Advocacy Groups as Agents for Change in Health and Risk Messaging
Summary and Keywords
Advocacy can be defined as the systematic process set in motion by an individual or group of individuals to encourage, support, and empower others surrounding a topic in need of change. Individuals may become an advocacy group in support of an issue, such as health care, civil rights, environment, or labor. Advocacy groups often serve as mediators between vulnerable/underprivileged populations and policymakers or decision-makers. The Health Communication Advocacy Model (HCAM) is a tested advocacy model comprising five phases including assembling the team, formative research, message development, message implementation, and evaluation. HCAM also includes a correction loop allowing for revisions of campaign messages. The HCAM is an adaptable model that offers a perspective in which advocacy groups may be considered a dynamic framework for building successful campaigns. Once the advocacy group is established, members can agree upon goals and responsibilities and craft a position statement. The group can then develop messages to reach the intended target audience(s). Target audiences may include legislators, the population affected by the issue, and media organizations. When crafting messages, care should be taken to ensure messages are stimulating, motivational, culturally consistent, resource contingent, and without barriers. Advocacy groups may use a number of channels to send messages through, such as social media, rallies, press releases, and other media outlets. Overall, advocacy groups must address a variety of needs to effectively reach the target audiences and impact change.
Definitions and Background
Advocacy is the systematic process set in motion by an individual or group of individuals to encourage, support, and empower surrounding a topic in need of change. Some terms and activities often associated with advocacy include activism, campaign, champion, educate, give voice, lobby, and promote. The concept of advocacy is used in a number of ways within health promotion (Carlisle, 2000). It can act as a vehicle through which opposing viewpoints can be mediated and mutually beneficial goals met. It can serve as a support mechanism for individuals to improve and take control over their own health by learning how to advocate for policy. In health promotion, advocacy is commonly considered a lobbying activity that seeks to address structures in which inequalities exist (Carlisle, 2000).
Advocacy is regularly thought of in a political context, which includes efforts aimed toward policy (Obar, Zube, & Lampe, 2012). Lobbying is a type of advocacy that is specifically geared toward influencing legislation by communicating with policymakers or legislators in an attempt to encourage them to support a cause or forward the proposition to others (Almog-Bar & Schmid, 2014; Salamon & Geller, 2008). Although lobbying often is considered synonymous with advocacy, it is important to note the distinction between the two concepts. Advocacy is a broader term that can encompass a number of aspects. Table 1 describes many types of advocacy that are not mutually exclusive as many advocacy groups overlap in structure.
Table 1. Types of Advocacy Groups
Type of Advocacy
Example of Advocacy Group
Patient Advocate Foundation
Citizens advocacy supports individuals to act on behalf of themselves and addresses how services are provided to individuals by institutions (Mattson, 2014).
National Court Appointed Special Advocate Association (CASA)
This type of advocacy consists of influencing the individuals involved in legislative decision making (Almog-Bar & Schmid, 2014).
Friends of the Earth
Grassroots advocacy is similar to indirect advocacy and includes activities such as protests and media campaigns directed at influencing individuals to contact legislators and decision makers.
Black Lives Matter
Health advocacy focuses on rights related to health care and the health of community members, and has interest in encourage policy surrounding quality of health care (Mattson, 2014).
March of Dimes
Indirect advocacy focuses on nonprofit advocacy efforts and encourages citizens to participate or act on behalf of a goal (Almog-Bar & Schmid, 2014).
Legislative advocacy aims to create change through the state and federal governments by communicating with legislators (Almog-Bar & Schmid, 2014).
Family Impact Institute
Media advocacy is the process of dissemination information through mass media to gain support for social or public policy initiatives (Wallack, 1994).
Berkeley Media Studies Group
In contrast to self-interested organizational advocacy, progressive advocacy focuses on nonprofit interests and addresses power inequities, while involving nonprofit constituents in the advocacy activities (Almog-Bar & Schmid, 2014; Donaldson, 2008).
Fostering Progressive Advocacy- Foundation
Self-advocacy involves individuals acting on behalf of oneself in support of their own rights (Gray & Jackson, 2002).
Self-Advocates Becoming Empowered (SABE)
Self-interested organizational advocacy
Related to lobbying, this form of advocacy is aimed at protecting agency funding (Almog-Bar & Schmid, 2014).
Federation of American Societies for Experimental Biology
Shock advocacy is a type of citizen advocacy that aims to raise awareness and promote change by using graphic images in their messaging (Mattson, 2014).
Applying the Health Communication Advocacy Model
The Health Communication Advocacy Model (HCAM) is a tested advocacy model that advocacy groups may consider as a dynamic framework for building a successful campaign (Mattson & Lam, 2015). It can be used as a foundation that outlines steps that advocacy groups consider in order to achieve their goals and can be adapted according to the type and goal of the advocacy group. The model comprises three phases plus a correction loop that allows for backtracking and revision along the campaign process. Group members should feel empowered to adapt the model to best suit their advocacy goals. The first phase includes assembling the team and defines who, when, and what is relevant to the advocacy group. The second phase includes formative research and message development. Specifically, during the second phase the assembled team identifies target audiences, develops theory-based messages, and determines a marketing mix that must be pretested. The third phase requires an advocacy team to implement and evaluate messages. During the third phase messages are disseminated to target audiences, and both the process and outcomes are evaluated. At this point in the model the campaign is either deemed successful or unsuccessful in meeting the campaign’s objectives. If the advocacy team succeeds, members will inform and update the affected populations. If the advocacy team does not succeed members will enter the correction loop. This step allows members to “correct” the campaign efforts and cycle back through phase two and phase three as needed. The following sections have been organized according to these phases in order to guide researchers and practitioners through the process of a health campaign led by an advocacy group.
