Mass Media Health Communication CampaignsCombined with Health-Related ProductDistributionA Community Guide Systematic ReviewMaren N. Robinson, MPH, Kristin A. Tansil, MSW, Randy W. Elder, PhD, MEd, Robin E. Soler, PhD,Magdala P. Labre, PhD, Shawna L. Mercer, MSc, PhD, Dogan Eroglu, PhD, Cynthia Baur, PhD,Katherine Lyon-Daniel, PhD, Fred Fridinger, DrPH, Lynn A. Sokler, BS, Lawrence W. Green, DrPH,Therese Miller, DrPH, James W. Dearing, PhD, William D. Evans, PhD, Leslie B. Snyder, PhD,K. Kasisomayajula Viswanath, PhD, Diane M. Beistle, BA, Doryn D. Chervin, DrPH, DSc,Jay M. Bernhardt, PhD, MPH, Barbara K. Rimer, DrPH,and the Community Preventive Services Task ForceContext: Health communication campaigns including mass media and health-related productdistribution have been used to reduce mortality and morbidity through behavior change. Theintervention is deﬁned as having two core components reﬂecting two social marketing principles:(1) promoting behavior change through multiple communication channels, one being mass media,and (2) distributing a free or reduced-price product that facilitates adoption and maintenance ofhealthy behavior change, sustains cessation of harmful behaviors, or protects against behaviorrelated disease or injury.Evidence acquisition: Using methods previously developed for the Community Guide, a systematicreview (search period, January 1980–December 2009) was conducted to evaluate the effectiveness ofhealth communication campaigns that use multiple channels, including mass media, and distributehealth-related products. The primary outcome of interest was use of distributed health-related products.Evidence synthesis: Twenty-two studies that met Community Guide quality criteria wereanalyzed in 2010. Most studies showed favorable behavior change effects on health-related productuse (a median increase of 8.4 percentage points). By product category, median increases in desiredbehaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to10.0 percentage points for smoking-cessation campaigns.Conclusions: Health communication campaigns that combine mass media and other communicationchannels with distribution of free or reduced-price health-related products are effective in improving healthybehaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriatepopulation targeting. The ability to draw more speciﬁc conclusions about other important social marketingpractices is constrained by limited reporting of intervention components and characteristics.(Am J Prev Med 2014;47(3):360–371) Published by Elsevier Inc. on behalf of American Journal of Preventive MedicineFrom the Community Guide Branch, Division of Epidemiology, Analysis andLibrary Services, Center for Surveillance, Epidemiology and LaboratoryServices (Robinson, Tansil, Elder, Soler, Labre, Mercer), Ofﬁce of AssociateDirector of Communications, Ofﬁce of the Director (Eroglu, Baur, LyonDaniel, Fridinger, Sokler), and Ofﬁce on Smoking and Health, NationalCenter for Chronic Disease Prevention and Health Promotion (Beistle), CDC,Atlanta, Georgia; University of California (Green), San Francisco; Agency forHealthcare Research and Quality (Miller), Rockville, MD; Michigan StateUniversity (Dearing), East Lansing, Michigan; The George WashingtonUniversity (Evans), St. Louis, Missouri; University of Connecticut (Snyder),Storrs-Mansﬁeld, Connecticut; Harvard School of Public Health (Viswanath),360 Am J Prev Med 2014;47(3):360–371Harvard University, Cambridge, Massachusetts; SciMetrika (Chervin), Durham; University of North Carolina at Chapel Hill, Gillings School of GlobalPublic Health (Rimer), Chapel Hill, North Carolina; and the University ofFlorida (Bernhardt), Gainesville, FloridaThe names and afﬁliations of the Task Force members are listed at .html.Address correspondence to: Randy W. Elder, PhD, MEd, Guide toCommunity Preventive Services, 1600 Clifton Rd., Mailstop E-69, AtlantaGA 30333. E-mail: email@example.com/ 4Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Robinson et al / Am J Prev Med 2014;47(3):360–371361ContextOverview of Health Communication CampaignsPHealth communication campaigns apply integrated strategies to deliver messages designed—directly or indirectly—to inform, inﬂuence, and persuade target audiences’ attitudes about changing or maintaining healthful behaviors.12Messages can be transmitted through a variety of channels,such as traditional mass media (e.g., TV, radio, newspapers);the Internet and social media (e.g., websites, Facebook,Twitter); small media13 (e.g., brochures, posters, ﬂiers);group interactions (e.g., workshops, community forums);and one-on-one interactions (e.g., hotline counseling).14In particular, use of traditional mass media in healthcommunication campaigns has the potential to transmit abehavior change message faster and farther than mostother communication approaches.15 A variety of such massmedia campaigns have been found to be effective. Theinternationally recognized SunSmart campaign, whoseslogan