Are social marketing campaigns effective in preventing child abuse and neglect?

Overview

Social marketing campaigns are a common strategy for raising awareness about social problems such as child abuse and neglect. However, questions have been raised about the role social marketing campaigns could play, and their potential efficacy in the prevention of child abuse and neglect and in supporting vulnerable children and families.

In this NCPC Issues paper, evidence for the impact of media-based social marketing campaigns related to child protection, parenting and child abuse prevention are examined.

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Introduction

Child maltreatment continues to be a significant social problem in Australia and many other nations. The best available data suggest that between the ages of 0-18 years: 5-10% of children experience physical abuse; around one-in-ten are emotionally maltreated; 12-23% witness family violence; and 4-8% experience serious (i.e., penetrative) sexual abuse (Price-Robertson, Bromfield, & Vassallo, 2010). There were 55,000 cases of child abuse or neglect investigated and confirmed by child protection services in Australia in 2008-09 (Australian Institute of Health and Welfare [AIHW], 2010).

Media-based social marketing campaigns have been identified by the World Health Organisation as having the potential to contribute to the prevention of child maltreatment (World Health Organization [WHO], 2006). Social marketing involves the application of commercial marketing techniques and technologies to "influence the voluntary behaviour of target audiences to improve their personal welfare and that of society" (Andreasen, 1994, p. 110). A media-based social marketing campaign could contribute to the prevention of child maltreatment by raising public awareness of the issue and educating and fostering pro-social behaviours within families.

This Issues paper presents the results of a systematic review of literature about social marketing campaigns related to the prevention of child abuse and neglect, and to parenting problems. The paper aims to identify the characteristics of campaigns in this area and the evidence regarding their effectiveness.

What is social marketing?

Social marketing differs from other branches of marketing in that it relates to the wellbeing of the community (rather than the wellbeing of the marketer) (Donovan, 2005). The fundamental goal of social marketing campaigns is to bring about behavioural change (Andreasen, 2003). This can range from encouraging people to change a specific behaviour on their own (self-regulation) to seeking professional help about a difficult problem. Social marketing draws from a broad range of social sciences for the purpose of influencing people in socially desirable ways and generating social good (Donovan & Henley, 2003; Stead, Gordon, Angus, & McDermott, 2007).

Social marketing campaigns are generally categorised according to whether they appeal to positive motivations and emotions in order to bring about the desired behavioural change (referred to as "incentive appeals") or whether they rely upon fear to bring about the desired behavioural change (referred to as "threat appeals") (Henley, Donovan, & Moorhead, 1998; Henley & Donovan, 1999).

It has been proposed that effective social marketing include strategies that target change in social environments, communities, social policies and legislation, rather than solely relying on individuals to change their behaviour (Donovan & Henley, 2003; Siegel & Doner, 1998). For example, the Ottawa Charter for Health Promotion (WHO, 1986) and more recently, the Bangkok Charter for Health Promotion in a Globalised World (WHO, 2005) recommended that contemporary public health social marketing campaigns invest in the social and environmental determinants of health and welfare, stating that: "people cannot achieve their fullest health potential unless they are able to take control of those things which determine their health" (WHO, 1986). According to Donovan and Henley (2003) a social marketing campaign that targets social structures will be more likely to produce a "social good" (p. 6).

Although social marketing campaigns aspire to achieve social good there can be potential for unintended harm to occur (Donovan, Jalleh, Fielder, & Ouschan, 2009). For example, there has been concern from some sectors that social marketing campaigns with "hard-hitting" content (i.e., graphic, emotive and/or shocking content) can be damaging in certain contexts. As an illustration, a media campaign that was intended to reduce violence against women and featured depictions of gratuitous violence was criticised for being potentially counter productive (i.e., promoting violence rather than discouraging it) (Donovan et al., 2009, p. 7). Social marketing campaigns that utilise hard-hitting content to address child sexual abuse are especially fraught, as they have the potential to expose children to traumatic themes and images and re-traumatise child sexual abuse survivors (Australian Centre for the Study of Sexual Assault [ACSSA], 2010). Social marketing campaigns with hard-hitting content have been the subject of heated debate in Australia (Donovan et al., 2009; ACSSA, 2010).

Public health and law enforcement are the main fields that have conducted social marketing campaigns in Australia. Social marketing emerged during the 1970s as a strategy to communicate messages about social issues, with topics related to hygiene, family planning and attitudes towards women (Donovan & Henley, 2003). During the 1980s, social marketing in Australia became established as an approach to educate the public and target individual behaviours. Social marketing campaigns at this time targeted drink-driving, heart disease prevention, and increased use of car seatbelts. By the 1990s health-related behaviours dominated the Australian social marketing field, such as Quit campaigns (anti-smoking) and the famous "Grim Reaper" advertising (HIV/AIDS) (Rigby, Brown, Anagnostou, Ross, & Rosser, 1989; Scollo & Winstanley, 2008). Social marketing campaigns related to child maltreatment are one of many competing for public attention in a crowded media environment (Randolf & Viswanath, 2004).

Advertising is a core element of social marketing and is most useful where there is a lack of awareness about a social issue. One of the benefits of social marketing campaigns that include a mass media advertising component is that they are likely to increase public awareness, irrespective of the specific aims of the campaign. It has been argued, however, that advertising alone is not as effective in bringing about population-wide changes as a social marketing campaign that is incorporated with a broader set of intervention strategies (Wise, 2000). According to this perspective a social marketing campaign that includes, for example, advertising and a community-capacity building component or advertising and the provision of practical support is likely to be more effective at bringing about population-wide changes than an advertising campaign alone.

The public health model and social marketing targeting child maltreatment

Tertiary child protection services in Australia struggle to meet the needs of children in need of statutory intervention as well as the needs of children and families who are below the threshold for child protection intervention (O'Donnell, Scott, & Stanley, 2008). The National Framework for Protecting Australia's Children (Council of Australian Governments, 2009) recognises the current challenges for statutory child protection services and has a strong focus on prevention, operationalised through an adoption of a public health approach to preventing child abuse and neglect. In a public health approach, statutory child protection services are a last resort (tertiary intervention), with the bulk of support for families served by universal health and welfare services (primary prevention). Additional services are then provided for more complex concerns (secondary prevention). Interventions for issues such as parental substance misuse or mental illness, also act as sites for early intervention and prevention of child abuse (O'Donnell et al., 2008).

A public health approach to child protection interventions also provides a useful model for social marketing campaigns that intend to address child maltreatment and parenting issues (Allen Consulting Group, 2009; Tomison & Poole, 2000). In a public health approach, universal social marketing campaigns that target the whole community or all families are a form of primary intervention. These interventions support the safety and wellbeing of all children. An example of this would be a mass media campaign targeting parents and other adults to be aware that they are modelling alcohol-related behaviour to children when drinking alcohol in their presence. Secondary level social marketing interventions can seek to address risk factors to prevent child maltreatment and escalation of parenting problems, for example, a campaign about how risky alcohol consumption (e.g., binge drinking) can negatively impact the quality of parenting while intoxicated and/or hungover. A social marketing campaign can be designed as a tertiary intervention for the purpose of reducing harm to children and preventing the recurrence of maltreatment, for example, a campaign that aims to educate drink-driving offenders with child passengers of the harm to children if they are in a collision. It is also possible for a social marketing campaign to combine more than one type of intervention.

Developing a social marketing campaign

A range of theories and approaches could inform the development of a social marketing campaign. A public health approach can inform the decision regarding the target audience (e.g., primary, secondary or tertiary intervention) and health promotion theory can also be used to inform the way in which a social marketing campaign is developed and implemented. When considering the key steps involved in a social marketing campaign the Precede-Proceed model is especially useful. Developed by Green and Kreuter (2005) in the 1990s and updated in 2005, the Precede-Proceed model proposes that health promotion interventions should be multi-dimensional and participatory at an individual and/or community level in order to be effective (Lin, Smith, & Fawkes, 2007).

The Precede-Proceed model has four sequential stages:

Assessing the needs of the population - assessing the social, environmental, educational and policy contexts behind the social issue, drawing on demographic information and knowledge of community needs and priorities to assess the needs of the population (DiClemente, Crosby, & Kegler, 2009; Lin et al., 2007);
Selection of an appropriate theory - theories of individual and community change provide the logic for designing a social marketing campaign, guiding the definition of the social problem, planning a solution, implementing and evaluating the campaign (Nutbeam & Harris, 2004);
Implementation - implementing the program as planned utilising the strategies deemed appropriate to the program objectives (Nutbeam & Harris, 2004); and
Evaluation - assessing whether the campaign has been effective and whether it should be continued, modified or discontinued (Egger, Spark, & Donovan, 2005).

