Tuesday, May 13, 2014

A Critique of the “Make the Call. Don’t Miss a Beat.” Campaign – Petra Schubert

Heart attacks are generally believed by women to be a “male problem,” but women are actually just as much at risk of a heart attack (1). 435,000 American women have heart attacks annually; although 70 is the average age for a woman to have a heart attack, 83,000 women under 65 and 35,000 women under 55 have heart attacks annually (2). Most American women don’t identify heart disease as the number one killer of women, in fact 267,000 women die each year from heart attacks, which is six times more than deaths from breast cancer (2).
Once a heart attack or myocardial infarction (MI) is suspected or identified, treatment is needed as soon as possible. Prompt medical care can alter the course of a heart attack and limit heart damage thus effecting morbidity and mortality (1). Use of emergency medical services (EMS) can drastically improve outcomes of heart attacks because they shorten the pre-hospital delay time (1). Regardless of gender, most patients with acute MI symptoms will actually delay calling for an ambulance or seeking medical care for longer than two hours (3).  Many studies debunk the fact that women delay longer than men and find that delay times are actually similar; however, there does seem to be a gender difference in the reasons why specifically women delay (3). Understanding and addressing these reasons is key to creating interventions that actually motivate women call 9-1-1. 
While many campaigns exist which aim to raise awareness of heart disease in women, the “Make the Call. Don’t Miss a Beat.” seeks to save lives at the level of heart attack symptom identification. The national public educational campaign aims to educate and encourage women to call 9-1-1 if they feel any the seven most common symptoms of a heart attack (4). The campaign, launched in 2012 by the U.S. Department of Health and Human Services’ Office on Women’s Health promotes a short and a long version of one public service announcement (PSA) and seven poster prints based on the PSA. The campaign materials depict seven women each feeling one of the seven most common symptoms of a heart attack for women: chest pain, unusual upper body discomfort, shortness of breath, cold sweat, unusual fatigue, sudden dizziness and nausea. Between each listed symptom the narrator urges women not to make excuses and to call 9-1-1.
            Although “Make the Call. Don’t Miss a Beat.” is a relatively new campaign and its effectiveness has yet to be judged, I believe its approach as it is now will not be successful. As an educational campaign it seeks to inform, but also requests women take this knowledge and act – “call 9-1-1;” without a foundation in the right behavioral theories this message may fall flat. As they are, the current theories this campaign is based on are actually weakening it. In this critique of the “Make the Call. Don’t Miss a Beat” campaign I will highlight three major flaws of the campaign and advance a counter-campaign that will attempt to address these flaws to ultimately improve the campaign.
Flaw 1: Ineffective Framing
A frame is the way an issue is presented or packaged that conveys a certain meaning; the way an issue is framed can have a powerful impact on response (5). In public health frames play a large role in campaign and policy formation. A successful use of framing can change public opinion and actually change behavior at the level of the individual (5). Strong frames incorporate a strong core value such as freedom, choice, and liberty and evoke metaphors, symbols, visual images and catch phrases. Almost every issue is framed in some way, however when elements of a frame are weak or missing, it’s easy for the issue to lose power and be forgettable. One can argue that one of the major flaws of the “Make the Call. Don’t Miss a Beat” campaign is that it lacks a strong frame. The PSA takes the core position of ‘call 9-1-1 if you feel any of these seven symptoms of a heart attack.’ While there isn’t anything significantly wrong with this position, it isn’t backed by a core value. The message of this campaign is too simplistic that it doesn’t connect to a value or belief shared by the target audience. It lacks a metaphor and its catch phrase of “don’t make excuses” doesn’t exactly inspire action.
Feeling any one the symptoms of chest pain, unusual upper body discomfort, shortness of breath, cold sweat, unusual fatigue, sudden dizziness and nausea may also seem very common to a woman that she may easily attribute the symptom to something else. Thuresson et al. found in their study that while women may feel more atypical symptoms as the ones listed in the PSA, typical symptoms like chest pain are the strongest symptom predictors of MI in women (6). Therefore this issue should not be framed around knowing all seven symptoms, but rather it should be framed around trying to get women to initially consider a heart attack when they have unusual symptoms of persistent pain. The presentation of these symptoms in the PSA can also be quite confusing to the viewer; the PSA hopes to accomplish too much in a short timespan. Information on the seven symptoms are listed for 30 or 60 seconds will not stick with viewers in a meaningful way – there are simply too many to remember them. The most effective campaigns have simple messages that are presented in an easy to remember way.