was “slip on a shirt, slop on sunscreen, slap on ahat, seek shade, and slide on some sunnies,”16 used bothbroadcast and print media to communicate skin cancerprevention messages, substantially increasing the sunprotection behaviors recommended by the campaign.17Similarly, over the last several decades, tobaccocounter-marketing campaigns have led to reductions intobacco use in the U.S. and internationally.18,19 TheFlorida “Truth” campaign used paid TV and radioadvertisements, along with billboard and other printmedia, to expose youth to the tactics of the tobaccoindustry, the truth about addiction, and the health andsocial consequences of smoking.20reventable hazardous behaviors contribute toinjuries, illnesses, and deaths each year in theU.S., from engagement in wheeled sports withoutproper protective gear (e.g., helmets) to makingpoor dietary choices that heighten cardiovascular disease risk.1 Over the last several decades, health communication campaigns and social marketing concepts2,3have been used widely in the ﬁeld of public healthto disseminate health promotion messages designedto change behaviors and reduce morbidity andmortality.Health communication campaigns that incorporatesocial marketing concepts were ﬁrst used in familyplanning to promote use of contraceptives.4–7 In the late1960s, such campaigns were used in intensive nationaltobacco counter-marketing campaigns. Since then,health communication campaigns have been used inmany other public health domains. These campaigns cantransmit messages that inﬂuence knowledge, awareness,and social norms, and help to change many healthrelated behaviors.Commercial marketing principles of combining massmedia with product distribution were well establishedlong before their adoption into the public health domain.8Over time, reﬁnement of communication theories andcampaign strategies and their application to an extensiverange of health behaviors have led to more sophisticatedcampaigns.9 Evidence demonstrates that health communication campaigns, when combined with other strategies(e.g., community events), compared to those that use onlya single strategy (e.g., poster campaign), have a greaterimpact on improving health behaviors.10A meta-analysis11 of the effectiveness of mediatedhealth communication campaigns on a broad range oftopics (which delivered messages through at least oneform of media but no product distribution) found thatsuch campaigns generally improve health behaviors, witha mean relative increase of approximately 10% in thetargeted behaviors. Mass media approaches, althoughsometimes cost prohibitive, have both a broad reach andawareness-building potential among consumers.This Community Guide review aimed to extend thisbody of research by assessing the effectiveness of healthcommunication campaigns that include both mass mediaand health-related product distribution to increasehealthy behavior change. The criterion requiring campaigns to use a mass media channel was developed todecrease the challenge of distinguishing campaigns fromhealth education interventions, resulting in a morehomogenous body of evidence, and allowing for a welldeﬁned scope for a systematic review.September 2014Overview of Social Marketing CampaignsSocial marketing is the adoption of strategic marketingpractices to promote social change.3,14According to the National Social Marketing Centre, eightbenchmark criteria should be considered in designing asuccessful campaign: consumer orientation, behavior, theory,insight, exchange, competition, segmentation, and methodsmix.21,22 The most notable criterion of a social marketingcampaign is “the marketing mix,” often referred to as thefour P’s (product, price, place, and promotion).14,16,17 Additional P’s have been suggested in the marketing literature,including factors pertinent to behavior change (e.g., people,process, purse strings, and physical evidence).14,21One common public health application of socialmarketing is to combine a health communication campaign (i.e., promotion) with the distribution of free orreduced-price products (i.e., product and price). Accompanying a product with a campaign “enables the target tomanifest its motivation and ability” to see the beneﬁts ofengaging in that behavior without force.8