In the following sections the final three stages of the Precede-Proceed model are explored (selecting an appropriate theory, implementation and evaluation) in order to illustrate the stages involved in the development of a social marketing campaign and the models that could be used to guide social marketers through these stages. (The first stage, the special issue of child maltreatment, has been addressed above.)

Selecting an appropriate theory

One or more theories of individual or community-level change could be selected to inform the design of a social marketing campaign. This section presents the main theories for generating individual and community-level change that are commonly applied to social marketing campaigns (see Table 1 below).

**Table 1**. Theories of change associated with social marketing
Theory	Description
Individual change
Health Belief Model	Individuals will change their behaviour when they perceive there is a threat to themselves, there is personal benefit to be gained and they have self-efficacy to make the desired change.
Theory of Reasoned Action and Planned Behaviour	Behaviour can be predicted by people's intentions. An individual's attitudes, subjective norms (perceived approval/disapproval of others and motivation to comply) and perceived behaviour control can be influenced to change intentions and behaviour outcomes.
Social Cognitive/Social Learning Theory	Based on the premise that behaviour is a product of interactions between an individual (especially their self-efficacy) and their environment. Role modelling, observational learning and expectations of positive or negative reinforcement are key concepts for behaviour change.
Stages of Change Model/ Trans-theoretical Model	There are five stages in the process of change: pre-contemplation, contemplation, preparation/determination, action, and maintenance. One or more stages can be targeted in social marketing interventions. Acknowledges that behaviour change is a process.
Community change
Diffusion of Innovation	Introducing a new idea, practice or product into a community. These campaigns emphasise "newness" and benefits of adopting the innovation to appeal to community groups.
Community Organisation	Involving a segment of the community (community coalition) in problem solving and planning social marketing interventions for social issues.
Community Building	Also known as locality development and community capacity, this involves building capacity and empowerment across the whole of community. It emphasises enabling communities to help themselves.

Note: The information in this table was adapted from the following sources: Baum (1998); DiClemente et al. (2009); Lin et al. (2007); Noar (2005-2006); Nutbeam & Harris (2004).

The theories of individual change in Table 1 assume that awareness, knowledge and attitudes influence a person's behaviour (Nutbeam & Harris, 2004). Persuading an individual to change their behaviour relies on their self-efficacy to identify, make and sustain behaviour change. There is an assumption that there will be social gains for individuals who do change their behaviour, such as approval from others and peer acceptance (Nutbeam & Harris, 2004). A social marketing campaign based on individual change is relatively easy to implement and evaluate compared to community-based social marketing. Social marketing that targets community-level change includes more variables, making empirical evaluation more difficult to control (Nutbeam & Harris, 2004).

Implementing a social marketing campaign

There are a number of models that could be used to guide the implementation of a social marketing campaign. The two most influential models are the Four P's marketing mix (Andreasen, 1994) and the Communication-Persuasion Matrix (McGuire, 2001). These models are derived from commercial marketing. Each is briefly described below.

The Four Ps

The Four Ps is an approach to planning and implementing a social marketing campaign adopted from commercial marketing (Grier & Bryant, 2005). The marketing elements of product, price, place and promotion form a marketing campaign strategy (Andreasen, 1994). Some of the elements of the Four Ps approach are similar to the Precede-Proceed model. For example, the Four Ps model suggests that the product (i.e., the behaviour being promoted) should be responsive to the needs and wants of the target audience in the same way the Precede-Proceed model highlights the importance of assessing the needs of the population. A product should offer a solution to the social problem. The place is where the desired behaviour is put into action (Grier & Bryant, 2005). The place where the behaviour is performed needs to be accessible and convenient for the target audience. The price is comprised of social, psychological and economic costs and benefits to the individual engaging in the behaviour. Finally, the product of the campaign needs to be visibly promoted through media or other activities to reach the target audience. This requires a promotion strategy that is compatible with the lifestyle and personal preferences of the audience (Andreasen, 1994).

The Communication-Persuasion Matrix

The Communication-Persuasion Matrix (known also as the Communication-Behaviour Change Model) was developed by McGuire (2001) to guide the development of public education campaigns. It comprises five "input" communication variables:

source - the person, group or organisation delivering the campaign message (e.g., government, non-government organisation);
message of the campaign - including content, tone and form;
channel through which the campaign is delivered, usually involving mass media;
receiver or intended audience for the campaign (requires knowing social and demographic variables, current attitudes and behaviour and media preferences); and
destination - the intended short-term and long-term outcomes of the campaign, such as specific changes in awareness, attitudes and behaviour (McGuire, 2001; McGuire, 1981; Nutbeam & Harris, 2004).

The Communication-Persuasion Matrix provides a model for implementing social marketing strategies, such as: what the message of the campaign should be, what tone the message should take (e.g., hard-hitting or a positive message) and which medium should be used.

Evaluating social marketing campaigns

In the context of social marketing campaigns about child maltreatment, evaluation is important because it can determine whether social marketing campaigns contribute to a reduction in child maltreatment and child abuse and, if so, how they can do so in the most effective way. Without embedding evaluation into the design of a campaign, it is difficult to determine if it has achieved any positive impact on the entrenched social problem of child maltreatment.

It is important to note however, that empirical evaluation of social marketing campaigns is challenging. A lack of access to expertise, technology and resources can impinge upon evaluation efforts. Evaluation can be perceived as diverting precious funds away from an intervention that is supposed to help people, meaning that there can be some reluctance to spend money designing and implementing an evaluation strategy (Tomison, 2000). There may not be the resources for rigorous experimental or quasi-experimental designs across the population that is exposed to the campaign. It is also difficult to isolate the impact of the campaign when there may be other factors influencing the community's attitude about child maltreatment. For example, a highly publicised fatal child maltreatment incident that occurs at the same time a social marketing campaign about child maltreatment is underway could impact upon people's attitudes about child maltreatment.

Systematic evaluation of social marketing campaigns is important, however, as it can provide insight into whether these campaigns are effective. Evaluation evidence is critical to justify the economic costs of a social marketing campaign and, most importantly, to ensure that unintended negative impacts have not occurred and there have actually been positive gains (Grier & Bryant, 2005). Evaluations of social marketing campaigns can also be used to build an evidence base regarding intervention effectiveness, and thereby have the potential to inform future campaigns and influence evidence-informed policy (Greir & Bryant, 2005; Nutbeam & Harris, 2004).

Box 1: Evaluation of social marketing campaigns

There are five main types of evaluation that can be used to evaluate social marketing campaigns (Bauman, 2000; Donovan & Henley, 2003; Hornik, 2002a; Noar, 2006; Nutbeam & Bauman; 2006; Valente, 2001). The types of evaluation reflect the stages of the Precede-Proceed model. These can be used to evaluate specific stages of a social marketing campaign, from design, through to implementation and campaign outcomes.

Formative assessment determines the need for a social marketing campaign in a population. This can involve determining the social problem to be addressed, what the needs of the population are and what type of intervention would be most appropriate for the population. At this stage, a baseline population survey of the community is typically conducted for later comparison with a post-campaign survey.
Pilot (or efficacy) testing is a trial of the social marketing campaign on a sample audience, often to determine if an intervention meets face validity. One of the benefits of pilot testing is that it provides an opportunity to adjust the campaign materials based on feedback from the participants.
Process evaluation evaluates the implementation and dissemination of the campaign. This focuses on the degree to which the campaign was conducted as planned.
Impact evaluation measures the direct, short-term effects of the campaign. This could include measures of mass media exposure and changes in awareness, knowledge or behaviour in the target audience.
Outcome evaluation estimates the long-term effects, if any, associated with the campaign at a population level. This can include cost-benefit analysis. Examples of relevant outcomes include changes in prevalence or incidence rates, ongoing trends in help-seeking behaviour and sustained improvements in awareness, knowledge or behaviour.

