HOW WELL DOES SOCIAL AND
BEHAVIOR CHANGE
COMMUNICATION WORK?
LESSONS FROM SYSTEMATIC
REVIEWS AND METAANALYSES
Leslie Snyder, Ph. D.
University of Connecticut
LESSON 1:
MEDIA CAMPAIGNS HAVE SMALL EFFECT SIZES
ON AVERAGE, WHICH TRANSLATE TO AFFECTING
LARGE NUMBER OF PEOPLE IF YOU HAVE
SUFFICIENT REACH

5 percentage points change in behavior on
average from persuasive campaigns in the U.S.
(Snyder, 2001; Feeley et al., 2015).

Positive impact for 81% of material child health
campaigns in low & middle income countries in a
systematic review (k=32) (Naugle & Hornik, 2014)
LESSON 2:
THE IMPACT OF MEDIA CAMPAIGNS VARIES BY
TOPIC.
IMPACT OF CAMPAIGNS USING MEDIA
Youth
Alcohol use (Snyder et al., 2004)
Fruit & vegetables (Snyder et al., 2006)
Smoking prevention (Parcell et al, 2006;…
Fat consumption (Snyder et al., 2006)
0.05
0.05
0.03
Adults
Fat consumption (Snyder et al., 2006)
Seat belt use (Snyder et al. 2004)
Condom use (Snyder et al. 2009)
Fruit & vegetables (Snyder et al., 2006)
Oral health (Snyder et al. 2004)
Alcohol use (Snyder et al., 2004)
Seat belt use (Moore 1990)
Family planning (Snyder, Badiane,…
Organ donation (Feeley & Moon 2009)
Heart disease prevention (Snyder et al.…
Mammography (Han et al., 2009; Snyder…
Smoking cessation (Snyder et al., 2004)
-0.05
(Snyder & LaCroix, 2011)
0.07
0.20
0.15
0.14
0.13
0.13
0.07
0.06
0.05
0.05
0.04
0.03
0.00
0.05
0.10
0.09
0.15
Average Effect Sizes (r)
0.20
0.25
LESSON 3:
THE IMPACT OF MEDIA CAMPAIGNS VARIES BY
CONTEXT AND POPULATION.
HIV INTERVENTIONS ARE MORE
EFFECTIVE IN COUNTRIES WITH LESS
DEVELOPMENT
Condom Use Effect Sizes by National
Human Development Index (HDI)
Effect Size
0.40
0.22
-0.04
Low
Medium
High
Human Development Index
LaCroix, Snyder, Huedo-Medina, & Johnson (2014). Effectiveness of Mass Media Interventions for HIV
Prevention, 1986-2013: A Meta-Analysis. J of Acquired Immune Deficiency Syndrome, 66, S329-340.
LESSON 4:
COMPREHENSIVE INTERVENTIONS ARE
SOMETIMES MORE EFFECTIVE THAN SINGLE
INTERVENTION APPROACHES.


Systematic review in maternal child health found
approaches combining media with another
approach are more likely to be successful
(Wakefield, Loken, & Hornik, 2011).
But need more research to understand how to
optimize combinations
MEDIA CAMPAIGNS + DISTRIBUTION OF
FREE OR DISCOUNTED PRODUCTS
(CDC COMMUNITY GUIDE TO PREVENTIVE HEALTH SERVICES)

Behavior change percentage point gain:
10.0 smoking cessation
8.6 child seat use
8.4 helmet use
4.0 condom use
(Robinson, et al., 2014, Am J Prev Med 47(3): 360-371)
VACCINES:
INTERVENTION STRATEGIES WORTH DOING
ALONE (CDC COMMUNITY GUIDE TO PREVENTIVE HEALTH SERVICES)
Recommended based on strong evidence:

Client reminders

Provider reminders

Provider assessment & feedback

Home visits

School, daycare, & MCH programs track & provide vaccines

Reducing client out-of-pocket costs for vaccines

Immunization information systems

Client or family incentive rewards (e.g. food vouchers, gift cards)

Requiring vaccines for attendance to child care, school, college
Insufficient evidence:



Provider education when used alone
Community-wide education (person to person, community
mobilization, mass or small media) when used alone
Clinic-based client education when used alone (brochures, videos,
face-to-face sessions)
VACCINES:
EFFECTIVE COMBINATION OF STRATEGIES
(CDC COMMUNITY GUIDE TO PREVENTIVE HEALTH SERVICES)

Increase demand (e.g. reminders, outreach and
tracking, incentives) with
Enhance access (expand healthcare access, home
visits, reduce costs)
OR
 Healthcare system improvements (provider
reminders, standing orders, provider assessment
& feedback)

TOBACCO
 Approaches
that are sufficient to have an
impact when used alone:
Mass-media campaigns (cessation, use of quit
services, & prevention)
 Mobile phone-based interv.(cessation only)
 Quitlines
 Price increases in tobacco products (cessation
& prevention)
 Reducing cessation costs to smokers
(cessation)
 Smoke-free policies

COMPREHENSIVE TOBACCO CONTROL
PROGRAMS ARE RECOMMENDED OVER
PIECEMEAL APPROACHES

Assistance to community-based organizations,
local & state partnerships, media, cessation
services, support for policy changes, smoking
surveillance, program monitoring, & evaluation.