362Robinson et al / Am J Prev Med 2014;47(3):360–371For example, the National Safe Kids campaign,23 whichused both mass media and small media and distributed freeand reduced-price helmets, increased awareness amongparents about the importance of wearing helmets toprevent injury and deaths related to wheeled sports, thusincreasing children’s helmet use.23–26 “Hombres Sanos,”an HIV-prevention campaign targeting Spanish-speakingmen who have sex with men, markedly increased safe sexpractices by simultaneously distributing free condomsand promoting condom use via broadcast media, printmaterials, transit ads, and activities at local venues.27The goals of this review were to (1) assess and evaluatehigh-priority public health outcomes; (2) evaluate thepotential utility of social marketing concepts in improving effectiveness of health-promotion campaigns; (3)provide speciﬁc recommendations to enhance currentstrategic and operational approaches; (4) answer questions about the value of using health communication andsocial marketing principles in the ﬁeld; and (5) determinewhether these principles are broadly applicable.This review considered only those health-relatedproducts that were1. previously demonstrated through an evidence-basedprocess (such as a peer-reviewed systematic review ormultiple rigorous studies) to improve health-relatedoutcomes (e.g., increased physical activity; smokingcessation; and reductions in disease, injury, or death);2. tangible;3. not a service (e.g., mammogram);4. not exclusively available through prescription or administration by a health professional (e.g., vaccination orprescribed medication);5. used repeatedly or continually for desired healthbehavior change and disease and injury preventioneffects (e.g., using condoms, wearing helmets) ratherthan a one-time behavior (e.g., installing smoke alarms);and6. not a food marketed as being “healthful” (e.g., oatmeal).Evidence AcquisitionIntervention DeﬁnitionThe speciﬁc interventions evaluated in the systematicreview combine health communication campaigns promoting behavior change through multiple communication channels, including mass media, with the distributionof free or reduced-price products that facilitate the adoption or maintenance of health- promoting behaviors (i.e., increased physical activitythrough pedometer distribution combined with walking campaigns);facilitate or help to sustain the cessation of harmfulbehaviors (i.e., smoking cessation through free orreduced-cost over-the-counter nicotine replacementtherapy [NRT]); andprotect against behavior-related disease or injury (i.e.,condoms, child safety seats, recreational safety helmets, and sun-protection products).In this review, mass media health communicationcampaigns combined with health-related product distribution are deﬁned as campaigns that1. use messages designed to increase awareness of,demand for, and appropriate use of a product. (Toprovide multiple opportunities for exposure, messageshad to be delivered through multiple channels, one ofwhich had to be mass media.); and2. distribute a product to facilitate adoption or maintenance of health-promoting behaviors, sustain cessationof harmful behaviors, or protect against behavior-relateddisease or injury. (To reduce cost-related barriers to use,distributed products were free or discounted.)Methods for Conducting the ReviewGeneral methods to conduct systematic reviews for the Community Guide and to develop evidence-based recommendations aredescribed in detail elsewhere.28,29 The conceptual approach andmethods speciﬁc to this review, including intervention selectionand outcome determinations, are described here.Systematic Review Development TeamThe systematic review development team (the team) consisted ofscientists and research fellows from CDC’s Community Guide branchcollaborating with subject matter experts and consultants, includingmembers of CDC’s former National Center for Health Marketing;members of the Community Preventive Services Task Force (TaskForce); and liaisons to the Task Force. Subject matter experts fromHarvard University, Agency for Healthcare Research and Quality,and Fielding School of Public Health contributed perspectives fromresearch, practice, and policy related to marketing, social marketing,health communication, health education, and health literacy.Conceptual ApproachThe analytic framework (Figure 1), which helped guide thesystematic review process, illustrates the conceptual pathways bywhich health communication campaigns combined with productdistribution can increase the adoption or performance of healthrelated behaviors to improve population health and ultimatelydecrease morbidity and mortality. It was developed through teamdiscussions and an in-depth literature search of health communication and social marketing intervention studies and reviews.The intervention may affect ultimate health outcomes throughchanges across varied levels of the social ecologic model (e.g.,individual, organizational, community), leading to use of productswith direct protective effects (e.g., bicycle helmets) or that facilitateadoption of healthy behaviors (e.g., physical activity with use of awww.ajpmonline.org