Establishing the Advocacy Group
An advocacy group is a collection of individuals or groups formed to act in support of a topic that is perceived to be underrepresented and in need of change. The topics advocacy groups focus on include (but are not limited to): health care, civil rights, environment, and labor (Obar, Zube, & Lampe, 2012). Any advocacy issue may be addressed within a community but may reach beyond a local level and address state, federal, or even international governments. Members of advocacy groups can include those individuals affected by the issue that is being advocated for as well as those who wish to serve as representatives for affected populations. Advocacy groups often serve as mediators between vulnerable/underprivileged populations and policymakers or decision makers (Almog-Bar & Schmid, 2014). Understanding group dynamics and establishing an advocacy group are important first steps in the advocacy process. Two relevant group dynamic theories are reviewed followed by considerations for developing an advocacy group.
Bona Fide Group Theory
Putnam and Stohl’s (1990) Bona-Fide Group Theory takes a communication perspective on systems theory to understand the dynamics of small groups. One characteristic of a bona-fide group is that it has stable yet permeable boundaries. The permeability of a group’s boundaries, which considers the constantly changing nature of group membership, takes place through communication between groups, intersections of formal member roles, how group members interact within informal roles, and variability of membership. Boundaries are necessary to define and guide the group, but it is important that these boundaries are not too rigid as to hinder group flexibility and creativity. Group boundaries must also not be too permeable to allow being controlled by other groups (Putnam & Stohl, 1990).
Another characteristic of bona-fide groups is interdependence with immediate context. This means that intersecting communication and interpretations within and between groups stems from how a group contributes and relies upon the environment of a system of groups (Putnam & Stohl, 1990). There is a close connection between the characteristics of stable yet permeable boundaries and interdependence with immediate context within bona-fide groups. This type of group commonly changes in membership because individuals choose to be members, and these members also are affected by their membership within other groups to which they belong. For example, a health advocacy group could comprise several members who come from a variety of backgrounds. Members could be doctors or experts on the particular health topic for which they are advocating. Also, there could be group members who are physically and/or mentally affected by the health issue. For example, the Amputee Coalition of America (ACA) is composed of physicians and members coming from a range of professions, as well as amputees and nonamputees who may serve as caregivers. Considering bona-fide groups in an advocacy context can help researchers and practitioners understand how small groups function, are influenced, and vary in member commitment.
Weick’s Model of Organizing
Many advocacy groups focus on health-related issues, such as promoting nutrition, exercise, and avoiding drugs and other unhealthy habits. Karl Weick’s model of organizing can aid in understanding the role of communication in health promotion campaigns. Built upon the theoretical foundations of sociocultural evolutionary theory, information theory, and systems theory, Weick’s model looks at the organizing process and how organizational members maintain a balance between hierarchical levels and managing information to promote health (Kreps, 2009). Organizational members work to process information and disseminate coherent messages for others. The concept of information equivocality addresses how group members must appropriately respond to and make sense of the ambiguity of information in order for a health campaign to be successfully understood (Kreps, 2009).
To deal with the complexity and ambiguity of information, the model identifies the communication processes of rules and cycles (Kreps, 2009). Rules provide guidelines for how to interpret and respond to an input, and cycles consist of message interactions that make highly ambiguous information less complex enabling the organization to process the information. Weick’s model prescribes that the lower equivocality of the message, the less need there is for cycles and the more group members can rely on rules. Within this model, rules and cycles exist in each of the three communication phases consisting of enactment, selection, and retention (Kreps, 2009). In the enactment phase, group members attach meaning to information they obtain by recognizing the level of equivocality and then apply rules and cycles in order to process the information. During the selection phase, members observe which rules and cycles are normally used by others and then choose which rules and cycles to adopt. During the retention phase, individuals store information about how other group members communicate for dealing with situations in the future. Through this process, members can learn from experience about how best to formulate health promotion messages to effectively reach their audience. For example, the Price-Pottenger Nutrition Foundation (PPNF) aims to educate individuals as well as professionals about healthy eating and lifestyle habits in order to promote overall health. They acknowledge that the amount of information available about nutrition can be daunting, so they offer a number of classes and seminars to help people learn how to manage their health.
Considerations for Advocacy Groups
The members of the group all play a crucial role in the success of reaching the goals described in the position statement. Consequently, in many types of advocacy groups there are people or organizations that are key contributors to the team. Some of these include health issue experts, community partners, public health and/or communication specialists, and lobbyists (Mattson & Lam, 2015). Health issue experts hold knowledge within a specialized area, which can help the advocacy group fact check and avoid mistakes while also establishing the group’s credibility. Health issue experts may include physicians and nurses who have academic knowledge but also may be patients who have experiential knowledge about a particular health issue. Community partners may consist of organizations such as unions, clinics, and associations that help to build a coalition to promote the issue for which the group advocates. Collaboration is an important aspect of an advocacy campaign because it supports the advocacy effort with further knowledge and resources that contribute to the success of the group. For example, public health specialists have training in public policy and community health while communication specialists can help tailor effective messages to the target audiences, making both types of individuals valuable in advocating around health issues. Finally, lobbyists have ties to legislators and the policy community and their experience influencing policy change may provide vital political power to an advocacy group. Advocacy groups may also collaborate with others due to religious or other ideological reasons. Each group should evaluate their unique advocacy goals when selecting individuals or other groups to provide assistance.