This campaign is also framed around individual responsibility - to teach a woman the signs of a heart attack and call 9-1-1 for her own sake. However research shows that women are more likely to be at home with family when initial symptoms begin (3). In a study conducted by Moser et al., two-thirds of patients studied were with someone when they experienced pain (3). Similarly Finnegan et al. found that of patients questioned, those at home or work reported consulting others as a coping mechanism when initial symptoms began and while many resisted calling 9-1-1, few reported making the final decision to seek help alone (1). Women also expressed that they would call their friends, family or primary care physician before calling 9-1-1 (1). These findings indicate that a frame that is focused on individual responsibility can only go so far. When symptoms strike more women are likely to be with and consult other people; therefore education campaigns like “Make the Call. Don’t Miss a Beat.” should frame cardiac symptom recognition and reaching out to EMS as a family or community responsibly, rather than just the woman’s responsibility. In this way the framing of the campaign completely disregards the context and environment where women commonly experience initial cardiac symptoms. The target audience of the “Make the Call. Don’t Miss a Beat” campaign needs to shift focus from the woman to the woman and her social network.
Flaw 2: Campaign’s Foundation in the Health Belief Model
The Health Belief Model (HBM) is the oldest individual behavioral theory that remains one of the most popular theories used in public health practice today. At its core the HBM explains behavior as an outcome of perceived susceptibility, severity, benefits, barriers, cues to action and self-efficacy (7). The “Make the Call. Don’t Miss a Beat.” campaign is grounded in the belief that if women are educated on the symptoms of a heart attack they will be able to accurately assess perceived susceptibility and severity, while measuring perceived benefits and barriers and finally they will act and call 9-1-1 based on self-efficacy. The HBM model focus of this campaign simply implies that with education of symptoms women will make a good decision to call 9-1-1.
The HBM line of thinking is flawed because, it assumes that women will make the rational decision to call 9-1-1 if they feel cardiac symptoms – especially in novel moments accompanied by high stress. In a study conducted by Moser et al., only one-third of patients of either gender initially attributed cardiac symptoms to a heart attack, most thought they were experiencing a gastrointestinal incident or believe symptoms to not be serious and hoped they would go away (3). People will often dismiss signs of a heart attack wanting it to be signs of something less serious and consequently women will often delay calling 9-1-1. As Moser et al. discovered in their study, only 9% of women called 9-1-1 as their first reaction to symptoms, most tried taking medication to remedy the pain, simply tried to relax or prayed symptoms would go away (3). While a person having cardiac symptoms knows they’re in pain they will often act irrationally and make excuses to why they can’t be having a heart attack. This may be due to optimistic bias, which causes people to think they are at less risk of getting a heart attack compared to others; optimistic bias often defeats rationality and has a great influence on initial reactions to cardiac symptoms (8). The campaign’s foundation in the HBM fails to consider environmental factors that similarly prohibit rational decision-making. Common reasons why women delay care are not wanting to trouble others or feeling that they have other responsibilities to their children and family that are more important and can’t be delegated to anyone else (3).  Others also cite reluctance to call because of potential embarrassment if symptoms turned out not to be serious and thus creating a “fuss” in the neighborhood (1). These factors often will have more of an influence on decision-making than knowledge of the “right” thing to do when symptoms arise.