Identifying child maltreatment social marketing campaigns

Method

For this NCPC Issues paper, we undertook a systematic literature review to determine whether there was evidence that social marketing campaigns were effective in preventing child maltreatment. In a systematic review, sets of key terms or subject words are used to identify publications in academic databases and websites. The findings are then analysed to form an evidence-base (Petticrew & Roberts, 2006). By using a disciplined, replicable method for searching the literature and synthesising results, systematic literature reviews offer a transparent and reliable account of the current evidence (Littell, Corcoran, & Pillai, 2008). The aims of this systematic review were to:

identify social marketing, media or community education campaigns in the area of child abuse and neglect or parenting problems;
determine the characteristics (including notable strengths and limitations) of social marketing campaigns targeting child abuse and neglect and the factors that are known to contribute to the risk of abuse and neglect occurring (e.g., parenting problems, parental substance misuse, domestic violence in families and the impact of these on children) (referred to as child maltreatment campaigns);
examine whether social marketing campaigns targeting child maltreatment had an effective impact on the awareness, knowledge, attitudes or behaviours perpetuating the social problem that they were designed to address; and
draw conclusions about the usefulness and potential effectiveness of social marketing campaigns for child abuse and neglect prevention in Australia.

Literature searching was conducted between August and December of 2009. For a full description of the search strategy for identifying literature for this paper, including databases searched and the search terms employed refer to the online Appendix.¹

The campaigns

A search of literature identified thirty-six publications about child maltreatment campaigns released between 1995 and 2009. These publications formed the evidence-base for this project (see the online Appendix).² These thirty-six publications described 21 distinct social marketing campaigns that had been implemented between 1995 and 2009. Those campaigns that were evaluated for impact and/or outcome were identified (see Table 2).

**Table 2**. Identified child maltreatment social marketing campaigns*
	Australian	International	Total
Child maltreatment social marketing campaigns	12	9	21
Campaigns with any evaluation	7	8	15
Campaigns with impact and/or outcome evaluation	5	7	12

Note: * Campaigns directly related to child protection, child abuse and neglect or the determinants of child abuse and neglect (e.g., parenting problems, parental substance misuse, the impacts of domestic violence on children). Published from 1995-2009.

¹ See online Appendix.

² Not all the campaigns self-identified as social marketing campaigns. Some of the ways in which they were described included: media campaigns, media interventions, public health and community education strategies and community education media campaigns.

Characteristics of child maltreatment social marketing campaigns

One of the primary aims of this project was to determine the characteristics (including strengths and limitations) of social marketing campaigns targeting child maltreatment. The characteristics of the 21 social marketing campaigns identified are described and examined in terms of:

campaign type according to the public health model (primary, secondary, tertiary);
aim of the campaign (i.e. what does it aim to influence) (awareness, attitudes, knowledge, behaviour);
primary target audience;
stand-alone campaigns (narrow) or part of a broader community-level intervention (broad);
the media mix (television, print);
content - either positive messages (incentive appeals) and/or hard-hitting (threat appeals);
types of evaluation identified (formative, pilot, process, impact and outcome, see Box 1 for definitions);
duration of the campaign;
funding (government, not-for-profit organisation etc); and
paid and/or community (i.e., unpaid) advertising.

For a brief description of each individual campaign see Table 3 (Australian campaigns) and Table 4 (International campaigns).

The table can also be viewed on pages 10–11 of the PDF.

**Table 3**. Australian social marketing campaigns related to child maltreatment
Campaign (year of campaign)	Topic	Type	Aims to influence	Key message	Primary audience	Strategy	Media mix	Content style	Evaluation type	Duration	Funding	Advertising
NEWPIN parenting campaign (n. d.)	Parent support	Secondary	Attitude Behaviour	It is ok for parents to get help.	Parents	Broad	TV, print media	Positive message	None	Not stated	NGOs - originally established by UnitingCare Burnside	Community advertising
Families (Part of Triple-P trial) (n. d.)	Positive parenting	Primary	Awareness Behaviour	Teach parents positive parenting strategies.	Parents	Broad	TV	Positive message	Pilot testing	12-episode television series over 6 weeks1	Not stated	Not stated
It's Not OK to Shake Babies (1994)2	Child abuse prevention	Primary, secondary & tertiary	Knowledge Behaviour	Shaking babies is dangerous and can cause brain damage or death.	Parents	Broad	TV, radio, cinema,	Hard-hitting	Pilot testing Impact evaluation	3 months	Government	Paid advertising
It's Got to Stop (1995)	Impact of domestic violence on children	Secondary & primary	Awareness Attitudes	Domestic violence is not love. Two TV commercials portrayed the impact on children.	All adults	Broad	TV, radio, cinema, print media, phone helpline	Hard-hitting & positive message mix	Impact evaluation	12 months3	Government	Not stated
NAPCAN child abuse prevention media campaigns independent evaluation (1994-2000)4	Child abuse prevention	Secondary & primary	Awareness Behaviour	Overall message to promote effective care and protection of children, including a positive behaviour for adults or parents to seek help for a specific problem.	Parents	Narrow	TV, radio, print media	Hard-hitting & positive message mix	Impact evaluation	Various5	NGO	Community advertising
Accentuate the Positive (1996)	Positive parenting	Primary	Attitudes Behaviour	Promoted positive parenting and normalised help-seeking. Models of positive parenting behaviours, e.g., "praise works wonders".	Parents	Broad	TV, radio, print media, Internet, phone line, resources, community outreach	Positive message	Formative assessment Impact evaluation Outcome evaluation	2 years	Government	Paid advertising
Be Cool ... Not Cruel (1998-99)	Effect of domestic violence on children & young people	Tertiary & secondary	Awareness Attitudes	Domestic violence is not acceptable & help is available for children and young people who experience it at home.	Children & young people (10-15 years)	Broad	TV, print media, information resources, posters, child-friendly consumables (e.g., stickers), phone helpline for children and parents	Positive message	Formative assessment Impact evaluation	Not stated	Government	Paid advertising
Every Child Is Important (2000-04, national 2003-05)	Child abuse prevention	Primary	Knowledge Attitude Behaviour	Children are valuable and need safe, respectful, non-abusive relationships.	Parents	Broad	TV, radio, print media, Internet, resources	Positive message	None	Not stated	Government, corporate and philanthropic sectors	Community advertising
16 Days of Activism: Survivors of Child Sexual Assault (2002)	Child sexual abuse	Tertiary & primary	Awareness Behaviour	Child sexual abuse occurs in the community. People need to believe and support victims who disclose they have been abused.	All adults	Narrow	Posters, postcards, bus adverts, some radio & newspaper attention	Hard-hitting & positive message mix	Formative assessment Process evaluation	16 days (bus advertising was visible for 30 days)	NGO	Community advertising
Child Abuse Hurts Us All (2004-05)	Child abuse prevention	Primary	Knowledge Behaviour	All adults have a responsibility to "play your part, protect our children".	All adults	Narrow	TV, print media	Hard-hitting	None	Not stated	State government	Paid advertising
Children See, Children Do (2006-07)	Child-friendly communities	Primary	Attitudes Behaviour	Adults are always modeling behaviour for children, so adults should have a positive influence	Parents and other adults	Narrow	TV, cinema, Internet	Hard-hitting	None	Not stated	NGO	Not stated
Stop Child Abuse Now (2008-09)	Child abuse prevention & intervention	Tertiary & primary	Awareness Behaviour	Messages of "child abusers are counting on you doing nothing", "stop doing nothing" and a list of 10 actions for adults to intervene and prevent abuse.	All adults	Narrow	TV, radio, print media, posters, Internet, resources	Hard-hitting	None	Not stated	NGO	Paid advertising

Notes:

Parents were provided with 12 videotapes of 20-30 minutes in duration, with a 5-7 minute Triple-P component. They were instructed to watch two of those videotapes in their own home each week.
The National Association for the Prevention of Child Abuse and Neglect (NAPCAN) "It's Not OK to Shake Babies" campaign was also included in the Key Young (2000) independent evaluation of NAPCAN media campaigns. However, the It's Not OK To Shake Babies campaign was separately evaluated in 1995. Therefore, the two publications represent two individual evaluations. Both the NAPCAN (1995) evaluation and Keys Young (2000) evaluation were each located in the Informit (Family and Society Plus) database. The Family and Society database is a bibliographic database that indexes and abstracts articles from published and unpublished material on research, policy and practice issues about, or of relevance to, Australian families from 1980 onwards.
This is the period of time during which three surveys were conducted in order to evaluate the campaign. The first survey was conducted before the launch of the campaign (October 1995) and the last surveys were conducted upon the cessation of the screening of the television advertisements. The date at which the media ceased to show the campaign advertisements is not recorded in the available publications.
There was a range of campaigns included in this evaluation. Six examples of these campaigns are included in the associated publication. It is not clear how many campaigns in total are included in the evaluation.
Two media campaigns in the examples provided include information about duration: the Use Words That Help, Not Hurt national community education campaign and the It's Not OK To Shake Babies campaign. The Use Words That Help, Not Hurt campaign was 3 months in duration. The It's Not OK To Shake Babies campaign was also 3 months in duration although on some television and radio stations the advertisements ran for 12 months.