Once an advocacy group assembles, members must agree upon goals and responsibilities (Mattson & Lam, 2015). One critical component of an advocacy group is its position statement, which includes the group’s standpoint and goals pertaining to the advocacy issue of interest. The position statement may include an aim to pass a law, forward a legislative bill, or a combination of multiple related goals. An example of a position statement from an advocacy group called Physicians for a National Health Program (pnhp.org) asserts their goal is “to educate physicians, other health workers, and the general public on the need for a comprehensive, high-quality, publicly-funded health care program, equitably-accessible to all residents of the United States.” This organization “advocates for universal, comprehensive single-payer national health insurance” and collaborates with physicians and other health-care workers as well as the public to accomplish their goal. Their position statement clearly outlines the mission and goals of the organization. Following is a table of some advocacy groups and their position statement.
Table 2. Advocacy Group Position Statements
Name of Health Advocacy Group
Brief Description of Their Position Statement
Action on Smoking and Health (ASH)
“To be a prime mover in domestic and global tobacco control through advocacy, communication, the force of law and our essential partnership with the Framework Convention Alliance for Tobacco Control.”
American Cancer Society (ACS)
“The nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.”
Amputee Coalition of America (ACA)
A non-profit organization that aims “to reach out to and empower people affected by limb loss to achieve their full potential through education, support and advocacy, and to promote limb loss prevention.”
Community Oncology Alliance (COA)
“A non-profit organization dedicated to advocating for community oncology practices and, most importantly, the patients they serve.”
Doctors Without Borders USA (also called Medecins Sans Frontieres—MSF)
“Help people worldwide where the need is greatest, delivering emergency medical aid to people affected by conflict, epidemics, disasters, or exclusion from health care.”
March of Dimes (MOD)
“To improve the health of babies by preventing birth defects, premature birth and infant mortality.”
National Association for Biomedical Research (NABR)
“Dedicated solely to advocating for sound public policy that recognizes the vital role animals play in biomedical research.”
Physicians for a National Health Program (PNHP)
“A single issue organization advocating a universal, comprehensive single-payer national health program.”
Price-Pottenger Nutrition Foundation (PPNF)
A non-profit education foundation committed “to teach the public and professionals about foods, lifestyle habits, healing modalities, and environmental practices that can help people attain vibrant health.”
“Dedicated to achieving a culture where all youth and young adults reject tobacco. We speak, seek and spread the truth about tobacco through education, tobacco control research and policy studies, and community activism and engagement.”
Women’s Health and Action Research Centre (WHARC)
“Educates women, youth, community gatekeepers and policymakers about sexual and reproductive health, and advocates for policy change at the local, state and federal level.”
World Alliance for Breastfeeding Action (WABA)
“To protect, promote and support breastfeeding worldwide in the framework of the Innocenti Declarations (1990 and 2005) and the Global Strategy for Infant and Young Child Feeding through networking and facilitating collaborative efforts in social mobilisation, advocacy, information dissemination and capacity building.”
Advocacy Message Development
Identifying Target Audiences
All advocacy groups act in support of a topic perceived to be in need of change, but each group develops a unique team of individuals and a tailored position statement. Each advocacy goal is geared toward a specific target audience, and strategic messages must be designed to effectively support an identified topic. The HCAM emphasizes three target audiences for advocacy groups attempting to change policy, which include legislators, relevant populations, and media organizations. Although the HCAM was created to assist in the process of policy change, other advocacy groups can attend to these same audiences in their work. However, when determining target audiences for any advocacy effort, target audience selection should be strategic. Target audiences should complement one another and try to make achieving the defined position statement an attainable goal.
The HCAM identifies legislators as a target audience for advocacy groups to send messages. Legislators often are connected to a large network, and these connections may be of use to groups advocating for a cause. This audience can advance policy change at the local, state, federal, or international levels, which may result in significant strides toward achieving advocacy goals. To take advantage of available legislative skills, advocacy groups must carefully plan attention-gaining strategies to reach this audience. There are two recommended methods for influencing legislators. First, elected officials value the welfare and support of their constituents. Therefore, framing messages from this perspective can help win the support of policymakers. However, secondly, legislators want to put forward their own agenda. Therefore, framing the position as personally relevant to the official’s goals will encourage support (Mattson & Lam, 2015). There are often many factors that influence policymaking and implementation, including conflicting interests, and therefore messages must sometimes consider how the policy can benefit decision makers in other areas. Although this group’s primary objective is to advance policy, legislators may be a valuable target audience for many types of advocacy groups and so these considerations can be taken into account. Advocacy groups should develop rapport with relevant government officials to help support the group’s advocacy effort (Mattson & Lam, 2015). For example, the March of Dimes effectively reaches relevant legislators by targeting both local and federal policymakers.
Forming relationships with legislators serves a purpose beyond policy change on behalf of an affected population. Funding is becoming more and more competitive, and advocacy efforts often require monetary resources to achieve desired goals. Many human service nonprofit organizations rely on funding from government agencies not only to achieve goals but also to sustain daily operations. Advocacy groups’ increased reliance on funds provided by policymakers shifted how organizations advocate and what they advocate for. Advocacy groups must walk a thin line to balance sustainable organizational operations and create needed change for an identified population. This reliance on the target audience heightens the need to create lasting relationships with legislators. These relationships work best when both parties sense a history of trust and interdependence (Mosley, 2013). To build this relationship, an advocacy group must consider what issues are relevant and important enough to warrant the legislators’ attention (Mattson & Lam, 2015). Groups can review future meeting agendas, current policy goals, and officials’ position statements to determine current topics and then tailor messages with the intention of satisfying mutual interests. The March of Dimes achieves this goal by targeting federal policy proposals to match the congressional session agenda. The organization advocates for funding of programs already in place to ensure their advocacy goals are continuously met. For example, in the 114th Congress a top federal priority includes renewing the Children’s Health Insurance Program (CHIP).
