cancer prevention billboards evaluation in american samoa, sara krosch

American Samoa Community

Cancer Network

Cancer Prevention Billboards Evaluation Report December 2008

Sara Krosch, [email protected]

Cancer Prevention Billboards Evaluation Report , 12/08 | Sara Krosch, [email protected]

2

Contents Introduction .............................................................................................................................................. 3

Billboard Aims ........................................................................................................................................... 3

Billboard Message & Target Audience ...................................................................................................... 4

Billboard Evaluation Criteria ..................................................................................................................... 4

Billboard Evaluation Methods ................................................................................................................... 5

Billboard Observations .............................................................................................................................. 5

Community Survey .................................................................................................................................... 5

Evaluation Criteria ..................................................................................................................................... 6

Billboard Locations .................................................................................................................................... 6

Billboard Observation Results ................................................................................................................... 7

Community Survey Results ..................................................................................................................... 12

Respondent Demographics ..................................................................................................................... 12

Billboard Recall Results ........................................................................................................................... 17

Billboard Opinion Results ........................................................................................................................ 20

Billboard Behavior Change Results ......................................................................................................... 21

Billboard Design Evaluation .................................................................................................................... 22

Billboard Recommendations ................................................................................................................... 23

Survey Respondent Recommendations .................................................................................................. 23

Evaluator Recommendations .................................................................................................................. 23


3

Introduction During 2007‐08, the American Samoa Community Cancer Network (ASCCN) erected 13 cancer prevention billboards on the main island of Tutuila in the Territory. Four (4) billboards encouraged screening for breast and cervical cancer; 3 billboards encouraged smoking cessation and Quitline calling; and 6 billboards encouraged screening for cancer in general. All billboards listed the ASCCN as sponsor but other office phone numbers were usually given.

The lumber and nails for each billboard were donated by ACE Hardware, $37.00 per billboard. The front messages were produced by Local Graphix but they could not recall the exact price of the billboards. Currently, they are creating billboards of similar size for about $200.00 each. So, to construct or replace a billboard would cost about $240.00 each.

By November 2008, 2 breast and cervical cancer screening billboards had been removed and one general cancer screening billboard had been vandalized. This evaluation report does not assess billboards encouraging breast and cervical cancer screening, initiatives covered by the Breast and Cervical Cancer Early Detection and Prevention program under the American Samoa Department of Health.

In an effort to assess the impact of the 3 smoking cessation and 6 general cancer screening billboards, evaluation activities were implemented September – November 2008: a convenience sample survey of 200 community members and observations of billboard traffic. This report documents the results of these evaluation activities.

Billboard Aims The mission of the ASCCN is to reduce cancer health disparities—incidence, morbidity and mortality—in American Samoa via research and the support of education and service partners.

The cancer prevention billboards specifically aimed to 1) Increase utilization of screening services offered at the Lyndon B. Johnson Tropical Medical Center (LBJ) and the Tobacco Quitline managed by the AS Department of Health; and 2) Stimulate interpersonal dialogue about cancer screening and smoking cessation.

While the billboards have been standing, the ASCCN sponsored or supported screening clinics/events for breast, cervical and prostate cancers and billboard messages were reiterated on local radio, television media and elaborated on regularly in a local newspaper. Therefore, the billboards were a part of a lager social marketing campaign. Social marketing is the use of commercial marketing techniques to promote the adoption of a healthy behavior. This approach is best used to increase service use, but it may be ineffective when the health issue is beyond individual control. Billboards are only one method of conveying social marketing messages. They are great for reaching commuters, allow for repetition, and are a relatively inexpensive way to reach many people. On the downside, billboards cannot provide much information, their message must be understood within seconds, and they can become unnoticeable after time especially if they are near other outdoor advertisements (Kline Weinreich, 1999).

Kline Weinreich, Kendra. (1999) Hands‐on Social Marketing: a Step‐by‐Step Approach. Sage:Thousand Oaks, CA. 4, 85.


4

Billboard Message & Target Audience Billboards are meant to convey a single action‐oriented message. There is no evidence of prior research or stakeholder involvement in the development of the cancer screening or smoking cessation billboard messages or designs. No specific target audiences were defined for the billboards. Nor were the messages and designs pre‐tested with any target audiences before billboards were erected.

The billboard messages were as follows with the targeted behavior underlined:

General Cancer Screening Billboards Smoking Cessation/Quitline Billboards Screen for your life! Screen for cancer Find the cancer Beat the cancer It's best to be sure.