The table can also be viewed on pages 12–13 of the PDF.

**Table 4.** International social marketing campaigns related to child maltreatment
Campaign (year of campaign)	Topic	Type	Aims to influence	Key message	Primary audience	Strategy	Media mix	Content style	Evaluation type	Duration	Funding	Advertising
Some Secrets You Have to Talk About (1991) (Netherlands)	Children's disclosure of abuse	Tertiary	Behaviour	Message to children that abuse was not their fault, they were not alone and to tell someone.	Victims (children & adolescents)	Narrow	TV, radio, print media, billboards, phone line, child & adult resources	Positive message	Formative assessment Impact evaluation Outcome evaluation	9 months	Community fundraising	Paid TV advertising, TV documentaries and radio. Free newspaper advertising.
Alcohol Abuse, Drug Abuse, Child Abuse, One Thing Leads To Another (1993-94) (US)	Child maltreatment & parental substance abuse	Tertiary & secondary	Knowledge Behaviour	Family members and friends of parents with substance abuse problems can engage in helpful behaviours to stop child abuse and neglect.	Adults who know a parent with a substance problem	Narrow	TV, print media, billboards, posters, phone line	Positive message	Formative assessment Process evaluation Impact evaluation	TV campaign went for a week, other forms of advertising lasted up to 10 months.	Federal Government grant & NGO	Paid TV advertising, newspaper/magazine advertising. Community billboards paid for by sponsors.
Stop It Now (1995-97) (US)	Child sexual abuse	Primary, secondary & tertiary	Knowledge Attitude Behaviour	Perpetrators and parents of young people with sexually abusive behaviours should seek help.	Parents & perpetrators	Broad	TV, radio, print media, bus adverts, Internet, phone line, community outreach	Hard-hitting	Formative assessment Impact evaluation	2 years	NGO	Paid TV, radio and bus advertising
Breaking the Cycle (1995-2000) (NZ)	Child abuse & early intervention	Tertiary & secondary	Awareness Knowledge Behaviour	Appealing to parents that a "change in your behaviour can change the behaviour of your child and make your lives more enjoyable".	Parents	Broad	TV, radio, print media, phone line, resources	Hard-hitting	Formative assessment Pilot testing Impact evaluation	Not stated	Government	Paid TV advertising
It's OK to Talk About Incest (1998) (NZ)	Child sexual abuse & incest	Tertiary & primary	Awareness Behaviour	Incest is a social problem in New Zealand and encouraged victims to get support.	Victims	Narrow	Posters, print media, unpaid media exposure, phone line	Hard-hitting	None	One week	Government	Not stated
Darkness to Light (2001-08) (US)	Child sexual abuse	Secondary & primary	Knowledge Behaviour	Messages on talking to children about sexual abuse, prevalence, consequences of child sexual abuse and how to get more information.	Parents & adults in contact with children	Narrow	TV, resources, Internet	Hard-hitting	Pilot testing	Not stated	NGO	Not stated
Triple-P Parenting Population Trial - included a mass media component (2003-09) (US)1	Positive parenting	Secondary & primary	Knowledge Behaviour	Positive parenting is an effective parenting strategy and it is normal for parents to seek support.	Parents	Broad	Radio, print media, household mail, community events, Internet	Positive message	Impact evaluation Outcome evaluation	2 years	Not stated	Community advertising
It's Not OK (2007-08) (NZ)	Family violence	Secondary & primary	Awareness Attitudes Behaviour	"It's not OK... but it is ok to ask for help" about family violence.	Perpetrators of family violence (fathers)	Broad	TV, media advocacy, print resources, website, information helpline, community projects	Positive message	Formative assessment Impact evaluation	Not stated2	Government	Not stated
Domestic Abuse - There's No Excuse, wave 11: Domestic Abuse Effects Children Too (2007-08) (Scotland)	Domestic violence & effects on children	Primary	Awareness Attitudes Behaviour	Domestic violence effects children too.	General public & mothers	Broad	TV, radio, billboard posters, public relations activity	Positive message	Impact evaluation Outcome evaluation	1 month	Government	Not stated

Notes:

The Triple-P program was developed in Australian and then adapted for an overseas audience.
Funding for the It's Not OK campaign was originally projected to 2011, however at the end of 2009 funding for the final round of the campaign ceased. It is not clear from the available documents when the campaign ceased (it began in September 2007).

Campaign classification according to the public health approach

The majority (16/21) of the social marketing campaigns identified were classified as taking a primary intervention approach, either specifically or in combination with a secondary and/or tertiary approach. For example, the Children See, Children Do campaign (2006-2007) in Australia carried the message that all adults are modelling behaviour to children all the time, and encouraged all adults to consider their behaviour and make their influence on children positive.

Campaigns that had a secondary intervention component (10/21) usually included additional tertiary and/or primary approaches. The secondary approach was most frequently used to appeal to parents to seek support when they were experiencing difficulties that had not yet reached a threshold for statutory child protection intervention. For example, the Triple-P parenting population trial (2003-2009) in the United States involved a mass-media campaign to promote positive parenting, de-stigmatise help-seeking and to recruit parents to participate in a Triple-P program to improve parenting capacity (Prinz & Sanders, 2007; Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009). The various levels of the program engaged parents according to the severity of their problems. Campaigns, like the Triple-P mass-media campaign, constitute a secondary intervention because they offer a way to encourage parents to recognise when they need support and to seek support services before problems escalate to a level of severity requiring statutory intervention.

Nine of the 21 campaigns included a component that could be classified as a tertiary level intervention. Tertiary interventions intended to reach families in which child maltreatment was occurring. For instance the Stop It Now campaign (1995-1997) in Vermont (USA) aimed to appeal to perpetrators of child sexual abuse to seek help. The campaign promoted a confidential helpline and referral to treatment services.

Aim of the campaign

Almost half (10/21) of the child maltreatment social marketing campaigns stipulated that generating awareness among the general community about child abuse or parenting issues was a specific aim. A smaller sub-set of campaigns aimed to change attitudes (9/21) and to increase knowledge (8/21).

As the fundamental goal of social marketing is behaviour change (Andreasen, 2003) it is perhaps not surprising that the most prevalent aim of the campaigns was behaviour change: 19/21 campaigns intended to generate a specific behaviour related to the theme of child maltreatment prevention. Of those campaigns that sought to bring about a change in behaviour some clearly aimed to stop end-behaviour, that is, stop or prevent maltreatment itself (e.g., don't shake babies), others aimed to bring about a change in intermediate behaviour, that is, behaviours that can indirectly influence the incidence of child maltreatment (e.g., teaching positive parenting strategies) and some aimed to influence both intermediate and end behaviours.

Overall help-seeking behaviour was the most common desired action across the campaigns, such as motivating fathers who perpetrate family violence to make contact with a phone helpline service or website (e.g., It's Not OK, New Zealand). Evidence for the effect of campaigns that aim to promote behaviour change is examined further in relation to impact evaluations in section 3 of this NCPC Issues paper.

Primary target audience

The most common primary target audience of child maltreatment social marketing campaigns was "parents" in general (13/21), however one of these campaigns specifically targeted fathers and another specifically targeted mothers. Secondary audiences (not specified in the tabular descriptions above) were targeted at the whole of a community (all adults). Mass media is useful in this sense because it has a wide reach and thereby can communicate with a broad range of people, not just a specific target group (Saunders & Goddard, 2002). It is appropriate that campaigns would seek to appeal to parents given that they have primary responsibility for ensuring the care and protection of their children, however there is limited evidence for campaign messages specifically designed to make protecting children everyone's responsibility.

Only two campaigns were designed to primarily address children and young people. One Australian campaign, the Be Cool...Not Cruel campaign (1998-1999, Northern Territory), aimed to increase awareness amongst children and young people that domestic violence is a problem and that there is help available if they are experiencing domestic violence at home. This campaign included children and young people in the design process thereby potentially strengthening the message of the campaign. This occurred despite some opposition from adults who expressed concern children would "dob in a parent", undermining "their right to have arguments and discipline children" (Rudd & Jacob, 2000, p. 8).

