For the Office-based Teacher of Family Medicine

Editor’s Note: In this month’s column, Sean David, MD, SM, of the Department of Family Medicine at Brown University, provides information about population-based health interventions using public media. I welcome your comments about this feature, which is also published on the STFM Web site at www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it to their preceptors (with the appropriate Family Medicine citation). Send your submissions to Paul Paulman, MD, University of Nebraska Medical Center, Department of Family Medicine, 983075 Nebraska Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@unmc.edu. Submissions should be no longer than 3–4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.Paul M. Paulman, MD Feature EditorMedia Advocacy for the Office-based Teacher of Family Medicine Sean P. David, MD, SM

Media Advocacy for the Office-based
Teacher of Family Medicine

As an office-based preceptor, imagine that you have been approached by family practice residents and students who have performed community needs assessments as part of a community-oriented primary care (COPC) curriculum. These learners tell you that smoking prevalence in public schools is much higher than the national average.

After speaking with teachers, health educators, and school nurses, you learn that many students buy cigarettes from vending machines at the corner drug store. You are also informed that binge drinking rates are high in the local college, but bartenders do not routinely check for identification, students are permitted to drink in dormitories, and athletic events are sponsored by beer companies.

Moreover, domestic abuse is high, as measured by emergency department visits, but the leader of the local women’s shelter informs the student that the police department does not routinely investigate and prosecute batterers in your town.

It becomes clear that the most important threats to public health require more than patient education and secondary prevention (screening). What you decide you must do is work for environmental and policy change to ban cigarette vending machines, train bartenders to check identification, persuade the college to make dormitories alcohol free, abandon beer company advertising of athletic events, and convince the police department to prosecute batterers. You are concerned, however, that without substantial political clout, you will be unable to change laws or convince the college and police department to crack down on binge drinking and domestic abuse.

You perform a literature search and find that mass media campaigns have been a cost-effective way to promote policy initiatives that save lives.1 You would like to develop a mass media campaign but don’t know where to start.

In this article, I describe a powerful method of health promotion that is available and feasible for office-based family physicians. This method is called media advocacy.

Media Advocacy

Media advocacy is defined as the strategic use of mass media to advance public policy initiatives.2 In media advocacy, the mass media (television, radio, print, the Internet) are used to mobilize community action in support of policy changes. One example of media advocacy is a family physician in California who informed a local television news affiliate of a rise in shooting deaths caused by children who mistook a newly available toy gun with real guns. Public outcry following the airing of televised news stories convinced toy stores to stop carrying the toy guns.

Another example is a family physician in Massachusetts who worked with a group of public health students to develop a radio and Internet campaign to promote letter writing to members of Congress. The group used the leverage of the media campaign to meet with Congressional leaders and disseminate information about international tobacco control issues to other health policy makers and opinion leaders.3 In both of these cases, individuals or small groups with limited resources used the leverage of the media to mobilize large numbers of people to alter decision making of governmental and corporate elites.

Functions of Media Advocacy

Wallack, a social epidemiologist, describes three major functions of media advocacy:2

(1) Agenda Setting: Media Advocacy Uses the Media to Place Issues on the Public Agenda
Several studies have shown that the public agenda is determined by what is covered by the media.2,4-6 Prior to 1980, drunk driving was nonexistent on the national public agenda. A group of women in California established Mothers Against Drunk Driving (MADD) to mobilize grass roots support for policies to reduce alcohol-impaired driving deaths. Following many staged rallies and protests, the group drew first local and then national media attention. By 1982, President Reagan announced a Presidential Task Force on Drunk Driving. In 1984, a federal statute raised the minimum drinking age to 21. By 1994, alcohol-related traffic deaths reached a 30-year low. 7

(2) Media Advocacy Allows Issues to Be Framed in a Way That Promotes Policy Change
Media advocacy allows advocates to frame the issue so the public sees “upstream” social or environmental forces (eg, the tobacco industry and cigarette advertising that targets youth) as responsible for the problem and takes the focus away from the individual. The family physician in California was able to focus attention on the toy industry, rather than children, as responsible for the increase in shooting deaths.