Robinson et al / Am J Prev Med 2014;47(3):360–371363Figure 1. Conceptual model of effects of health communication campaigns that include mass media and health-relatedproduct distributionpedometer). Incorporating a product distribution component tothe intervention improves access by providing products free ofcharge or at a reduced price. Products can be distributed at variousevents30 or through partnerships with local businesses.Media campaigns can support a variety of strategies topromote healthy behaviors. In a physical activity study,31campaign implementers collaborated with city council membersto promote walking by installing permanent motivational signsthroughout the community. Policy initiatives can occur early ina campaign or after assessment of a campaign’s effectiveness.Such campaigns may beneﬁt from increased awareness of thehealth issue generated by earned media,32 which involve reporting by local media, often prompted by a news release generatedfrom state or local health departments about campaign effortsand outcomes.The intervention may generate more favorable social normsabout the promoted behavior, which, in turn, may enhance selfefﬁcacy and intentions to engage in the behavior. Over time,campaigns may also garner community support, as persistentcampaign messages create shifts in attitudes about the promotedbehavior.33Ecologic-level changes have enormous potential to inﬂuenceindividual-level behaviors. The principles of health promotion34,35plant a strong foundation to capitalize on the interaction betweenchanges at the individual and ecologic levels. A well-designedcampaign uses formative research to create messages that effectively inﬂuence the knowledge, attitudes, and behaviors of thetarget audience.36Audience exposure to the messages inﬂuences engagement inthe desired behavior. As messages are reinforced through repeatedexposure, the campaign’s message reach and target audienceexpand, as does the likelihood of, at least, short-term effects onSeptember 2014behavior.6 Further, the enhanced “availability, accessibility, andaffordability” of a health-related product may increase adoptionand maintenance of the healthful behavior, resulting in a decline inmorbidity and mortality.6Economic EvaluationEvaluations of economic efﬁciency are conducted if the Community Preventive Services Task Force recommends an intervention.The methods and ﬁndings of the economic evaluation of massmedia health communication campaigns combined with healthrelated product distribution interventions are described in anaccompanying article.37Search for Evidence and Criteria for InclusionElectronic searches were conducted for literature publishedbetween January 1980 and December 2009. References listed inall retrieved articles were examined and information from subjectmatter experts on the team were incorporated. The full searchdetails are available at ortingmaterials/SScampaigns.html.The inclusion criteria for this review required that studiesevaluated an intervention that met the deﬁnition speciﬁed above;were published in English; were conducted in a high-income economy ps);were a primary study rather than, for example, a guideline orreview; and applied a study design that compared an exposedgroup to an unexposed group (i.e., no intervention), measured agroup’s exposure pre-intervention and post-intervention, or compared a post-only design with a concurrent comparison group.
364Robinson et al / Am J Prev Med 2014;47(3):360–371Abstraction and Evaluation of StudiesEvidence SynthesisEach study that met the inclusion criteria was abstractedindependently by two reviewers, using the standardized Community Guide abstraction form.28 Discrepancies betweenreviewers were reconciled by consensus among team members.Design suitability was rated as greatest, moderate, or least,depending on the degree to which the design protected againstthreats to validity.29The intervention and study quality of execution was rated asgood, fair, or limited, based on population and interventiondescription, sampling, measurement of exposure, reliability andvalidity, how the data were analyzed, and how the results wereinterpreted.29 Only studies with good or fair quality of executionwere included in the review. From the data in those includedstudies, the team calculated effect estimates for study outcomeswhenever sufﬁcient information was available to do so.Intervention EffectivenessEffect Estimate CalculationsHealth-related behavior change was calculated from use of theproduct that directly protected the user or facilitated change. Usingdata from the last available time point in each study, the absolutepercentage point (pct pt) change in the proportion of peopleengaging in a health-related behavior change (e.g., booster seatuse) was calculated for people exposed to the intervention, andcompared to changes among people unexposed to the intervention:Absolute pct pt change ¼ (Intervention Prop.post – InterventionProp.pre) – (Comparison Prop.post – Comparison Prop.pre),where Prop. ¼ proportion of people.For continuous variables (e.g., number of steps per day), asimilar difference in differences approach was used to calculateeffect estimates for changes in group means:Difference in differences of the mean ¼ (Intervention Meanpost– Intervention Meanpre) – (Comparison Meanpost – ComparisonMeanpre).For pre–post studies, simple differences were used.Results were summarized using descriptive statistics (mediansand interquartile intervals [IQIs]) for the