The HCAM also identifies relevant populations as target audiences for advocacy groups. Relevant populations include groups directly and indirectly affected by the advocacy issue. These groups vary widely depending on the advocacy team and its position statements. Those directly affected by a health issue often are the most enthusiastically supportive of an advocacy effort because of their direct experience and related perception that their situation warrants change. The advocacy group should engage with the directly affected population in order to correctly identify and meet the needs of these individuals. However, it is important to note this group may not have the means to directly support the advocacy effort. Instead, indirectly affected populations may contribute more resources to the advocacy effort. Indirectly affected individuals have a second-degree connection to the advocacy issue and often care for the directly affected individuals or group. Indirectly affected members may include family members and/or caregivers of the directly affected. The advocacy team should recognize potential burdens and use relevant strategic communication strategies when targeting those indirectly affected by a health issue (Mattson & Lam, 2015).
Advocacy group members should keep in mind there may be more than one indirectly affected subgroup. Each subgroup may hold different beliefs of the correct way to support the directly affected population. Consider the March of Dimes as an example. This advocacy group directly and indirectly supports a host of other subgroups, such as current and future parents and caregivers of infants. The organization also recognizes the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health’s (NIH) work in children’s health advocacy. These organizations all identify similar goals in their position statements and can work together to achieve agreed-upon solutions. Regardless of challenges, the engagement on behalf of directly and indirectly affected individuals may make or break an advocacy effort. Advocacy group members must use creative and sustainable strategies to capture the attention of and engage with relevant populations.
The HCAM also identifies media organizations as an audience for advocacy groups to target messages. Media organizations specialize in information dissemination through a wide range of channels. Media outlets skillfully disseminate messages to a large group of people in a short period of time. Advocacy groups can potentially gain support for their cause and come closer to achieving defined goals with the help of media amplification. New advocacy groups may find it challenging to build rapport with the media. However, there are three approaches a group can use to creatively gain attention. First, the group can pay a premium to gain visibility. Secondly, the group can construct messages that positively reflect the advocacy goal while enhancing the media’s public image. Thirdly, the group can propose a sponsorship plan to the media organization. The advocacy group can offer to advertise for the media during the advocacy effort as a strategy to gain air time (Mattson & Lam, 2015). Before choosing a method, however, several considerations should be made. If the group plans to pay for air time, sufficient monetary funds must be available. This can be challenging especially if the advocacy effort takes a long time to conclude. If the group plans to enhance its media’s image, careful attention should be made to preserve the authentic mission of the advocacy effort. Altering messages to appease third-party groups can negatively affect the advocacy goals to help a disadvantaged population. If the group proposes a sponsorship, careful attention should be paid when selecting potential outlets. Advocacy groups may inherit the public opinion toward selected media outlets by nature of the partnership. Groups should use this to their advantage and choose outlets that are positively viewed by other stakeholders.
After target audiences are identified, the model suggests that the advocacy team assess the dissonance between the position of each target audience and advocacy goals. Formative research can help bridge this gap and provide all parties reason to care and act in support of the advocacy group’s position. Conducting formative research involves the advocacy group collecting statistics that outline the prevalence, problems, and forecast of the health issue. The action of conducting formative research allows the advocacy team to develop credibility and create a backdrop for persuasive messages. It would be beneficial for the advocacy team to gather information specifically related to the identified health issue. To identify the prevalence of the problem, the group can start on a global scale and then narrow the research scope to the national, and then the more localized, area of interest (Mattson & Lam, 2015). The advocacy team should first conduct an extensive search of accessible information. The CDC and the World Health Organization are valuable resources for groups to begin collecting macro-level formative research. Groups can use the state or local health department to find relevant micro-level information. After a meticulous search, the advocacy team can determine if the information warrants a continuation of their effort. If the information does provide enough evidence to support advocacy messages, the team can forecast the current health issue.
If the gathered information does not sufficiently provide enough support to warrant the defined position statement, this does not necessarily mean the advocacy effort is not needed. The group could also conduct novel research to further determine the issue’s prevalence. Groups that are economically disadvantaged may consider applying for a research grant or petition the support from an academic with vested interest in the topic area. Quantitative and qualitative approaches to research can be used to paint the most accurate picture of the health issue under review. Qualitative approaches can include interviews and focus groups, while quantitative approaches include distributing a survey or using an experimental design to identify a need for change. After methods for data collection are selected, the team must follow through with collection and build an argument that exemplifies the current problem. Selected evidence including statistics should use clear reasoning and not purposefully skew data in favor of a certain point of view. For example, the March of Dimes displays a series of press releases and reports on their website to help create a need for advocacy action. In addition to providing research, these written documents and videos help to disseminate messages that inform their target audiences.
After the team constructs an argument, they can begin forecasting the current health issue. This step requires the group to connect pieces of information that link the identified problem with the defined position statement and create relevancy for target audiences. To achieve this, the advocacy group should clearly identify the short-term and long-term effects while outlining a realistic solution. The outlined plan must provide target audiences enough efficacy to engage with the proposed solution (Mattson & Lam, 2015). After this connection of information has been made, the advocacy group can begin the messaging process.