Campaign strategy

Almost half of the campaigns identified (9/21) were implemented along with broader community-level strategies, such as activities that build community capacity or the provision of practical support. Some theorists have argued the social marketing campaigns will be more likely to bring about population-wide changes when coupled with broader community-level strategies (Donovan & Henley, 2003; Siegel & Doner, 1998). It is important to take into account however that a campaign that is implemented along with a broader community-level strategy is likely to require more intensive resources (e.g., time and funding), than a campaign that does not. Not all social marketing campaigns will have the resources available to implement a community-level strategy.

Of the nine campaigns that were implemented along with a broader community-level strategy, the two most common community-level approaches linked the campaign to either government social policy or activities that build community capacity. Three campaigns demonstrated these approaches:

The Domestic Abuse - There's No Excuse campaign in Scotland has been implemented over 12 waves to date as part of their anti-domestic violence policy. This demonstrates the power of government to make a long-term commitment to social marketing as a way to challenge entrenched social norms.
The It's Not OK family violence campaign in New Zealand used a community development fund to sponsor 93 local projects across the country. The projects were intended to engage whole communities and build community capacity to respond to family violence. The strength of this approach was demonstrated by the strong campaign awareness achieved amongst Maori and Pacific communities.
The Accentuate the Positive parenting campaign in Western Australia established parent information resource centres in community shopping areas. This strategy sought to normalise parents' help-seeking behaviour and deliver support for parents in their community.

The media mix

All the campaigns identified in this systematic review used, or had planned to use, some form of media as part of the dissemination strategy. The majority of campaigns used television advertising as the main channel to deliver messages (18/21). Although television was relied upon as the main communication channel, 17 of the 18 campaigns that used television also utilised at least one additional form of mass media, such as print media (newspapers, magazines) and posters or billboard advertising. Using more than one form of media increases the exposure of the campaign and recognises that people often use a range of sources to obtain information (Palmgreen & Donohew, 2006).

Nine out of the 21 campaigns used paid advertising as part of the campaign, five used community advertising, and for seven campaigns the advertising arrangement was not stated in the papers identified. Whether or not advertising was paid is especially significant for those campaigns that utilised television advertising (18/21). Television is a popular source of information for social marketing campaigns with messages about child maltreatment, however the success of television as a medium depends upon the amount of funding available to buy advertising. Relying on television corporations to broadcast advertising for free (community advertising or public service announcements) can be problematic because these advertisements tend to be aired outside normal viewing times (Fuhrel-Forbis, Nadorff, & Snyder, 2009). Australian social marketing campaigns appear to be more reliant on community advertising than international campaigns; only 1/9 of the international campaigns relied upon community advertising compared to 4/12 of the Australian campaigns.

Phone lines and Internet websites were the most common communication channels for people to access further information, directly receive help or be referred to services. Eleven of the 21 campaigns used a phone line and/or the Internet. Half of the 12 Australian campaigns were reported as providing a phone line and/or website for help or information compared to almost all international campaigns (8/9). This may have limited the audience reach of the Australian campaigns.

Campaigns that do not have an associated phone line and/or website may be less likely to bring about individual behaviour change because they do not have an accessible source through which people can begin to seek information or help. Poor utilisation of Internet technology in the campaigns reviewed may partly be explained by the availability and cost of that technology at the time the campaign was undertaken.

Style of the content of the campaign

There was a relatively even spread of hard-hitting (i.e., graphic, emotive and/or shocking content) and positive messages (i.e., positive, affirmative and/or "feel good" content) styles of content across the 21 campaigns; 8 were exclusively hard-hitting, 10 used only soft content and 3 campaigns utilised both hard-hitting and positive message content.

Hard-hitting content was used in the Breaking the Cycle campaign (1995-2000) in New Zealand, which, it is reported, "shocked New Zealanders into debating the issue of child abuse" (Stannard, Hall & Young, 1998: p. 64). The campaign portrayed emotional and physical abuse as a vicious cycle and conveyed the message to parents that they can change their abusive behaviour (Stannard, Hall, & Young, 1998; Young, Rout, Hall, & Stannard, 1999).

An example of positive message content comes from the Accentuate the Positive campaign (1996) in Western Australia. The campaign message conveyed the benefits of positive parenting, including "praise works wonders" and "be firm but fair". The message also portrayed corresponding affirmative emotions (joy, humour, love). Accentuate the Positive has been recognised in social marketing literature as having a positive incentive approach to motivate parenting behaviour change (Henley, Donovan, & Moorhead, 1998).

The evidence from this systematic review does not suggest that hard-hitting content is more effective than positive message content or vice versa. Atkin (2001) claimed that social marketing campaigns that employ positive appeals can bring about more desired behaviours. However, Henley and Donovan (1999) claimed that it is widely agreed that social marketing campaigns that utilise "fear arousal" are effective provided the desired behaviour can be consciously controlled by the audience, and is perceived by the audience as effective - the stronger the threat, the more effective the appeal. In some contexts and with some specific audiences however, positive messages may be more effective (Henley & Donovan, 1999).

The issue of whether hard-hitting social marketing campaigns are effective in reducing child maltreatment requires further investigation. It is a particularly pertinent issue to address in light of the risks of hard-hitting child maltreatment social marketing campaigns to children and to child abuse survivors. These risks, including exposing children to traumatic themes and re-traumatising child abuse survivors, have been highlighted in relation to campaigns that target child sexual abuse (ACSSA, 2010), however it is likely that a hard-hitting campaign targeting other types of child maltreatment would also pose similar risks.

Are social marketing campaigns about child maltreatment effective?

In this section, evidence is examined regarding the extent to which social marketing campaigns targeting child maltreatment had an effective impact on levels of awareness, knowledge, attitudes, behaviours and prevalence of the social problems that they were designed to address. Box 2 below describes the common measures of success applied to social marketing campaigns targeting change in individuals and the broader community. The evaluation of social marketing campaigns is important because it provides an insight into the impact and effectiveness of this approach to reducing child abuse and neglect.

Box 2: Measuring success of social marketing campaigns related to child maltreatment

Raising awareness - measured as awareness of either the level of recognition or recall of the key campaign (campaign awareness) or of the social problem (topic awareness) across the population exposed to the campaign.
Imparting knowledge - an improvement in people's knowledge about what constitutes child abuse and improvement in people's knowledge about the risk factors of child abuse.
Changing attitudes - a measured improvement in people's attitudes related to child maltreatment. The importance of this change is based on the theory that attitude change is a precursor to behaviour change.
Changing behaviour - can be indicated by people's self-reported changes in contemplating and enacting behaviour (subjective) or by objective measures. Objective measures of behaviour change include:
- reports from an independent observer (such as a social worker or psychologist report);
- a decrease in demand for statutory child protection services (e.g., a change in rates of notifications and substantiations of child abuse and neglect); and
- an increase in help-seeking behaviour, such as calls to a phone helpline and growth in demand for family support services.
Actual prevalence of child maltreatment - a measurable reduction in the prevalence of child abuse and neglect in the population would indicate community-wide change. This measure of success relies on accurate baseline prevalence data. However, this information is not currently available in Australia.

As shown in Table 2, 15 of the 21 campaigns had some form of evaluation but only 12 had reported evidence of impact and/or outcome evaluations. Box 3 provides a list of the 12 campaigns with published impact and/or outcome evaluation. Overall, this means that less than half of the Australian campaigns (5/12) compared to the majority of international campaigns (7/9) had published evidence pertaining to their impact. This finding is significant because it indicates that social marketing campaigns are not routinely evaluated in Australia for their effectiveness. Consequently, there is only limited evidence available to assess the short-term and longer-term outcomes in the Australian context.

The lack of published evidence on impact/outcome of Australian-based campaigns could be a reflection of limited resources. As discussed previously, evaluations require resources and publication of evaluation findings in the form of a report or journal article require further resources. Limited resources may also influence the impact of a social marketing campaign. The impacts of a campaign that is relatively short in duration (e.g., 6 weeks) are likely to be of less intensity than a campaign that is longer in duration (e.g., 2 years).