Because the campaign is based on the HBM it focuses on the symptoms and asks women to assess their susceptibility. Its limited approach therefore does not take into account women's attitudes about heart attacks or perceptions regarding 9-1-1 or emergency medical services. Results of many qualitative studies found that a majority of women questioned perceive heart attacks to be mainly a male problem (1). Studies show that women often will resist calling EMS or 9-1-1 when they feel the symptoms of a heart attack. “Make the Call. Don’t Miss a Beat.” focuses solely on the message to call 9-1-1, that it doesn’t take women’s concerns about EMS into account. Many don’t understand the benefits of EMS over having family drive them to the emergency room and have general negative feelings about it. For instance, African American women are more likely to be distrusting of EMS/9-1-1 and have negative feelings about it (1). These perceptions could cloud a women’s judgment when deciding whether or not to take action regarding symptoms. A more successful campaign would address these perceptions and attitudes to help women understand their risk of heart attack and the best way to get help.
Flaw 3: Campaign Message Open to Reactance 
            Reactance theory is centered around the idea that when people’s freedom is threatened they experience reactance, which is a state that motivates them to restore this freedom (9). This explains why threatening messages often have a “boomerang effect” and people chose to engage in the forbidden alternative (10). The core message of the PSA and even the name “Make the Call. Don’t Miss a Beat.” inspire reactance because they tell the audience what to do. The campaign is all about repeatedly telling women “Don’t make excuses” and  “Make the call” or “Call 9-1-1” (4). The narrator’s condescending tone and message of “Don’t make excuses if you feel this way” are paternalistic, giving the PSA a degree of dominance that also inspires high reactance.  The main message of this campaign is important and is expressed quite explicitly, but because it is presented in a domineering way it may actually deter women from listening and acting.
Proposed New Campaign: An Improved “Make the Call. Don’t Miss a Beat.”
The main component of the “Make the Call. Don’t Miss a Beat” campaign is education on cardiac symptoms in women; hopes are that this education will ultimately motivate women to call 9-1-1. However, evidence shows that symptom experience among women is actually more similar than different to men’s and therefore this new campaign should focus less on identifying exact, atypical symptoms (6). Needless to say the message and approach of this campaign needs to change if the ultimate goal is for more women to seek care. The focus of the new campaign instead will be on behavioral theories and models that can have an effect on the decisions women make to call 9-1-1 when they feel persistent pain and cardiac symptoms. The three new strategies of improving the “Make the Call. Don’t Miss a Beat” campaign are to re-frame the issue and assign a core value, shift the foundation from the outdated HBM to social expectations and labeling theory and to create a PSA that incorporates a story and connects to women without creating reactance.
Creating an Effective Frame
A major fault in the “Make a the Call. Don’t Miss a Beat” campaign is the way the issue of seeking care for heart attack symptoms is framed. What essentially makes a strong frame is a strong core value, which is missing from this campaign’s main message. To improve the campaign I would ground the new framing of this issue in the core value of family. Most women heavily value family, which explains why women often find themselves, surrounded by family when cardiac symptoms strike and why some women express delaying care due to their first responsibility to their family (3). Framing acting on heart attack symptoms around family is an improvement on the initial campaign because it takes into account the environment and context of most heart attacks. The core position would be that if you are feeling unusual and persistent pain it may be a heart attack; you want to take care of your family and you and your family can do this by calling 9-1-1 to save your life. The catch phrases would still remain “call 9-1-1” but incorporate phrases like “unusual and persistent pain,” “family.”  The metaphor would be that this is similar to flights when the flight attendants tell you to put your own mask on first in case of a change in air pressure before attending to children. As for symbols and images I would make the campaign more two-dimensional by moving away from depictions of symptoms and show images that relate to the core value – image of children, spouse and love.