(3) Media Advocacy Seeks to Advance Social or Public Initiatives as a Primary Approach to Solving the Problem
Tobacco control activists from seven communities in Minnesota generated news stories about tobacco industry manipulation of youth, made contacts with community leaders, and staged public events, which led to implementation of comprehensive tobacco control ordinances in all seven communities. 8

Steps of Media Advocacy

(1) Establish what your practice’s policy goal is. What do you want to happen? Do you want to increase bicycle helmet use, reduce youth smoking, or reduce college student binge drinking?
(2) Decide who your target audience is. Who do you want to reach with your media messages? Who has the power to change policies? Do you want to focus on policy decision makers, adult women, college administrators, etc? For example, you may wish to target the City Council to advocate for a local ordinance banning cigarette vending machines.
(3) Frame your issue and construct your message. You could put the focus on environmental aspects of youth smoking (vending machines, teachers smoking on campus, etc). Before you construct your message, do some formative research (focus groups, interviews) with the target audience to identify barriers to behavior change and design messages that resonate with the people you are trying to reach.
(4) Construct an overall media plan that creates pressure for change. Consider how you can attract news coverage. Staged rallies outside the town council, court house, or television station are effective ways to attract the media. Radio public service announcements (PSAs), newspaper editorials and opinion pieces, and e-mail campaigns are effective and relatively inexpensive ways to advance the issue on the public agenda
(5) Build a coalition of political decision makers, media gatekeepers, and advocacy groups. The family physician and public health students in Boston worked with the American Cancer Society to perform focus group research, had facility space donated by the American Heart Association, and Internet home page space donated by Save Lives Not Tobacco. C. Everett Koop, MD, ScD, wrote a letter to a US senator and donated his time to record the radio PSAs. The Boston group approached a Washington, DC-based news radio station that played the PSAs free of charge. Once contacts are made with media gatekeepers, it becomes easier to obtain news coverage of campaign-related events and issues in the future.
(6) Evaluate your campaign. Count the number of news stories before and after the campaign.

Media advocacy is powerful tool for promoting health in practice communities through environmental and policy change. Coalition building is key to reaching policy makers and harnessing resources. Residents and students will not only learn by example from short-term involvement in media advocacy but are likely to be empowered to become more civically active in their future practice communities.

Correspondence: Address correspondence to Dr David, Brown University, Department of Family Medicine, 111 Brewster Street, Pawtucket, RI 02860. 401-729-2071. Fax: 401-729-2923. sean_david@brown.edu. References
1. DeJong W, Wisten JA. The media and the message: lessons learned from past public service campaigns. Washington, DC: Released by the National Campaign to Prevent Teen Pregnancy, February 1998.
2. Wallack L. Media advocacy: a strategy for empowering people and communities. J Public Health Policy1994;15(4):420-36.
3. David SP, Dansinghani K. Public health coalition uses stats against big tobacco. Harvard Medical School Focus 1999 Oct 15. www.med.harvard.edu/publications/Focus/ (accessed 10-15-1999 issue on 2-29-2000.)
4. McCombs M, Shaw D. The agenda-setting function of mass media. Public Opin Q 1972;36:173-94.
5. Rogers E, Dearing J. Agenda-setting research: where has it been and where is it going? In: Anderson JA. Communication yearbook. Beverly Hills, Calif: Sage Publications, 1988.
6. Dearing J, Rogers E. AIDS and the media agenda. In: Edgar, Fitzpatrick, & Freimuth, eds. A communication perspective. Hillsdale, Ill: Lawrence Erlbaum Associates, 1992: 173-94.
7. Mothers Against Drunk Driving (MADD) Home page: www.madd.org/aboutmad/madd-history.shtml. Accessed 3-1-2000.
8. Blaine TM, Forster JL, Hennrikus D, et al. Creating tobacco control policy at the local level: implementation of a direct-action organizing approach. Health Educ Behav 1997; 24(6):831.