Some campaigns used more than one method to collect impact evaluation data. The three most common methods used to evaluate the impact and/or outcome of the 12 campaigns were:

pre- and post-campaign comparison surveys (4/12);
post-campaign survey only (4/12); and
data on the number of calls to phone helplines (4/12).

Box 3: Campaigns with impact and/or outcome evaluation evidence

The 12 social marketing campaigns related to child maltreatment that had information published pertaining to impact and/or outcome evaluations were:

It's Not OK to Shake Babies (NAPCAN, 1995) (Australia);
It's Got to Stop (Crundall & Trevena, 1997) (Australia);
NAPCAN child abuse prevention media campaigns (Keys Young, 2000) (Australia);
Accentuate the Positive (Moorhead, 1998; Henley et al., 1998) (Australia);
Be Cool...Not Cruel (Rudd & Jacob, 2000) (Australia);
Alcohol Abuse, Drug Abuse, Child Abuse, One Thing Leads to Another (Andrews, McLeese, & Curran, 1995) (US);
Stop It Now (Chasan-Taber & Tabachnick, 1999) (US)
Breaking the Cycle (Hall & Stannard, 1997; Stannard et al., 1998; Young et al., 1999) (NZ);
Triple-P Parenting Population Trial - mass media component (Prinz & Sanders, 2007; Prinz et al., 2009) (US);*
It's Not OK (Ministry of Social Development and Families Commission, 2007) (NZ);
Some Secrets You Have to Talk About (Hoefnagels & Baartman, 1997; Hoefnagels & Mudde, 2000) (Netherlands); and
Domestic Abuse - There's No Excuse: wave 11 Domestic Abuse Effects Children (Scotland Government, 2008) (Scotland).

Note: * The Triple-P Positive Parenting Program is an evidence-based parenting program that is often delivered within the context of a parenting group. The Triple-P parenting population trial sought to provide quality parenting information to a broad audience.

Raising awareness

Measures indicating awareness can relate to either awareness of a campaign itself (referred to below as campaign awareness) and awareness of the social problem (referred to below as topic awareness) that is the subject of the campaign. There was mixed evidence for how effective the campaigns were at raising campaign and topic awareness.

Campaign awareness

High levels of awareness of campaign awareness were generated in five out of 12 campaigns:

Accentuate the Positive: 69% of participants were aware of the television advertisement.
Be Cool...Not Cruel: 60% of participants had heard of the key character from the campaign (Captain Harley) and 22.5% could name him without prompting.
Breaking the Cycle: Awareness of three different advertisements was measured and reported as follows: 56% aware of "Backwards/Forwards" ad; 47% aware of "Vicious Cycle" ad; and 48% aware of parenting radio ads.
It's Not OK: 95% of participants recalled something from at least one of the It's Not OK advertisements.
Domestic Abuse - There's No Excuse (Wave 11): 72% of participants were aware of advertising/publicity on domestic abuse.

Awareness of the six NAPCAN child abuse preventions campaigns ranged from a low of 22% (Fathering the Future, 1997) to a high of 71% (It's Not OK to Shake Babies, 1994; Keys Young, 2000). Keys Young (2000) noted that campaign slogans had a higher rate of recall than media announcements.

Two problems associated with low levels of awareness were identified. The post-campaign survey of 300 people for the It's Not OK to Shake Babies campaign found less than half of respondents recalled the campaign message (NAPCAN, 1995). This was partly attributed to the TV adverts being screened too late at night due to reliance on pro-bono airtime. The second problem was that increasing awareness was less likely to be achieved when there were already high levels of community awareness about the subject of a campaign.

Topic awareness

In relation to topic awareness there was an overall 8% increase in unprompted awareness of emotional abuse as a social problem between the pre- and post-campaign surveys for the Breaking the Cycle campaign, in addition to awareness of the campaign itself (Hall & Stannard, 1997; Stannard et al., 1998; Young et al., 1999). In particular, there was a 12% increase in the proportion of participants who acknowledged that yelling/screaming and swearing at a child is a form of emotionally abusive behaviour.

For the It's Got to Stop campaign, there were no significant improvements in awareness about the negative effect of domestic violence on children (Crundall & Trevena, 1997). This was because, as the pre-campaign survey showed, existing levels of awareness were already high.

The effectiveness of a campaign can be misunderstood if existing levels of awareness, and existing attitudes and behaviours, are not taken into account. A formative assessment may overcome this problem by determining the current awareness, attitudes and behaviours of the target audience before the campaign is delivered.

Knowledge gain

Gains in knowledge were achieved by three out of 12 child maltreatment social marketing campaigns. Interestingly, not all survey measures recorded knowledge gain even though knowledge gain was a common aim across all the campaigns.

The Breaking the Cycle campaign recorded a 10% increase in knowledge of emotional abuse in the pre- and post-campaigns surveys (Stannard et al., 1998). The post-campaign survey (n = 1,012) for the Domestic Abuse - There's No Excuse campaign found 58% of respondents identified the message about the effects of domestic violence on children (Scotland Government, 2008). The Stop It Now campaign recorded a significant improvement in knowledge of child sexual abuse, with a 20% reduction in the number of people unable to define child sexual abuse across the pre- and post-campaigncomparison surveys (Chasan-Taber & Tabachnick, 1999).

Although the Stop It Now campaign recorded an increase in knowledge of the definition of child sexual abuse, the campaign evaluation reported that there was no significant improvement in the proportion of participants who knew the characteristics or warning signs of a child sexual abuser. After 2 years of the campaign only 27% of participants thought they would take action if they suspected child sexual abuse. It may be that the hard-hitting content of the Stop It Now campaign was ineffective because the campaign did not offer a positive model from which the audience could learn about responding to child sexual abuse.

Attitude change

Impact evaluations measured the extent of change in audience attitudes for four out 12 campaigns. Three campaigns recorded significant improvements in audience attitudes about child maltreatment:

10% decrease in the proportion of participants who self reported that "parents who need help in their parenting role are failures" (Accentuate the Positive)
10% increase in the proportion of participants who believe it is possible for child sexual abusers to live within one's own community³ (Stop It Now); and
24% of participants state that their views on family violence have changed as a result of the It's Not OK campaign.

The fourth campaign associated with attitude change was Domestic Abuse - There's No Excuse about the effect of domestic violence on children. Although changes in attitude towards the view that domestic abuse is unacceptable did not change significantly between wave 10 and wave 11 of the campaign, strong agreement that domestic violence is unacceptable was sustained (Scottish Government, 2008).⁴ Progress had also been recorded since the inception of the original campaign in 1998.

All four campaigns were associated with community capacity building, public health initiatives and/or social policy. It is possible that the positive impact that the four campaigns had upon attitudes was aided by their broader community-level strategies.

Behaviour change

Of the 12 campaigns with impact and/or outcome evaluations, 10 intended to have an effect on either the intermediate or end behaviour of individuals. It is important to note that almost all the results discussed below are based upon parent self-reports of behaviour change. One limitation of self-reported measures is that they introduce the potential for response bias (Nutbeam & Bauman, 2006). It is possible that some people will be less likely to admit to behaviour as a result of a social marketing campaign because they are more aware of the sensitivities surrounding the issue. "Gold standard" evaluations that utilise independent observational measures can be costly (Sanders et al., 2000; Tomison, 2000). Observational measures are also problematic when investigating "hidden" social problems such as domestic violence and child maltreatment.

Intermediate behaviours

The intermediate behaviours reported upon were primarily related to help-seeking. For three campaigns, their effectiveness in influencing intermediate behaviours was measured according to the number of phone calls to helplines:

The Stop It Now campaign recorded an increase from 100 calls in the first year to 141 in the second. As of September 1997 the helpline had received a total of 241 calls. Of those callers 23% were perpetrators of child sexual abuse and 50% were people who knew a perpetrator or victim (Chasan-Taber & Tabachnick, 1999).⁵

The phone helpline for the Alcohol Abuse, Drug Abuse, Child Abuse, One Thing Leads to Another campaign provided information and advice to people who were concerned about a parent struggling with a substance abuse problem (Andrews et al., 1995). The helpline recorded a growth in average monthly calls, from 33.9 per month pre-campaign to 54.7 per month during the campaign. However, a key concern raised in the evaluation of the campaign was the poor capacity of support services to respond to the influx of referrals (Andrews et al., 1995). This reflects the need to adequately prepare the service system for the growth in demand when people are motivated to seek support following exposure to a social marketing campaign related to child maltreatment.