The messaging process requires groups to use communication theories and concepts to develop and revise messages that align with the previously defined position statement. Groups should construct several messages with the intention of reaching different audiences through a variety of outlets. Messages should vary but also reiterate strategic core arguments. Although negotiating policy outcomes is important, careful message framing can help audiences reach the desired outcome. Communication used in advocacy activities such as lobbying, dialogue, and negotiation include carefully crafted messages to address the advocacy group’s goal, and lobbying efforts can serve as the vehicle for these messages. Advocacy groups may make specific demands and then work with policymakers to revise them to address conflicting interests, budgets, logistical circumstances, and other details. Communication theories, such as the Extended Parallel Processing Model (EPPM; Witte, 1992) can help guide message construction and provide advocacy efforts the greatest chance for successful persuasion. Although the ultimate goal of advocacy efforts is persuasion, messages should abide by ethical codes to ensure target audiences support the advocacy goals with a clear understanding of the health issue.
Advocacy groups must present all identified audiences with a well-developed, consistent frame to best gain support for the perceived issue. Legislators can use illustrative frames to argue for policy options. Media gatekeepers can use frames to create effective news reports (Nisbet, 2015). Also, adequate message framing will help directly affected and indirectly affected populations understand and engage in an advocacy effort. The directly affected and indirectly affected populations should be considered the primary audiences throughout an advocacy effort. These audiences must understand the messages in order to support the advocacy group’s mission. Oftentimes, those directly affected are members of a vulnerable population, which can exacerbate challenges in the messaging process. Vulnerable groups can include the elderly, health-care consumers who are minorities (ethnic or otherwise), those socioeconomically challenged, and immigrants (Kreps, 1986). These individuals often experience significant health literacy challenges making it difficult to make sense of and apply relevant health information (Kreps, 2005; Gazmararian, Williams, Peel, & Baker, 2003). Engaging with this population through messages will require the advocacy group to utilize audience-analysis strategies (Kreps, 2002b). The advocacy group could also encourage members of the directly affected and indirectly affected populations helping to create messages as members of the target community will know what appeals work best for reaching individuals similar to themselves. Once the team understands the target audience’s beliefs and values, messages can be designed. It is important to note that this process can be complex, time-consuming, and appropriate for some circumstances but not for others. There is a diverse array of policymakers and stakeholders, each including issues of power and different interests. It is likely messages will go through several rounds of revisions as feedback from target audiences are provided.
Crafting Effective Messages
The HCAM describes five aspects that advocacy groups need to consider to create effective messages. Messages should be stimulating, motivational, without barriers, culturally consistent, and resource contingent to reach the target audience (Mattson & Lam, 2015). It is important to note that although communication campaigns also use messages to raise awareness, advocacy campaigns often create messages to persuade a target audience to take specific action, such as to change policy. First, stimulating messages grab the target audience’s attention. The team should choose channels that present messages in dramatic and memorable ways to encourage audience attention (Kreps, 2002a). Social media provides a medium for groups to target their messages using text, images, audio, video, or a combination of these elements and reaches a large audience of people for a relatively low cost (Obar et al., 2012). Second, messages should motivate the audience. Motivational messages use a pathos appeal, and these messages typically tap into the emotions of fear, anger, and guilt (Mattson & Lam, 2015). Third, messages should eliminate barriers between the target audience and the plan of action. Members of the directly affected population may belong to a vulnerable population, and special attention should be paid so the message can reach them. Not only must the message reach the target audience, to be effective the target audience must have the cognitive ability to understand the message. To ensure comprehension, messages should be adapted for language and health literacy challenges (Chew, Bradley, & Boyko, 2004; Hardin, 2005; Kreps, 2006; Parker & Kreps, 2005). Fourth, messages should remain culturally consistent with the target audience. Advocacy groups must exhibit cultural sensitivity when crafting messages, which greatly affects a message acceptance by the audience. Different groups, sub-groups, and individuals all hold a unique set of health beliefs, values, norms, and expectations. Understanding these differences will enable the advocacy group to tailor messages that are relevant to the target audience to achieve a desired response (Kreps & Kunimoto, 1994). Lastly, messages should consider available resources on behalf of the target audience. Vulnerable populations often experience a high number of inequities that may prevent completion of a desired action (Gray & Jackson, 2002). Advocacy groups must rely on formative research and audience analysis to design messages that best meet the needs of the target audience. The EPPM is one approach to designing messages that may be effective.
Extended Parallel Process Model
Advocacy groups often use persuasive messages to reach their target audience and encourage action. The target audience in this case can mean a number of people and/or groups, such as citizens, policymakers, officials, among others depending on the goals of the advocacy group and will therefore be referred to generally as “audience.” This does not indicate that there is no two-way dialogue between the advocacy group and the audience, but the group should consider who they are creating their messages for in order to appropriately address them. The use of threat and risk, as well as provocation tactics, are often used in advocacy. One type of persuasive strategy is a fear appeal, which aims to scare individuals into doing something by showing them the deleterious effects that will result by not taking action (Witte, 1992). An example of a fear appeal is an anti-smoking commercial featuring a person with a stoma in his or her throat. Witte’s Extended Parallel Process Model (EPPM) expands on fear appeals by adding an additional element, efficacy. This theory builds from Leventhal’s (1970) parallel process model framework to distinguish between danger control and fear control. Danger control allows the audience to focus on the solution by perceiving that they have power over the outcome, whereas fear control prevents the audience from seeing past the problem because it is perceived as being too severe and unmanageable (Gass & Seiter, 2011). The EPPM suggests that along with showing a vivid image of a smoker with a stoma, a message should appear that provides efficacy for possible smokers never to start or current smokers’ efficacy to quit.
