Use of Mass Communication by Public Health Programs in Nonmetropolitan Regions

Mass communication is one component of effective public health program implementation (1). It includes news stories (“earned media”), paid media (advertising), and social and digital media (eg, social networking sites, text messaging, mobile applications, websites, blogs) (1). Earned media can increase the visibility of public health issues and support from community members and leaders (1). Sustained media campaigns are recommended population approaches to modifying diet, physical activity, and tobacco use behaviors (2). Mass communication using various channels has helped increase public awareness, knowledge, attitudes, and behaviors on a multitude of health topics (3,4).

To understand what contributed to successful communication efforts in nonmetropolitan regions, we conducted individual, 60minute telephone interviews with personnel overseeing programmatic activities ("program managers") and mass communication activities ("communication leads") in 6 REACH/PICH programs. These programs achieved or exceeded annual communication objectives and dedicated at least 10% of annual funding to mass communication. Each interviewed program worked in municipalities with populations of 250,000 or less across multiple US Census regions. Two were tribal programs. By uing a semistructured interview guide, programs were asked open-ended questions about the challenges, opportunities, and promising strategies they encountered when implementing mass communication in small and mid-sized communities. Inductive qualitative analysis identified 4 emergent themes.

Theme 1: Building Capacity for Mass Communication
For most interviewed programs, the perceived value and role of communication activities grew over time. Hiring communication staff or consulting services built long-term communication capacity. Increasing program capacity for mass communication had the potential to inform the organization more broadly, especially when staff who had gained communication training and experience advanced within the organization or worked across programs or grants.
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Theme 2: Partners
Community-based organizations, local agencies, hospitals and educational systems, nonprofit entities, and local businesses may partner -formally or informally -to complement one another's efforts. Programs worked with existing partners to increase the reach of communication efforts. Program partners were reliable and motivated to work with programs to promote messages and materials. Improving the communication capacity of partners was viewed by some as a method to achieve sustainability of program efforts.
Determining a core vision and aligning communication strategies advanced efforts of partner coalitions. Programs noted that many key partners for communication efforts were unpaid but shared similar goals. These partners frequently shared messages on behalf of the programs, expanding reach to audiences that may otherwise be less accessible.

Quotes regarding partners
Unpaid program partners were reliable and motivated to work with programs to promote messages and materials.
We didn't have too many paid partners. It was more of "grassroots for the betterment of the community" partner, or it was an initiative that directly benefited their audiences or their membership or their group According to programs, operating in a less populous area has advantages for mass communication. Programs felt it was relatively easy to access existing networks for communication activities in nonmetropolitan regions using existing networks to involve partners and access channels for mass communication. In small, closeknit communities, these relationships were frequently useful and reliable avenues for message dissemination.
Special considerations apply to the selection of communication channels in nonmetropolitan regions. Programs serving rural areas noted that channels designed to maximize reach in larger markets (eg, television or outdoor advertising) need to be carefully considered in less populous regions. For example, billboards lack exposure if placed in areas without heavy traffic flow, transit advertising is not relevant in areas with limited to no public transportation, and television and radio broadcasts may reach beyond the key population or geographic region, or alternately, may not reach isolated areas. Programs frequently used alternative, often economical, channels to communicate to these audiences, including social media posts and paid messaging on social media platforms, local-access or cable-access television or radio, internet radio programs, podcasts, newsletters, and mass mailings. Almost all refined and expanded their social media presence during the fund- REACH programs emphasized the importance of allowing cultural contexts to guide program planning, implementation, and mass communication when addressing health disparities. Celebrating and embracing the cultural roots of the community can empower and encourage community members in the process of communicating about public health programs. According to interviewees, consideration of cultural and spiritual aspects like language, ethnic background, church events, and cultural practices reinforced powerful community connections and improved message dissemination. Programs valued the involvement of community members in the cocreation and testing of messaging, particularly when program staff were not from the same social and cultural backgrounds as audiences. The tribal programs emphasized the importance of considering the unique attributes and infrastructure of tribal communities in all aspects of program planning and implementation, including approaches to mass communication.

Quotes regarding cultural competence
Celebrating the cultural roots of the community empowered and encouraged community members in the process of communicating about public health programs.

Discussion
Small-to mid-sized public health programs may be unsure of the feasibility of using mass communication in their program activities. REACH/PICH programs in nonmetropolitan regions demonstrated the successful use of mass communication strategies to promote and support programmatic efforts. The experiences suggest that nonmetropolitan communities can achieve communication objectives through various adaptive approaches, frequently leveraging local partners, networks, and resources.
Undertaking mass communication for public health programs requires defined objectives, understanding the audiences to reach and the best channels and strategies to reach them, and evaluation methods to track changes over time -each grounded in health behavior change and communication theory (7). To implement mass communication activities successfully, programs can hire dedicated communication staff and external media contractors with public health experience and use a mix of cost-effective media channels and categories to reach key audiences.
Audience research using established methodologies -such as focus groups, in-depth interviews, or surveys -supported the creation of mass communication approaches that reflected the local contexts of the communities in which the programs operated. Culture has been identified as an influential factor in how message content, structure, sources, and channels are perceived and received by key audiences, and is associated with multiple facets of health behavior (8). Health programs can look beyond epidemiological and demographic characteristics (eg, age, race/ethnicity, geographic boundaries) to consider culture when understanding key audiences (8). Incorporating cultural aspects into mass communication efforts can increase the salience of health messages and programs offered in communities.
These examples illustrate that it is feasible for public health programs in nonmetropolitan regions to increase internal capacity for mass communication to reach target audiences. CDC provides resources on health communication and social marketing for public health programs that are applicable in nonmetropolitan settings (9). These program experiences may inform future research and evaluation to identify the most effective communication strategies in these settings. With dedicated technical assistance and resources, programs serving small to mid-sized populations can develop communication activities that increase internal capacity and gain organizational support for communication, establishing the groundwork for sustaining communication efforts.