Stop Smoking: Do you wish to quit smoking? We can help you quit.

Before impact evaluation activities commenced, the following primary and secondary target audiences (TA) were defined:

General Cancer Screening Billboards Smoking Cessation/Quitline Billboards Primary TA‐ Adults age 40+, females and males Secondary TA‐ All females and males, ages 13+

Primary TA‐ current smokers, females and males Secondary TA‐ All females and males, ages 13+

The Primary TAs are more likely to be diagnosed with cancer while the secondary TAs may be influential in encouraging uptake of target behaviors.

Billboard Evaluation Criteria Marketing experts offer these criteria for planning and assessing billboard design:

1) Visibility Can the message be read easily? Are the fonts easy to read and large enough (from a moving vehicle at 500‐1,000 feet in less than 5 seconds)? Are the words properly spaced?

2) Color Are contrasting colors used? Does the billboard stand out from the surroundings? Do the colors appeal to the TA?

3) Copy Are short and simple words used? Are the words memorable and culturally appropriate?

4) Images Are images attention‐getting? Does the TA relate to pictures? Do images reinforce the message?

5) Layout Is there are balance between copy and images? Are contrasting colors balanced? Is the design simple and not cluttered?

6) Message Is a single, behavior‐oriented message conveyed? Is enough information given to adopt the behavior?

7) Intrigue Does the billboard message and image grab the TA’s attention? Does the billboard prompt informal and formal discussion about the target behavior?


5

Billboard Evaluation Methods Three methods were used to evaluate the cancer prevention billboards:

• Observations of billboard traffic on site

• Convenience sample survey of 200 American Samoa residents

• Application of billboard evaluation criteria

Billboard Observations The author conducted 10 minute observations on site at all Screen for Your Life! And Stop Smoking billboards on sunny weekdays October 22‐27 between 10am and 12noon. An observation checklist was used to note the infrastructure immediately surrounding the billboard (within 100 yards) and the number of female and male adults, youth, and children who passed by. Adults were considered 25 years and older, youth 12 – 24 years and children anyone appearing to be under age 12. Observations were noted only if the person could feasibly see the billboard as most billboards were only visible from particular directions or angles. After noting the 10 minute tally of passerbys, this number was multiplied by 6 to estimate the amount of possible traffic per hour on a typical day per billboard.

Community Survey A convenience sample survey of 200 American Samoa residents was conducted September – November 2008. The sample was stratified by gender and age group such that 100 males and 100 females responded, 40 from each age group: under age 20; 20 – 29 years; 30 – 39 years; 40 – 49 years; and age 50 and older. The self‐administered survey was distributed at the 2008 Annual ASCCN Cancer Symposium (September), at workshops sponsored by the ASCCN (September – November), at an American Samoa Community Cancer Coalition Policy Skills Training Workshop (October), at the LBJ Billing Office (October), and in the villages of ASCCN staff and partners. On most occasions respondents were given the opportunity to win a prize (computer flashdrive or calling card) and all respondents were offered a free pencil.

The survey asked questions about respondent demographics, cancer billboard opinions, and uptake of behaviors related to the aims of the initiative. More than 200 residents responded to the billboard evaluation survey. One hundred (100) female and 100 male surveys, 20 per age group were analyzed. Incomplete surveys (*billboard evaluation, health beliefs and demographics) were not included. If more than 20 surveys were completed for a gender’s age group, surveys were randomly selected for inclusion. Three (3) survey respondents identified their gender as “Other” (neither male nor female). Given the small, unrepresentative proportion of this demographic, the 3 surveys were not included in the analysis.

Survey data was analyzed for differences between genders, age groups and education groups. Education groups were defined as Lower Education (highest attainment being elementary, secondary or 2 year college) and Higher Education (highest attainment being 4 year college degree or more than a 4 year college degree).

*The billboard evaluation survey was part of a larger survey pack that included media habits and health beliefs, results from which will be shared in future reports.


6

Evaluation Criteria After analyzing survey and observation results, the author assessed the cancer prevention billboards using these well‐establish (social) marketing criteria, assigning a score of high, medium or low achievement. Final recommendations were then made.

Billboard Locations Nine (9) billboards were assessed, numbers 3‐11 on the map below. All billboards were along main roads on Tutuila Island and all but one (#10) were in large to mid‐sized populated villages. Three (3) billboards (# 3‐5) were in the business canter and most populated village on the island, Tafuna.