entire body of evidenceand for subgroups of studies stratiﬁed by key methodologic andsubstantive variables. For subgroups consisting of ﬁve or morestudies, an IQI was presented as an index of variability; otherwise,a simple range of values was reported. Studies that did not reportdata in these metrics were summarized separately.31,38–41When outcomes were assessed at multiple time points, effectestimates were calculated using the earliest available measurementpre-intervention and the last available follow-up. For studies thatreported different measures of a given outcome, consistently appliedrules were used to select the “best” measure with respect to validityand precision (e.g., when different helmet use measures werereported, observed helmet use was selected over self-reportedmeasures). Results adjusted for effects of potential confounderswere used in preference to crude effect measures, when both werereported.In addition to assessing outcomes related to the intervention’seffectiveness in changing the health behaviors of interest, the teamassessed issues related to intervention applicability across contextsand populations. The team also considered other beneﬁts andpotential harms from the intervention, as well as considerations forimplementation, including barriers.Initially, 15,941 studies were identiﬁed in the search. Ofthese, 958 were obtained for full-text review. Followingthe review, 936 articles were excluded after full-textreview for not meeting the inclusion criteria.A total of 23 studies (with 26 study arms)24–27,30,31,33,38–53evaluating the effectiveness of health communicationcampaigns that use multiple channels, include massmedia, and distribute free or discounted health-relatedproducts were ultimately considered for inclusion. Onestudy, with limited quality of execution, was excludedfrom all analyses (Figure 2).47 Of the remaining studyarms, three38,42,43 had good and 1924,30,39–41,44–53 had fairquality of execution. Speciﬁc details on the 22 studiesincluded in analyses (25 study arms)24–27,30,31,33,38–46,48–53are provided at ortingmaterials/SETcampaigns.pdf. Analyses were conducted in 2010.Of all the health-related products that were eligible forthis review, six (i.e., child safety seats, condoms, recreational helmets, NRT, pedometers, and sunscreen) wererepresented in the included studies. The studies in thisreview reported outcomes using a variety of effect measuresfor each product or behavior outcome (Table 1). Althougha search was performed for studies of additional healthrelated products that assessed effectiveness or measured theoutcome of interest, none were found.In the 17 studies (20 study arms)24–27,30,33,42–46,48–53shown in Figure 3, data on intervention effects on theproportion of people engaging in a healthy behavior areshown as pct pt changes. Data points to the right of thezero line are in the favorable direction. The medianincrease in these studies was 8.4 pct pts (IQI¼2.7, 14.5).Although the magnitude of intervention effects varied,favorable results were found for at least one interventionpromoting each of the six distributed health-relatedproducts.Overall, results were consistently favorable acrossproducts and a wide range of baseline usage rates(median baseline usage rate of 9.7 pct pts, IQI¼5.1,18.2). Health behavior change for ﬁve included studiescould not be expressed as pct pt changes,31,38–41 but theresults were consistent with the rest of the body ofevidence. Three study arms33,45,51 did not show favorableresults, which the authors attributed to interventionstafﬁng issues, lack of proper investment in each implemented outreach event, and intervention exposure.Key intervention characteristics and stratiﬁed effectestimates are described in Table 2. The most commonlyevaluated interventions were those promoting use ofcondoms and recreational safety helmets. Results werewww.ajpmonline.org
Robinson et al / Am J Prev Med 2014;47(3):360–371365Figure 2. Flow diagram showing number of studies identiﬁed, reviewed in full text, reasons for exclusion, and total number ofincluded studiesconsistently favorable, without any clear differences inestimated effect magnitude across strata.Smoking-cessation campaigns and product distributioncan affect overall smoking rates in two complementaryways. First, the intervention can increase the total numberof smokers who called quitlines, which has been demonstrated to increase smoking cessation . The interventionresulted in large increases in calls to quitlines, rangingfrom 57% to 2,500%. Second, the proportion of quitlinecallers who actually quit smoking increased by a median of10 pct pts in the intervention group (Table 2), likely as aresult of distribution of free NRT. In one of the studies,89% of NRT recipients continued purchasing it after freesupplies ran out, showing that initial free distributionincreased longer-term demand for use of NRT.48Incremental effects of combining product distributionwith health communication campaigns. To