The Some Secrets You Have to Talk About campaign (Hoefnagels & Baartman, 1997; Hoefnagels & Mudde, 2000) established a helpline designed to support children and young people experiencing child sexual abuse. The phone helpline for Some Secrets You Have to Talk About recorded approximately 52,000 calls between the start of the campaign (23 September 1991) and the end of the school year (1 July 1992). This was triple the amount of calls received during the same period prior to the campaign. After three years though, the number of phone calls from children disclosing sexual abuse declined sharply (Hoefnagels & Baartman, 1997). The campaign can be considered successful given that it was implemented prior to the commencement of mandatory reporting of child sexual abuse in the Netherlands.

For these two campaigns however, the extent that children and young people felt that calling a phone line service actually helped them it is not known. Data on the number of calls to phone helplines provides some indication of the number of people who have recognised the social problem, contemplated taking action and then were motivated to take some action. A limitation of this measure though, is that it does not provide an indication of repeated attempts to practice a new behaviour or any long-term behaviour change after making contact with a helpline. The same limitation would apply to future evaluation measures using hits to campaign websites as an indication of help-seeking behaviour.

Another campaign that reported an impact upon intermediate behaviour was Accentuate the Positive. The Accentuate the Positive campaign evaluation reported that compared with the pre-campaign survey, parents responding to the post-campaign survey indicated 40% planned to change their parenting behaviour and 25% had already changed their behaviour because of the campaign.⁶ There had also been a 43% increase in parents nominating they would seek help for parenting problems. Given that the campaign strategy included community out-reach through positive parenting information shop-fronts, those motivated to change their behaviour had a location in the community to directly receive support.⁷

End behaviour

Changes in actual child maltreatment behaviours were reported in the evaluation of the Breaking the Cycle campaign. The pre- and post-campaign comparison surveys (n = 611) showed up to 44% of parents had contemplated changing their behaviour and up to 16% had actually changed their behaviour in relation to emotional and physical abuse of children. Some of the ways in which participants stated how their behaviour had changed included trying to stop yelling at, swearing at or putting their child down and ceasing to fight or argue in front of the child.

Furthermore, a post-campaign survey (n = 2,500) conducted to evaluate the It's Not OK family violence campaign showed that 22% of respondents reported having taken action against family violence (Ministry of Social Development and Families Commission, 2007). However, it was not specified what actions participants had taken in relation to family violence.

Two other campaigns that sought to impact upon actual child maltreatment behaviours, It's Not OK to Shake Babies (NAPCAN, 1995) and Domestic Abuse - There's No Excuse (Scotland Government, 2008) did not include measures of behaviour change in their impact evaluation. This limited the extent to which a positive change in individual behaviour could be demonstrated as a result of these campaigns.

Actual prevalence of child maltreatment

Strong evidence for changes in relation to actual prevalence of child maltreatment at a population level has been reported for the US Triple-P System Population Trial. One part of this trial was a media strategy relating to positive parenting. The outcome evaluation demonstrated a significant reduction in rates of substantiated child maltreatment, out-of-home care placement and child injuries requiring hospital attention compared to communities that were not exposed to the Triple-P campaign and the parenting education programs.

It is highly likely that the potential for a campaign to impact upon child maltreatment prevalence at a population level is reliant upon the resources and intensity of the campaign. The US Triple-P System Population Trial was 2 years in duration, a high level of intensity when compared with most of the other campaigns reviewed in this paper. The intensity of the campaign is demonstrated also by the fact that it was accompanied by a range of strategies including parenting seminars, skills training for parents and consultations for individual parents.

The success of the US Triple-P System Population Trial in reducing child maltreatment prevalence highlights the benefit of a program that pairs a media campaign with support services that are tailored to meet the needs of parents. However, it also highlights the benefit of an intensive program that incorporates a range of activities including a media campaign.

³ Chasan-Taber and Tabachnick (1999) described the significance of this particular finding as follows: “The findings indicate an increased level of awareness that child sexual abuse can happen within one’s own community to children with whom one is familiar” (p. 289).

⁴ Respondents’ attitudes towards domestic violence was measured via a series of attitude statements.

⁵ This helpline was instituted especially for the “Stop It Now” campaign (Chasan-Taber & Tabachnik, 1999, p. 285).

⁶ The available evaluation publications did not indicate how these parents planned to change their behaviour or what their changed behaviour constituted.

⁷ The published articles available for this systematic review do not report whether there was increased use of these supports within the community.

Conclusions

This systematic literature review has shown that there is relatively little evidence regarding the effectiveness of social marketing campaigns in preventing or reducing child maltreatment. Only 12 campaigns relating to child maltreatment were identified as having published evidence of impact and/or outcomes evaluation. As observed by WHO (2006), more evidence that social marketing campaigns can change community awareness, attitudes, knowledge and behaviour associated with child maltreatment is required, especially as campaigns can "highlight the extent and nature of child maltreatment and encourage the provision of services to children and families" (p. 37).

The 12 social marketing campaigns related to child maltreatment that provided impact and/or outcome evaluation evidence have collectively demonstrated some capacity to positively affect people's awareness, knowledge, attitudes and behaviour. One of the campaigns, that formed part of a broader strategy with a range of activities, demonstrated a capacity to bring about improvements in child maltreatment at a population level.

Based on the strengths and limitations of these campaigns, six key areas have emerged for optimising any future social marketing campaigns that aim to address child maltreatment in Australia. These are:

comprehensive evaluation;
pairing mass media with a community-level strategy;
issues relating to reliance on television advertising;
aligning campaigns with support services;
assessing the needs of the target audience; and
using a suitable theoretical framework.

The issue that emerges most strongly in this review is the importance of comprehensive evaluation of social marketing campaigns relating to child maltreatment. As previously discussed, interventions that intend to have an impact on child maltreatment or parenting problems need to be evaluated to determine if they have been of any benefit to children and their families (Holzer, Higgins, Bromfield, Richardson, & Higgins, 2006). Indeed it could be argued that there is a very good reason for evaluating social marketing campaigns that relate to child maltreatment, especially those with hard-hitting content, because they have the potential to be harmful to vulnerable members of the community, including children and maltreatment survivors. Any benefits of social marketing campaigns related to this sensitive issue need to be weighed against the potential risks. This type of assessment requires that evaluations of these campaigns are conducted and the findings of those evaluations are made publicly available.

Ideally evaluation should include measures of behaviour change, especially as this is the fundamental purpose of social marketing campaigns. Using the number of calls to a helpline as a measure of behavioural change is a relatively easy way of gathering data about a campaign, however the usefulness of these data are limited in terms of measuring whether children's lives are improved. Using data on self-reported behaviour change as a measure of the success of a campaign that targets a highly sensitive issue such as child abuse may also be problematic. As discussed previously, social marketing campaigns about child maltreatment may raise the awareness of the stigma surrounding a topic and thereby influence people's responses to a question regarding their behaviour. A self-reported change in behaviour in this case may not represent a change in actual behaviour.

As noted in this paper, the empirical evaluation of social marketing campaigns is challenging. Issues such as a lack of access to expertise, technology and resources can impinge upon evaluation efforts and rigorous experimental or quasi-experimental designs across the population can be inappropriate. Identifying any unintended negative consequences of a social marketing strategy is also critical to prevent people being harmed as a result of campaign messages. Given that most social marketing campaigns receive some form of government funding, evaluation ensures that public money is directed towards interventions that are effective and represent value for money.

Another important issue to emerge is the importance of pairing social marketing campaigns with a community-level component. The integration of both mass media and community-level strategies appreciates that attitudes and behaviours are complex and that a campaign is unlikely to produce long-term change without broader social reinforcement. Community-level strategies recognise that individual behaviour does not occur in isolation. Social relationships create the environment to either support or challenge child maltreatment, through neighbourhoods, schools, workplaces, health services and other institutions (WHO, 2006). Experts in the field of public health are optimistic about the potential of mass media-based social marketing to be a powerful strategy when paired with broader community interventions that actually address the social context of individual wellbeing (Abroms & Maibach, 2008; Hornik, 2002a). For child maltreatment, pairing mass media with a community-level component would help reinforce the message that child protection is everyone's responsibility.