According to the EPPM, a message receiver advances through three stages of cognition when evaluating a message. The message receiver first evaluates if a perceived threat exists, next perceived efficacy is determined, and as a result of these perceptions either danger or fear control occurs. Ideally, advocacy groups utilizing fear appeals construct messages that the targeted receivers process and as a result of perceiving risk and efficacy, they enter danger control and take constructive steps to reduce the risk of harm (Gass & Seiter, 2011). During the first stage of cognition the target audience member determines if a perceived threat exists. The theory states an audience rating of personal susceptibility and severity will lead to a decision of whether or not to continue processing the message. In order to encourage the targeted audience to perceive a threat, attention-gaining strategies should be used (Witte, 1992). The EPPM claims that failure to persuade the targeted audience of susceptibility and severity of the danger results in no further processing of the message.
If the target audience determines that the threat meets susceptibility and severity criteria, the message enters the second stage of cognitive processing, which is assessment of efficacy. Perceived efficacy consists of self-efficacy and response efficacy. Self-efficacy includes the audience’s belief in their ability to execute the desired behaviors (Witte, 1992). Response efficacy refers to audience’s belief that the response advocated in the message will actually mitigate the undesired effect. For example, in a campaign advocating for policy change regarding energy drink labels, response efficacy would be the audience’s belief that labeling all included stimulants and reducing energy drink packages to one serving size would reduce the number of emergency room visits due to over-consumption. Similar to the evaluation of susceptibility and severity, target audiences must perceive response efficacy and self-efficacy to continue cognitively processing the advocacy message.
During the third stage of cognitive processing, an audience uses previous reasoning of the perceived threat and perceived efficacy to come to a conclusion. The EPPM states that intensity of responses is influenced by the perceived threat, while the process of danger control or fear control is influenced by the perceived efficacy (Witte, 1992). An audience entering into danger control perceives that the threat is worth managing (perceived threat) and that they are capable of managing the response (i.e., perceived efficacy). Audiences that do not enter this danger control, instead enter fear control. Often an audience subconsciously reaches fear control because they interpret the message as too severe (i.e., perceived threat) and no longer feel a sense of control (i.e., perceived efficacy) to change the outcome. According to this theory then, advocacy groups using fear appeals should aim for the target audience to enter into danger control, and if the audience appears to be entering fear control the messages should be revised by increasing perceived efficacy and decreasing perceived threat. Although the EPPM offers an analytic framework that some advocacy groups can use to achieve their goals, it is important to note that the model does not encompass a broad area of risk communication. In other words, it offers one way in which messages may be crafted to reach an intended audience, but there exist other ways in which advocacy groups can think strategically about using risk information.
Overall, advocacy groups are granted more freedom than journalists to construct persuasive messages, however, advocacy groups should still refrain from providing the public with erroneous arguments in favor of the health issue. For example, an advocacy group could choose to use provocative tactics or fear appeals to gain attention and in the process may exaggerate the issue, which can result in an ethical dilemma. Creating effective and ethical messages is a difficult process because there are many perspectives and considerations. Advocacy groups should keep in mind applicable ethical guidelines when constructing persuasive appeals. There are many formal ethical guidelines already created that advocacy groups can adopt and follow while advocating for policy change or advocating for a cause. The most important factor to group ethics is choosing a standard and following it. Founder of the Institute of Global Ethics, Rushworth Kidder, proposes nine “checkpoints” for ethical decision making, including: (1) fully understand the moral issue, (2) identify the groups making decisions and their platform, (3) review the situation from a factual lens, (4) determine if a right and wrong answer exists, (5) determine if the ethical issue may include two equally ethical options, (6) create some guiding principles to create a stance on the issue, (7) if no choice stands out as the best option, create a new choice. This step is especially useful if only two good choices or two bad choices exist), (8) decide on a solution, and (9) evaluate the decision made and learn from the experience (Johannesen, Valde, & Whedbee, 2008). Following these ethical guidelines can help an advocacy group achieve goals while abiding by an agreed-upon moral code. Even with careful attention to ethics, complications may arise. In the event of controversy, groups should remain open to addressing issues and adjusting messages.
After messages are constructed that follow ethical guidelines and support the defined position statement, the advocacy group can begin brainstorming marketing tactics. The marketing mix, initially proposed by Borden (1964), provides strategies for proposing a plan of action accessible to the identified audiences. The marketing mix consists of product, price, place, and promotion and is especially useful for health campaigns. For example, the Truth Initiative works to inspire tobacco-free lives by targeting youth populations and in the summer of 2016 joined Vans Warped Tour to get their message out to youth attending the music festival that travels the country.
Product refers to the ways in which the proposed health advocacy effort is presented to the audience. A product is simply described as the mission of the advocacy group. The mission of the Truth Initiative includes “achieving a culture where all youth and young adults reject tobacco.” The product should be appealing to the audience and may need to be revised to persuade the target audience to change behavior. The organization uses education, research, and activism to achieve this ambitious advocacy goal.
Price refers to psychological, monetary, energy, or opportunity costs. Groups should be aware of what they are asking of audience members and try to mitigate potential burdens on their audience. The Truth Initiative targets adolescents because tobacco prevention is easier to achieve than addiction recovery. The organization asks students and young adults to get involved in their organization by using Truth Initiative resources to change tobacco use in their local communities. For example, the organization offers grants and scholarships for students to help pass policy on higher education campuses to eliminate tobacco usage. This allows students to gain valuable experience while alleviating monetary costs. Literature in social marketing suggests allowing the target audience to voluntarily change their behavior will result in behavior change (Andreasen, 1995; Grier & Bryant, 2005; Kotler, Roberto, & Lee, 2002).