7

Billboard Observation Results

Surroundings Observers (10min) Evaluator Comments • On far wall of Veteran’s Memorial Stadium

• Walled‐in compound with half of seating facing billboard

• 0 adults • 0 youth • 0 children • *potentially 150 at stadium events

• Potentially 0 /hour

• Poor location • Only visible at stadium events • Writing too small for anyone to read unless walk

up close to billboard • Message appears to target athletes who do not

practice at the stadium • Phone number very small

This evaluation report does not assess billboards encouraging breast and cervical cancer screening, initiatives covered by the Breast and Cervical Cancer Early Detection and Prevention program under the American Samoa Department of Health. The Community Cancer Network is the stated sponsor on these billboards, but the phone numbers provided are to other offices.


8

Surroundings Observers (10min) Evaluator Comments • In front of Tafuna Family Clinic

• Behind a chain‐link fence making difficult to see from the road

• Clinic, bus stop, businesses nearby

• 9 female & 5 male adults

• 0 youth • 2 female & 2 male children

• Potentially 108/hour

• Poor location, only visible within gated parking lot• Screening location not provided • Phone number no longer valid • Phone number of hospital should be provided

rather than ASCCN

Surroundings Observers (10min) Evaluator Comments • Major intersection, bus route

• Sometimes obscured by tree branches

• 3 Bus stops, businesses, homes nearby


• 37 female & 26 male youth

• 3 female & 1 male children

• Potentially 1,116/hour

• Poor location, drivers may be distracted by sign or ignore it due to busy traffic

• Best visible from two directions • Mostly bus passengers as potential observers • Message font good size, simple message • Phone numbers no longer valid • Phone number of hospital should be provided

rather than ASCCN


9

Surroundings Observers (10min) Evaluator Comments • In front of Department of Health offices

• Across from hospital emergency room

• 2 Bus stops, offices, businesses, parking lots, homes nearby





• Poor location, most drivers do not appear to look this direction

• Best visible from 1 bus stop • Message font good size, simple message • Location of screening services should be provided • Phone numbers no longer valid • Phone number of hospital should be provided

rather than ASCCN

Surroundings Observers (10min) Evaluator Comments • Intersection in front of government offices

• 2 Bus stops, offices, parking lots, businesses, park, school nearby





• Poor location, only bus stop and traffic leaving government office have clear view

• Aesthetic of park scenery degraded • Message font good size, phone number font too

small


10

Surroundings Observers (10min) Evaluator Comments • Main road in Pago Pago, on corner in family yard

• houses, businesses, market, park nearby





• Visible from one direction, going east towards cannery along main bus route

• Message font good size • Phone number font too small • Sometimes temporarily covered with other signs

Surroundings Observers (10min) Evaluator Comments • Intersection at cross‐island road to national park

• houses, businesses, church, school nearby





• Best visible from one direction, at intersection facing ocean, mostly bus traffic

• Aesthetic of coastal scenery degraded • Message font good size • Other billboards nearby


11

Surroundings Observers (10min) Evaluator Comments • Intersection at cross‐island road

• houses, businesses, church, school nearby





• Only visible from one direction, heading east rather than to urban center, mostly bus traffic

• Along main walking route to school, church and store

• Message font good size • Other billboards nearby

Surroundings Observers (10min) Evaluator Comments • Coastal road, corner of family yard

• Houses, water taxi to Aunu’u island nearby





• Only visible from one direction, heading east rather than to urban center, mostly bus traffic

• Graffiti damaged • Other billboards nearby • Phone numbers too small to read


12

Based on 10 minute observations on a typical sunny weekday morning, it can be estimated that during such times as many as 4,026 people per hour could potentially be observing at least one cancer prevention billboard.

Community Survey Results

Respondent Demographics

Females (n=100)

Under 20 years (n=20) Males (n=100)

Under 20 years (n=20) 20‐29 years (n=20) 20‐29 years (n=20) 30‐39 years (n=20) 30‐39 years (n=20) 40‐49 years (n=20) 40‐49 years (n=20) 50 and older (n=20) 50 and older (n=20)

Ninety‐four percent (94%) of females and 91% of males claimed a religious affiliation.

0

20

40

60

80

100

120

140

160

180

200

BB 3 BB 4 BB5 BB 6 BB 7 BB 8 BB 9 BB 10 BB 11

Billboard Passerbys ‐ 10 Minute Observation

All

Females

Males


13

The majority of respondents were born in American Samoa. More respondents were born in the United States (USA) than in Samoa. There was no significant difference in birthplace between genders.