A common feature of the campaigns that were explored as part of this systematic review was the utilisation of multiple delivery methods however television advertising continues to be a key medium for social marketing campaigns. The reliance upon television advertising is especially relevant to future social marketing campaigns considering mediums such as television and newspapers are becoming less popular as a means for accessing information, especially amongst younger age groups (Ahlers, 2006; Dimmick, Chen, & Li, 2004; Havick, 2000). However, any employment of new technologies such as the Internet need to be deployed strategically so as not to increase inequalities between social groups (i.e., unequal access to the Internet in rural and remote areas of Australia and low levels of digital literacy amongst some groups) (Wise, 2000). Furthermore, in Australia especially the reliance upon community advertising for televised social marketing advertisements needs to be considered in light of the evidence that suggests that the effectiveness of community advertising is limited by the fact it is often televised during non-peak viewing times.

Aligning social marketing campaigns with support services reflects the aspirations of a public health model for the protection of Australia's children (Council of Australian Governments, 2009). There are two important issues to consider in relation to this theme. First, social marketing campaigns related to child maltreatment must offer ways to access further information and support that are tailored to the needs of the target audience. Second, if mass media has the intended effect of generating individual and community change, then increases in demand for assistance, information and support services are to be anticipated. This requires investing in the economic and human capital of support services so that they are prepared for the public's response (Andrews et al., 1995).

Assessing the attitudes and beliefs of the target audience has emerged as a key process to undertake when deciding which social problem should be the subject of a campaign. This means tuning into the "consumers" of a social marketing campaign about child maltreatment by using formative assessment and research to find out what needs to be understood from the perspective of the target population (Stead et al., 2007). Extensive formative assessment and research provides insight into the existing awareness, knowledge, attitudes or behaviours of the target audience to increase the likelihood a campaign will have an impact (Stead et al., 2007). Incorporating a sample of the target audience as participants in the design and evaluation process also represents an ethical redistribution of power between those implementing a campaign and those whom the campaign is intended to impact (Grier & Bryant, 2005).

A theoretical framework for individual and community-level change is important to social marketing campaigns about child maltreatment. Underpinning the campaign with a theory of change guides the development, implementation and evaluation of the intervention. A theoretical framework builds an understanding of the determinants of individual behaviour associated with child maltreatment; identifies the social influences that can lead to desirable behaviour change; and informs the appropriate message required to influence the desired behaviour (Randolf & Viswanth, 2004; Stead et al., 2007). As Wray (2006) has argued in relation to public communication about interpersonal violence, "if we do not think through and test our theories of behaviour as an integral part of the intervention planning process, then we are broadcasting aimlessly" (p. 44). A theoretical framework provides a strategy to conscientiously tackle complex individual behaviour and community-level change and assess its efficacy.

Overall, the analysis has shown that future Australian social marketing campaigns that aim to address child maltreatment need to be empirically informed, designed with a theoretical foundation, be rigorously evaluated and embedded in a wider community strategy for the benefits of child abuse prevention and effectual interventions to be achieved.

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Appendix: Methodology and procedure

Search strategy

For this Issues paper, literature searching was performed between August 2009 and December 2009. Additional searching was undertaken in January 2010 to trace campaigns referred to within publications. Literature was collected from the following databases: EbscoHost (SocIndex, Psycinfo, Psycarticles, Psychology and behavioural sciences, Child development and adolescent studies and Family studies); Informit (Family and Society Plus); ERIC; National Criminal Justice Reference Service; Social Care Online; Proquest; Google and Google Scholar. The Australian Institute of Family Studies library was also systematically searched.

Key terms were entered in a sequential order into each database. Due to the large number of publications identified when using the terms "social marketing" and "media campaign" alone, the search was narrowed with "child abuse or neglect or maltreatment". This resulted in such a small number of hits, the terms "community education" and "community attitudes" were introduced to widen the evidence-base on child maltreatment and parenting. This experience reflected that of Stead et al. (2007), who found the search label "social marketing" to be insufficient for finding literature in databases on public health campaigns specifically targeting physical activity.

Note that the key terms did not specifically include domestic violence, drug use or mental health. Consequently, campaigns associated with these social issues that emerged from the literature search were found in relation to child maltreatment and were selected because the content of the campaign included a message about the effects of these problems upon children or parenting more generally.

The key terms for this systematic literature search were:

social marketing + evaluation
(social marketing + evaluation) + (child abuse or neglect or maltreatment)
(social marketing + evaluation) + parent*
(social marketing + evaluation) + child protection
media campaign + evaluation
(media campaign + evaluation) + (child abuse or neglect or maltreatment)
(media campaign + evaluation) + parent*
(media campaign + evaluation) + child protection
community education + (child abuse or neglect or maltreatment)
community education + parent*
community education + child protection
community attitudes + (child abuse or neglect or maltreatment)
community attitudes + parent*
community attitudes + child protection

Inclusion/exclusion criteria

The database searches produced 173 publications (journal articles, books, government reports, etc.) about social marketing campaigns. Ten publications were discarded because they did not comprise research on specific social marketing campaigns (e.g., general social marketing literature and opinion pieces). Seventeen publications were excluded as they described population-level surveys of attitudes about child abuse, neglect, maltreatment or family issues, which were not undertaken as part of a social marketing or mass media campaign. In order to focus on contemporary social marketing campaigns implemented during the last 15 years (i.e., 1995-2009), a further seventeen publications released prior to 1995 were also excluded. This resulted in a total sample of 129 publications.

The remaining 129 publications were coded into one of two topic areas: child maltreatment campaigns (defined as social marketing campaigns targeting child abuse and neglect and the determinants of abuse and neglect (e.g., parenting problems, parental substance misuse, domestic violence in families and the impact of these on children), and public health (non-parenting or child maltreatment) campaigns. The coding of publications was independently replicated to validate the procedure. Within these topic areas, the publications were further categorised into Australian or international campaigns. Following a preliminary review, the 93 publications relating to public health campaigns (e.g., domestic violence campaigns not related to families or exposure to children; exercise; quitting smoking; road safety) were also excluded. This resulted in a remaining sample of 36 publications, with 21 distinct child maltreatment-related social marketing campaigns that formed the evidence base for this project.

Authors and acknowledgements

At the time of writing Briony Horsfall was a Research Officer with the National Child Protection Clearinghouse at the Australian Institute of Family Studies.

At the time of writing Dr Leah Bromfield was Manager of the National Child Protection Clearinghouse at the Australian Institute of Family Studies. Dr Bromfield is now Deputy Director of the Australian Centre for Child Protection.

At the time of writing Dr Myfanwy McDonald was a Senior Research Officer at the National Child Protection Clearinghouse. Dr McDonald is now the Acting Coordinator of the Communities and Families Clearinghouse Australia.

The authors gratefully acknowledge Mr Rhys Price-Robertson for validating the coding of literature and Mr Alister Lamont for feedback and assistance with analysis. The authors would also like to acknowledge Dr Rob Donovan and Dr Danielle Zerk for reviewing this paper.

Publication details

NCPC Issues

No. 32

Published by the Australian Institute of Family Studies, October 2010

28 pp.

ISBN:

978-1-921414-47-3

ISSN:

1447-0004

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Are social marketing campaigns effective in preventing child abuse and neglect?

Are social marketing campaigns effective in preventing child abuse and neglect?

Overview

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Introduction

What is social marketing?

The public health model and social marketing targeting child maltreatment

Developing a social marketing campaign

Selecting an appropriate theory

Implementing a social marketing campaign

The Four Ps

The Communication-Persuasion Matrix

Evaluating social marketing campaigns

Box 1: Evaluation of social marketing campaigns

Identifying child maltreatment social marketing campaigns

Method

The campaigns

Characteristics of child maltreatment social marketing campaigns

Campaign classification according to the public health approach

Aim of the campaign

Primary target audience

Campaign strategy

The media mix

Style of the content of the campaign

Are social marketing campaigns about child maltreatment effective?

Box 2: Measuring success of social marketing campaigns related to child maltreatment

Box 3: Campaigns with impact and/or outcome evaluation evidence

Raising awareness

Campaign awareness

Topic awareness

Knowledge gain

Attitude change

Behaviour change

Intermediate behaviours

End behaviour

Actual prevalence of child maltreatment

Conclusions

References

Appendix: Methodology and procedure

Search strategy

Inclusion/exclusion criteria

Further reading

Safe and supportive families and communities for children: A synopsis and critique of Australian research

Evaluating child abuse prevention programs

Evaluating child abuse and neglect intervention programs

The role of mass media in facilitating community education and child abuse prevention strategies

Authors and acknowledgements

Publication details

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