Place refers to the location where audiences can go to translate motivation into action. Social marketing describes places as where the target audience will enact the desired behavior and obtain related tangible resources (Kotler, Roberto, & Lee, 2002). The place is not necessarily a geographical location although it can be, but Internet sites also are considered a place where audience members can become active in the advocacy effort. The place should be chosen based on the specific call to action while eliminating as many barriers as possible for audience members. During the summer of 2016, the Truth Initiative brought their campaign to at-risk youth attending Vans Warped Tour. The organization promoted their position statement and reached their target audience by attending a music festival where youth gather in celebration.
Promotion includes the action of presenting the audience with the health advocacy product. Through promotion the advocacy team should aim to raise awareness of the advocacy effort. Promotion can be approached from several angles and all options should be considered before selecting the best methods to reach the audience. The Truth Initiative’s decision to participate in the Warped Tour festival allows their advocacy products to be easily promoted. Throughout the day organization representatives host games for festival attendees to participate. The winners of each game are given fun promotional material that provides young adults efficacious strategies to avoid tobacco. The organization also effectively promotes their advocacy message in a clear and engaging way through their website, www.truthinitative.org.
A critical step in the message development process includes pretesting messages and the marketing-mix strategy. This step helps avoid a failed marketing attempt that could be costly or could hurt the advocacy group’s credibility for future advocacy efforts (Brown, Lindenberger, & Bryant, 2008; McKenna & Williams, 1993). Advocacy groups must consider communication objectives and ask target audience members whether the messages are effective. To accomplish this, the group should reach out to various representatives from each target audience and ask for feedback about the advocacy messages. Target audience representatives can report on whether the messages are comprehensible, inspiring, appropriate, culturally consistent, credible, and ultimately well received and persuasive (Brown et al., 2008). The advocacy group also can pretest media channels with each target audience for feedback on accessibility and persuasive appeal (Kreps, 2002b). Based on pretest results, changes can be made to the messages and the channels if necessary before implementation of the campaign. If pretesting indicates that significant changes need to be made, the group can cycle revised messages through the pretest process again until confident to implement messages. When confidence is achieved, the advocacy team can disseminate their tested message to the target audiences (Mattson & Lam, 2015).
After the advocacy group incorporates message feedback received from pretesting, the full marketing strategy can be implemented. The advocacy group can uniquely target the messages to each defined audience and monitor the dissemination success as the process moves forward through specific public relations strategies and tactics (Wilcox, Cameron, & Reber, 2015). Some considerations in choosing a channel through which to spread messages include cost, reach, efficiency, and accessibility (Atkin, 2001). One way to disseminate messages to the media is to hold a rally. Rallies bring vested people together to raise awareness about a topic (Mattson & Lam, 2015). Vested people may include those directly and indirectly affected by the topic. Participants passionate about the topic often utilize sensationalist props to gain attention and share their message. For example, participants may hold attention-getting banners with catchy slogans and shout advocacy messages through loudspeakers. Strategic selection of a geographical location can also aid in effectively presenting the advocacy message. For example, if an advocacy group wanted to gain the attention of legislators and the media, the group could consider holding a protest in front of a city hall building. The media’s interest likely will be piqued if the advocacy group takes an expressive approach. Another way to increase opportunities for media exposure is to inform relevant media outlets of the advocacy event. A press release including necessary information such as time, location, and purpose can be disseminated and serve as an invitation for media to attend. The advocacy group can prepare for media attention by selecting individuals to serve as representatives of the issue and engage in dialogue with reporters. To ensure a successful interview the interviewee should prepare clear statements that exemplify the advocacy group’s position (Mattson & Lam, 2015).
For example, the Indiana Amputee Insurance Protection Coalition utilized a rally and successfully gained media attention. On a winter day in Indiana a group of Amputee Coalition supporters gathered outside the statehouse in an attempt to attract attention to their efforts. By chance a reporter saw their demonstration and approached the advocacy team to ask questions. Members shared their story and got substantial media attention.
When disseminating messages to relevant populations, an advocacy group can use the media’s strengths to reach these populations. Ideally, following a rally the attending media sources will share the advocacy group’s position with their audiences. If careful selection was used when inviting media outlets, members of relevant populations will be exposed to the story. Often issues covered by the media are considered by their audiences to be more legitimate, serious, and urgent (Wallack & Dorfman, 1996). However, advocacy groups must not only rely on this medium to reach relevant populations but also must try and become involved in the community and engage with those affected by the issue. A facilitated community town hall can provide an advocacy group the opportunity to build trust, forecast the current health issue, create a need for involvement, and provide efficacy for target audience participation in the solution.
When disseminating messages to legislators an advocacy group can use media amplification and constituent well-being as persuasive tools. Legislatures care about their constituents’ health needs and are often willing to act on behalf of these individuals if they make their requests clear. Legislatures can be directly targeted through the use of a rally as well. For example, the advocacy group can schedule the rally to occur at or near a relevant government building. Ideally, the targeted officials will see the rally and potentially engage with participants face to face. Interpersonal communication can catapult the advocacy goals if the participants are prepared to share their story, need, and call to action. Media coverage of the rally also may also attract attention to legislatures.
Advocacy groups can put health needs on policymakers’ agendas by using another attention-gaining strategy. A petition signed by an array of constituents will help legislators understand their voters are requesting change. Social media provides a medium for advocacy groups to distribute a short message and solicit support through an online petition. Further, social media sites allow groups to create a brand and share user-generated content. The advocacy group can heighten their credibility by creating a transparent profile for the public to view. The group should also share their message in a variety of ways. The message content can be text, images, audio, video, or a combination of these elements. The online platform allows many people to become involved in the empowerment effort while keeping the cost of participation relatively low. However, the group should carefully consider its social media platform of choice. Social media outlets target various demographics and these outlets are continuously shifting in popularity. Choosing sites that are popular and accessible to target audiences will help elicit the desired response.
