing regions during a tailored intervention predicted smoking cessation at four month follow up (19).

When looking at the ads for this campaign, the print ad both in English and Spanish contain a picture of a Caucasian baby. The television ad features three mothers talking while their infants are playing on the floor. Two of these mothers were Caucasian and one was African American. Members of other races and ethnicities may not associate with these ads as well. Fathers will also not be engaged by this advertisement. The radio ad is more difficult to associate with culturally, however the ad features an interviewer talking with a child at a playground. Many families, especially inner city residents do not have access to playgrounds, thus they may associate less with this ad. The statistic that a one-size fits all approach in this campaign did not work is the low recognition rate after three years. With only 34% of parents reporting campaign recognition, the campaign was either not reaching the population, but more likely, large portions of the population were not associating with the ad campaign and thus not recalling the campaign.

No Promise – Critique #2

Successful product ad campaigns often sell their product by making a promise and backing it up. For example, Nike, in many of its advertisements, shows athletic individuals being successful while wearing their products. Their promise is improved athletic performance and they support that claim through visuals of people who fit this description. Targeted individuals’ self-interest is an important component and target in Marketing Theory (20). Beyond self-interest, successful marketing can be seen as an exchange (20). A successful exchange sets forth an explicit or implicit payback (promise) and the timing of the payback (20). An explicit promise with an immediate payback timing has been shown to be the most influential (20, 21). This influence is increased if there is greater involvement of the individual, such as tailoring the message in a way the individual can relate to easily (21). The results of the exchange are further reinforced if the exchange happens voluntarily as apposed to coercively, demandingly, or through fear (22). Unsuccessful public health campaigns typically neglect to address the costs and benefits for each said of the exchange (22). Instead, they typically focus on limiting the cost to the individual (22). A successful campaign will look to maximize the benefits each side receives from the campaign (22). The ‘Learn the Signs. Act Early’ advertising campaign fails to make any exchange and promise to the targeted individual. This problem of a lack of promise is shown in the statistic where knowledge of the main symptom of autism rose only to 52% from 37%. This indicates that many individuals are not integrating the message from the campaign, as there is no incentive for individuals to integrate the information.

Knowledge Is Enough – Critique #3

The ‘Know the Signs. Act Early’ campaign is essentially a knowledge dispersion campaign. The campaign views the lack of the desired behavior as a product of a lack of knowledge, that if the population only knew, they would change. This evokes the idea of the Health Belief Model (23). Much like the Transtheoretical Model, the Health Belief Model has large flaws. It also assumes that people think rationally and with the correct information and planning people will behave in a specific way (23). Simple knowledge dispersion has been shown to be an ineffectual process to produce behavior changes (20).

With knowledge also come other unwanted results, such as optimistic bias. Optimistic bias is the phenomenon where individuals will accurately if not overestimate the probability of a negative event happening to someone else while underestimating the probability of the same event happening to themselves (24). Optimistic bias has been shown to hold true across a wide range of situations including salary after graduation, smoking risk, and possibilities of one’s marriage ending in divorce (24, 25). Optimistic bias can also be observed on a fMRI. When subjects were asked to imagine a positive future event, the fMRI revealed activation in areas of the amygdala and in the rostral anterior cingulate cortex (26). Higher activation of the rostral anterior cingulate cortex was associated with higher optimism (26).

Along this line of thought, there is also the stigma surrounding the diagnosis of a developmental disability, especially autism, and the fear of a child being labeled (6). The CDC identified these worries as possible risks with the campaign (6). However, the CDC chose to try and mitigate this risk by not talking about it (6). The campaign’s lack of acknowledgement of this stigma and fear does nothing to try and alleviate parental concern. The campaign can pass as much knowledge to parents as possible, but if they are too worried or scared to act in accordance with the knowledge, their behavior will not change. A statistic to evaluate if this were the case would be to observe if more parents were actually scheduling and bringing their children in for developmental evaluations. This data is not available, but it is not a large leap to hypothesize that there was little change in this behavior over the three years of the campaign.

Looking Back

The ‘Learn the Signs. Act Early’ campaign began with a few solid and effective design strategies. However, the data obtained from this initial data was forced to fit an inappropriate health behavior model. The resulting campaign was implemented poorly and inefficiently which resulted in very little significant change in behavior and beliefs in the target population.

Looking Forward

This campaign attempts to intervene in a very important public health issue. With clear evidence supporting early intervention, before three years of age, in developmental delays, especially autism, there is great urgency to evaluate and diagnose these disorders as early as possible. Since there is the great need for intervention, the campaign, despite its shortcomings, should not be completely dismantled and forgotten about. There are a few changes that can be made to the campaign to address the current shortcomings and improve its efficacy.

The Tailored Look – Intervention #1

Research has shown that tailored messages cause more people to remember the message and more people to change their behavior in accordance with the message (16). It has also been shown that with increased tailoring of the message, more people will remember and act upon the message (16). Message tailoring must be included in to every aspect of the campaign. The easiest and least expensive place to start is the campaign website. Currently, it is an open website that is the same for everyone that logs onto it. To change this, the first time someone logs onto the site, they would be asked to answer a few simple questions about themselves. These questions would include information on gender, race, age, and profession (parent, educator, healthcare provider). From the answers to these questions, the website can be tailored to each individual who enters the site. This tailoring would include what types of information are available and how it’s presented (based on profession for example). Pictures can be tailored to the age, gender, and race of the individual. It has been shown that tailored pictures when placed next to text result in greater uptake of the information in the text when compared to non-matching pictures or general stock pictures not involving people (27).