Replacing the HBM Foundation
            The ultimate reason why this campaign will fail is because it is grounded in the HBM and therefore does not account for women’s attitudes or perceptions about heart attacks and assumes people are rational and make rational decisions. The HBM fundamentally promotes education as a way to elicit behavior but research shows that education alone does not lead to action (11). With all the faults of the HBM, I believe the issue this campaign seeks to address would best be grounded in the social expectations theory because it addresses the highly social nature of man that is ignored in the current campaign. Social expectations theory in media communication is based on the idea that the media conveys the rules of social conduct that individuals remember and this information directly impacts behavior (12). The way that social expectations theory could operate for this issue is that media could be the means to convey a rule of social conduct – calling 9-1-1 when symptoms arise. Norms are general rules that are known and understood by the general public (12). Media and ads are a great agent to either establish or change norms; currently this campaign isn’t creating an effective positive norm. The new campaign would focus on creating a positive norm of calling 9-1-1 when symptoms arise through positive labeling.  A research study by Rosenfeld identified two decision trajectories used by women when they experienced cardiac symptoms; those who were “knowing” and knew immediately they would seek care and those who were “managing” and minimized their symptoms/created alternative hypotheses (13). The women in the “knowing” group had shorter delay to seek care and had a more defined perception of heart disease threat (13). These results show that if the campaign for “Make the Call. Don’t Miss a Beat.” altered the norm, delaying care, and labeled role models in ads as women who are in the “knowing” group the campaign may be effective in decreasing delay to care. If the general public acts by norms, labeling women and family members as “knowing” would have a positive effect in women calling 9-1-1. When people are part of this “group” they take ownership in the norms that the group promotes and they take action when symptoms strike. Health care providers could take part in this positive labeling campaign by questioning women about what to do if cardiac symptoms arise and educating them if they do not know. At the end of the session women would get a certificate or sticker that certifies them as a knower. Being a “knower” promotes a behavior that is advantageous not just for women at risk but for all of society. When this campaign is centered on social expectations and labeling theory the social context, irrational thinking and attitudes/norms about heart attacks and seeking care are all considered, which is why this new approach is a great improvement on the HBM.
Limiting Reactance
            The “Make the Call. Don’t Miss a Beat.” PSA is very focused on telling women what they should do if they feel symptoms of a heart attack. A narrator delivers the PSA message with a high degree of dominance and while the women depicted in the PSA are close to the target audience, the women and they’re symptoms are placed out of context. The PSA as it is now, has a domineering message, which only inspires reactance and there’s very little connection to the audience that makes women want to act after seeing it.
To avoid psychological reactance, a new PSA for the campaign would be centered on a story. A good model for the new PSA that avoids reactance that is the Go Red for Women PSA “Just a Little Heart Attack” staring actress, Elizabeth Banks (14). The PSA features Banks as a busy mom getting her kids ready to leave the house when she starts feeling tightening of the jaw and pain in her arm. The symptoms persist and she seems to be a little disoriented. Her son mentions that she might be having a heart attack to which she responds, “Do I look like the type of person who has a heart attack?” Her son then hands her a phone with symptoms listed and she immediately decides to call 9-1-1 explaining she may be having “a little heart attack.” When she discovers that help will be there in two minutes she looks around at her messy house and asks if they could come in ten instead.
            What this PSA does well, which will be emulated in the new PSA is it portrays symptoms of a heart attack through a story of a relatable woman – most women can identify with this busy lifestyle or look back on a time when they had small children. The PSA also references attitudes and perceptions that women often express regarding heart attacks like low risk perception and that EMS cares about their messy house – but despite all these worries she does the right thing and calls 9-1-1. The woman is also a good role model because once she identifies the symptoms on her phone her immediate reaction is to call 9-1-1. The message of this PSA also really resonates with the audience because it incorporates a sense of humor and features a celebrity - both of which make it a memorable ad. Presenting the ad with a sense of humor not only defeats reactance but also portrays the woman as in control and the experience itself seems not as frightening as it is commonly portrayed.
“Make the Call. Don’t Miss a Beat.” is a national educational campaign that seeks to education women on atypical symptoms of a heart attack and inform them to call 9-1-1 if these symptoms arise. This campaign is so focused and framed around education that it completely ignores the context and environment that these cardiac events occur in and its domineering messages inspire reactance. A new approach to this campaign would be to frame the issue of calling 9-1-1 for cardiac symptoms around family and how this action will allow women to be there for their family in the future. The new campaign would also feature PSAs that include stories that reaffirm women’s fears and attitudes, but reduce fear about what to do when symptoms arise. Finally the campaign would seek to create new norms through positive labeling with the aim for women and their families to become “knowers” who call 9-1-1 immediately when cardiac symptoms.

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