Decrease 3.9 percentage points over 9 years on
average
(CDC Community Guide to Preventive Health Services)
HIV INTERVENTIONS – CONDOM
USE
Media campaign
0.11
Media campaign +
interpersonal
0.14
Computer, tailored
interventions
0.17
Interpersonal with small
media
0.15
Interpersonal interventions
0.04
0.00
0.05
0.10
0.15
Average Effect Sizes
0.20
0.25
LESSON 5:
E-HEALTH APPLICATIONS CAN BE EFFECTIVE.
Can be beneficial for both patients &
practitioners.
 Meta-analyses show a significant impact on
behavior change on average


Portnoy et al., 2008; Noar, 2009; Cugelman, 2010)
Systematic review of mHealth for maternal child
health in LDCs found evidence for effectiveness
for medication adherence, uptake of service,
education of caregivers, and provider compliance
with protocols (Higgs, 2014).
 Magic multiplier: Like mass media, may have
high development costs but low per person costs.
 May benefit from novelty affects

SMOKING CESSATION &
PREVENTION INTERVENTIONS
Prevention (youth)
Media campaigns
Interpersonal interventions
0.05
0.09
Cessation (youth)
Web-based interventions
0.09
Cessation (adult)
Media campaigns
Mobile phone interventions
Phone interventions (not…
Computer-based…
Interpersonal interventions
0.00
0.03
0.24
0.08
0.07
0.12
0.05
0.10
0.15
0.20
0.25
Average Effect Sizes
(Snyder & LaCroix, 2013)
0.30
0.35
LESSON 6:
TAKE ADVANTAGE OF NOVELTY
Adopting a new behavior is more successful
than preventing a new behavior or stopping old
behavior (Snyder et al., 2004)
 Messages with information that is new to
the user/receiver are more effective
 Novel channels (e-health, text messaging) may
garner more attention

LESSON 7:
TARGET PEOPLE WHO ARE ALREADY
MOTIVATED WITH REMINDERS
Reminders can be easy, inexpensive, & effective
 Media – text messaging, letters, phone calls, robocalls

MAMMOGRAPHY SCREENING
INTERVENTIONS
0.03
0.19
0.21
0.06
0.10
0.00
0.05
0.10
0.15
0.20
0.25
Average Effect Sizes
(Snyder & LaCroix, 2013)
PATIENTS & PROVIDER EVIDENCE

Meta-analyses of effectiveness of SMS show:

Short-term effects of 17 percentage point increase in
medication adherence for chronic diseases (Thakker,
2016, JAMA)

Appointment attendance (Free, 2013, PLOS Medicine;
Guy, 2012, Health Services Research).

Evidence for effectiveness of provider
reminders:


Increasing breast, cervical, and colorectal cancer
screenings
Vaccinations (Community Guide)
LESSON 8:
COMBINED CARROT AND STICK CAN BE
EFFECTIVE – PUBLICIZE ENFORCEMENT
ENFORCEMENT MESSAGE CAMPAIGNS
(SEAT BELTS, ALCOHOL SALES TO MINORS)
VS PERSUASIVE CAMPAIGNS (ALL TOPICS)
21
0.2
0.15
0.1
0.05
0
0.17
0.06
W/ Enforcemt
Persuasive only
Snyder et al., 2004
LESSON 9:
TAILOR MESSAGES FOR THE INDIVIDUAL USER,
IF POSSIBLE…

Meta-analyses show greater effects for
tailored materials than non-tailored
materials (Noar, 2007; Krebs, 2010; Lustria,
2013)


CDC Community Guide found evidence to
support tailoring small media (e.g.
brochure, poster) & interpersonal
interventions for breast cancer
screenings
Tailoring + reminders + incentives
increases retention to internet
interventions for teens & young adults
(Crutzen, 2011, Health Ed & Behavior)
AND IF TAILORING IS NOT POSSIBLE,
ADAPT MESSAGES TO YOUR TARGET GROUP

Meta-analyses
HIV (LaCroix, 2014)
 Lifestyle interventions greater effects when tailor by
culture, gender, & ethnicity (Wilson, et al., 2015)

LESSON 10:
FEAR APPEALS CAN WORK AND ARE NOT
LIKELY TO BOOMERANG

More effective when:
Include efficacy statements
 Depict high susceptibility and severity
 Behavior is one-shot (vs repeated)
 Target audience has more women
(Tannenbaum, 2015, Psych Bull.)

LIMITS
Meta-analyses lag behind cutting-edge work
 Only as good as the evidence that is available
 Less evidence is published for research &
evaluations in developing countries, but we know
context matters.
 Need more work on how to combine strategies for
different behavioral objectives & target
populations
 Need to take into account contextual, policy,
organizational factors.

THANK YOU!
አመሰግናለሁ
Leslie.Snyder@UConn.edu