Next, the print, radio, and television advertisements need to be tailored as well. These cannot feasible be tailored as much as the website, but more tailoring can be introduced beyond what is found now. The print advertisement would be the easiest to start with. Currently all print advertisements contain a picture of only a Caucasian baby. The picture of the baby could be changed out to infants of different races based on the demographics of the readership of the publication the advertisement will be in. It is difficult to tailor radio advertisements. Keeping the same current concept of an individual interviewing a child, different locations could be utilized for the interview. The current playground ad would be kept, but interviews could be held in locations such as a play date at someone’s home, or at a daycare. Lastly, there would need to be more than one television advertisement. The different advertisements would need to include mothers and children of different races and ethnicities. It would also be prudent to include advertisements that involved fathers.

With these simple tailoring efforts, it is conceivable that campaign recognition would increase. With this increased recognition, the hope would be an increase in the desired behavioral changes as has been shown previously with tailored interventions.

Promises, Promises, Promises – Intervention #2

The current campaign is very straightforward and blunt. It does not utilize any aspect of marketing or exchange theory in the design of its advertisements. These advertisements need to create a promise that is hinged on the central tenets of human nature. Two that should be specifically targeted are family and control. These two are very strong tenets and thus will create a more influential advertisement. While health is also a tenet, it has been shown to be relatively weaker and less influential. The advertisements could portray the model that if a parent closely monitors their child’s development and acts early to get them evaluated and initiate treatment, then they gain control over improving their child’s future and they improve their whole family’s quality of life. Control is also a powerful promise to promote as individuals who feel control or ownership over a thing or behavior place a higher value on it (28).

Done correctly, this promise creates an expectation for parents participating in the behavior. It sets up the promise as an incentive for participating in the behavior. This should create greater follow through by parents in being vigilant about paying attention for developmental delays and taking their children for evaluations when concerns arise.

Story Time – Intervention #3a

The current campaign focuses on giving facts and figures to parents. This is done with the premise that increasing parental knowledge will increase the desired behaviors. However, it has been shown that people are influenced more strongly when they are presented with stories (20). Use of stories in advertising also mitigates psychological reactance. Psychological reactance is the response to appose situations where they lose control or are being told what to do (29). These advertisements may be able to use psychological reactance in their favor, if not participating in the behavior can be portrayed as a loss of control.

This incorporates the previous two points. Again, these stories must be tailored to the audience for maximum effectiveness. This means the story and the person telling it must be relatable to the target audience. Bringing in the second point of promises, the story can be used to provide the evidence and support that the promise will happen if the behavior is followed.

For example, an advertisement that is to be delivered to a Hispanic population may include a television commercial in Spanish with a young happy Hispanic family with a child talking about how they noticed certain delays in their child’s development. They can go on to talk about immediately taking the child for evaluation and starting treatment. The conclusion of the commercial would be the family commenting on how much of an impact the treatment has made and how much it has improved their child’s life and his or her future possibilities.

By using stories to play to individuals need for control, these commercials are less likely to induce psychological reactance to the message. If anything,

Taking Down the Wall – Intervention #3b

The last shortcoming to address is how to handle the stigma and fear of a developmental diagnosis and labeling of a child. This is a very difficult barrier to develop a successful campaign around. This mentality is very deep seeded and is a very guttural response from parents. Since this is such a pervasive idea, the campaign cannot metaphorically burry its head in the sand and not address it. The campaign needs to address parental concerns head on. This must be done very tactfully or else the campaign risks alienating a large portion of the target population. This focus would almost certainly have to be a sub-campaign that focused only on the goal of demolishing the stigma and fear.

This portion of the campaign would need to use the same principles as described above. This would involve print, radio, and television advertisements that would again tell tailored stories. The focus of these stories would be shifted slightly to specifically focus on the diagnosis. An advertisement could contain a family who has a child diagnosed with autism. The family could talk about the improvements the child has made because they acted early and were not inhibited by the fear of the diagnosis. The advertisement would need to be explicit to show that the family overcame or did not cave in to the fear or perceived stigma of the diagnosis. If this fact is not placed in the forefront, it could be missed and the advertisement would be viewed as similar to the main campaign advertisements described above.

This portion of the campaign would hopefully empower parents to overcome their fears and to cast aside the perceived stigma surrounding autism and its diagnosis. They will instead hopefully realize that by overcoming this fear they are in fact doing what is best for their child. This again pulls back in the concept of control.

When All is Said and Done

The CDC’s effort to develop a campaign to promote early detection and intervention for developmental disorders was much needed. Even though the initial campaign missed the mark and was very ineffectual, it laid a groundwork from which a few changes can be made to create a more efficacious campaign. These new changes would without a doubt involve a greater cost than the original campaign. However, it would be better to develop and implement a few expensive campaigns that were very effective instead of running multiple less expensive campaigns that are mostly ineffectual.

The most distressing component in the initial campaign was the fact it completely ignored the fear and stigma surrounding developmental disability diagnoses. This shows a lack of willingness to tackle the tough questions and situations. Without breaking down that barrier, the effectiveness of even the best-designed campaign will have a limit to its effectiveness.

If these changes were to be made, this could be a very successful campaign for a very important public health need, a need that appears to be growing over time. Many more children would be evaluated and diagnosed early enough that treatment can result in the best outcomes possible for the child.


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