examinethe incremental effects of adding distribution of healthrelated products to health communication campaigns,three additional analyses were carried out for (1) a broadrange of health behaviors; (2) use of a speciﬁc product(i.e., condoms); and (3) a speciﬁc health communicationmessage with and without product distribution.To assess a broad range of health behaviors, resultsfrom studies in this review were compared to those froma meta-analysis of comparable, but not identical, healthcommunication campaigns.11 Those studies addressed asimilar range of behaviors and also included a massmedia channel but did not include product distribution.The meta-analysis review found that different types ofSeptember 2014campaign messages resulted in a relative increase ofapproximately 10% from baseline in the targeted behaviors. When results from the current review wereexpressed using the same metric, the median absoluteincrease (8.4 pct pts) in target behaviors translated to amedian relative increase of 77.8%, substantially largerthan the relative increase without product distribution.Among studies that assessed effectiveness of healthcommunication campaigns promoting use of a speciﬁcproduct (condoms), with27,33,44,49 and without54–58 productdistribution, studies with product distribution increasedcondom use by a median of 4.0 pct pts (four studies, IQI –4.0, 10.8) and studies without product distributionincreased condom use by a median of 1.5 pct pts (fourstudies, IQI –16.1, 7.3). Taken together, the weight of thisevidence indicates that integrating product distribution witha health communication campaign can increase effectiveness.A direct comparison of a speciﬁc health promotionmessage with and without product distribution wasperformed using supplementary evidence from asmoking-cessation campaign already included in thereview.48 This study directly compared a smokingcessation promotion message alone with one combiningthe message with offer of a free product: a cigarettesubstitute. After the promotion-only message, quitlinecalls increased by about 50%, compared with an increaseof about 100% after promotion with product distribution.Although the cigarette substitute did not meet criteria foran NRT health-related product, the conceptualization ofthe campaign and product promotion and distributionintervention process provide some evidence that addingproduct distribution does increase healthier behavior.
366Robinson et al / Am J Prev Med 2014;47(3):360–371Table 1. Health-related products and measurements of useProduct or target behaviorOutcome measuresInstrumentChild safety seatsUse of booster seatObservation of useCondomsCondoms at last intercourseQuestionnaireAny unprotected anal intercourse in the past 2 monthsQuestionnaireCondom use with main partner at last intercourseQuestionnaireUnprotected vaginal or anal sex with a female partner duringthe last 60 daysQuestionnaireProportion of times used condoms in the last 4 weeks amongthose reporting sexual activityQuestionnaireNumber of days in the past 60 days had vaginal or anal sexwithout a condomQuestionnaireUse of helmetObservation of useWore helmet at last rideQuestionnaireParent report of child wearing a bicycle helmet at least 50% ofthe timeQuestionnaireQuit ratesQuestionnaire6 months since abstinenceQuestionnaireQuitline callsCall volumeTime spent walking, moderate and vigorous activity during thelast weekQuestionnaireSteps per dayPedometer dataSunscreen (SPF 15) use (days)Sunscreen userecorded in diaryRecreational safety helmetsSmoking cessation (over-the-counternicotine replacement therapy)Physical activity (pedometers)Sun-protection productsSPF, sun-protection factorApplicabilityThe reviewed studies evaluated intervention effectivenessin a wide range of urban, rural, and suburban settings in theU.S. and Australia,31,40 Canada,24 Belgium,38 and Israel.25Many papers did not report details on population demographics, such as race, age, and education. Nonetheless,favorable results were found for interventions targeting avariety of speciﬁc demographic groups. Populationsaddressed included African Americans,41 people of Hispanicorigin,27,43,45 low-income groups,45 and men who have sexwith men.24,27,44 Owing to the consistency of these favorableeffects and the lack of any strong a priori reason to expectdifferent effects across populations for appropriately targetedcampaigns, the evidence from this review is likely to bebroadly applicable.reviewed studies or postulated by the review team.However, additional beneﬁts to implementing this intervention were identiﬁed through i
media, to expose youth to the tactics of the tobacco industry, the truth about addiction, and the health and social consequences of smoking.20 Overview of Social Marketing Campaigns Social marketing is the adoption of strategic marketing practices to promote social change.3,14 According to the National Social Marketing Centre, eight
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