Discussion of the Literature
Past Approaches in Researching Advocacy Groups
Extant research on advocacy groups and health campaigns is sparse, leaving abundant opportunities for scholars to fill the gap. However, interest in these topics is growing along with a recent surge in research. Historically, there are few scholars who have paved the way for future inquiry. For example, in 1968, Rothman proposed three models of community organization practice to serve as a framework for understanding community interventions. These models consist of locality development, social planning, and social action; they concern issues of participation, decision making, and mobilization of individuals, respectively. Cnaan and Rothman (1986) used these models as a starting point to investigate the professional work of individuals who engage in community organization. They pointed out the variations in the conceptualization of community organizing and the need for more empirical research in the field. Their findings revealed that interventions may employ a combination of the three models and that social action may be more complex than originally thought, prompting the need for further research on these concepts. Pilisuk, McAllister, and Rothman (1996) later looked at grassroots community organizing and the role it plays in the global-information society and social movements, addressing concepts of social action, locality development, and empowerment. Despite efforts to curb grassroots organizing, the authors argued that these community groups continue to emerge to promote social change.
Health campaigns also have been studied in terms of their message content and delivery. McKenna and Williams (1993) previously looked at messages developed by the Center for Disease Control and Prevention Office on Smoking and Health and tested their effectiveness with young teens. They found that the messaging approach was not appropriately received, leading to some misinterpretations. Their findings showed the importance of research in the health campaign process to ensure that messages are clearly understood. Similarly, Carlisle (2000) researched advocacy in health promotion, pointing out that health promoters must consider the type of framework that works best for their specific advocacy need. Kreps (2002a, 2002b, 2005, 2006) also considered various methods of communication in health, studying aspects such as the role of technological tools in health promotion and the dissemination of information to hard-to-access audiences and underserved populations. The research done by these scholars and others have helped to set the stage for more recent work in the areas of health advocacy and advocacy group development.
Recent Research on Advocacy Groups
Much 21st-century research addresses how the advocacy field is shifting due to external factors and how these factors affect advocacy outcomes. Mosley (2013) brought attention to the increasingly competitive nature of government funding which causes advocacy groups to adjust their approach in order to increase their chances of receiving monetary support. Advocacy groups are becoming more collaborative and introducing advisory boards or steering committees to help serve underprivileged populations. This collaborative governance approach allows not only nonprofit administrators to be involved in initiating change but also human service providers and other change makers. Mosley proposes that this shift encourages advocacy to become more common, cooperative, and collaborative. However, this shift may also invite third parties in who may try and exploit advocacy efforts for personal gain.
Obar, Zube, and Lampe (2012) also addressed social media’s role in changing how groups approach advocating. Social media is merely user-generated content that can be presented in the form of text, images, audio, video, or a combination of these mediums. From a research perspective, social media is hard to define because of the continuous ebb and flow of popular cites and when described social media achieves similar results to traditional media. Functionally, online communicative tools including e-mail, chat rooms, and bulletin boards allow advocacy groups a chance to organize themselves and rapidly gain global support for little cost. If used appropriately, social media can change how target audiences engage within their communities and collectively act in support of an advocacy effort. However, special care should be taken when designing messages that are written as one voice from the perspective of the advocacy group. These messages must take into account potential knowledge gaps and encourage personal relationships to develop between the group and target audience.
These challenges provide an opportunity for health communication scholars to provide insight into how to best advocate for a position. Strategic communication strategies can help inform consumers of health information and encourage healthy decision making. Knowing how to best serve target populations is not an easy task. Through the Center for Health and Risk Communication of George Mason University, Kreps et al. (2013) attempted to ease the burden for advocacy leaders. The Global Advocacy Leadership Academy (GALA) provides training, skills building, and support for individuals leading the initiative better to public health. This organization hosts in-house advocacy groups and travels globally to provide training for advocacy groups wishing to sharpen their communication tool kit in order to find ways to help those who need it most.
However, not all advocacy groups have the resources to go through extensive training. For smaller or newly formed groups, Mattson and Lam (2015) explained how the Health Communication Advocacy Model (HCAM) provides advocacy groups with a tool to guide ideas through the advocacy process. This model is tested and has been used to initiate policy change at the state level. In her own life Mattson used the model to transition self and individual advocacy to group advocacy. What started as a tragic accident snowballed into a campaign to help other amputees receive funding for prosthetics through their insurance.
Future Directions in Advocacy Work
As research on advocacy groups and health campaigns continues to grow, so does the need for future study in these areas. A number of recent calls have been made to further understand advocacy efforts and how they can be most effective. For example, Almog-Bar and Schmid (2014) called for more attention in the area of policy advocacy and perceptions of nonprofit leaders and how they work with the government to influence change. Additionally, more research should be done to understand the decision-making processes behind advocacy groups with regards to their goals and messaging approaches, as well as the impacts these decisions have on policy change. Mosley (2013) also called for an improvement in the practice of advocacy, suggesting further research particularly in areas of the role of the organization in advocacy, everyday collaborative interactions about advocacy, input from legislators and other social work advocacy end users about effective advocacy efforts, and the perceptions of social service advocacy efforts. Empirical research on other advocacy-related topics have been proposed as well, such as the use of social media for facilitating advocacy work and how nonprofits can create strategic messages and effectively engage in advocacy.
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