Respondents came from 38 of the 65 villages on Tutuila Island. Residents were surveyed from each village containing a billboard with forty‐six (46) respondents from the largest village with the most billboards.

0

20

40

60

80

100

Am Samoa

Samoa USA Other Pacifc Island

No Response

Birthplace by Gender

male

female


14

Nearly all survey participants were of full or partial Samoan ethnicity. There was no significant difference in ethnicity between females and males.

About half of respondents were married and about half were single/never married. This is largely due to two age groups being in their 20’s or younger. Slightly more females than males were married.

020406080

100120140160180

Samoan Other Pacific Islander

Asian White No Response

Ethnicity by Gender

male

female

0

20

40

60

80

100

Single Married Divorced Widowed No Response

Marital Status by Gender

male

female


15

Most surveyed were currently employed. The majority of the unemployed were age 29 or under. There was no significant difference in employment status between genders.

Most respondents had attained a secondary diploma or a 2‐year college degree. More males than females had only a secondary education while more females had either a 2 year college degree or more than a 4‐year college education.

For data analysis, respondents were divided into 2 educational attainment groups: Lower Education (highest attainment being elementary, secondary or 2‐year college) and Higher Education (highest attainment being 4‐year college degree or more than a 4‐year college degree). Most surveyed fell into the Lower Education group.

0

20

40

60

80

100

120

Employed Unemployed Retired No response

Employment Status by Gender

male

female

0

10

20

30

40

50

Education Attainment by Gender

female

male


16

Personal Cancer Status

Yes No

No Response

Female 9 86 5 Male 1 95 4 Total % 5% 90% 5%

Ten (10) survey respondents were cancer survivors, 5% of the sample. The majority had been diagnosed with breast cancer. More than twice as many females than males cited a family history of cancer possibly reflecting males’ lower awareness of the disease. Again, breast cancer was most prevalent in blood relatives, followed by lung cancer. However, 13 respondents did not recall what type of cancer a family member was diagnosed with.

0 20 40 60 80

Lower Ed

Higher Ed

No Response

Education Groups by Gender

All Females

All Males

Frequency Personal Cancer Site

Breast 5 Stomach 1 Lung 1 Skin 1 Unknown/ No Response

2

Family Cancer Status

Yes No

No Response

Female 53 41 6 Male 26 70 4 Total % 40% 55% 5%

Frequency Family Cancer Site Breast 38 Cervix 6 Stomach 3 Leukemia 7 Lung 9 Ovarian 3 Skin 1 Prostate 2 Brain 5 Pancreas 5 Liver 2 Throat 2 Lymph 1 Uterus 2 Unknown/ No Response

13 Colon 3


17

Billboard Recall Results

More females than males recalled seeing any cancer prevention billboard. Logically, more remembered seeing a Screen for Your Life! billboard as there are twice as many of these than Stop Smoking billboards. Half of all respondents had seen one of the three Stop Smoking, possibly proving they are in superior locations or have a more striking design.

There were more lower education than higher education respondents. Overall, a large percentage of lower education males, lower education females, and higher education males recalled seeing a billboard. Less than half of higher education females remembered observing a billboard so this target audience may be best reach via other means.

0

20

40

60

80

Any BBScreening BB

Smoking BB

65

5550

7671

51

Recalled Seeing Billboards by Gender

All Males

All Females

0

10

20

30

40

50

Male Lower Ed

Female Lower Ed

Male Higher Ed

Female Higher Ed

66% 73%

68%

48%

Recalled Seeing Billboards by Education Group(% of total in group)

Any BB

Screening BB

Smoking BB


18

Nearly all females ages 20‐29 and 40‐49 recalled seeing a billboard. Lowest recall percentage was amongst males ages 20‐29 and both males and females ages 50 and older. The latter group is concerning because they are the primary target audience for the Screen for Your Life! billboards.

Recall of Billboard Locations (Female n= 74, Male n=65)

All Females #,%

All Males #,%

In my village 19, 26% 18, 28% Near my workplace 9, 12% 12, 18% Near my school 18, 24% 10, 15% Near my church 10, 14% 5, 8% While driving or riding 67, 91% 54, 83% Other place 5, 7% 6, 9%

Most females and males recall seeing a billboard while driving or riding. One quarter of billboards were observed in home villages or near schools so complementary outreach activities could be happening in these locations to strengthen message impact.

0

2

4

6

8

10

12

14

16

18

20

16

14

10

18

15 15

13

19

1110

Billboard Recall by Age Group & Gender

Any BB

Screening BB

Smoking BB


19

Perceived Billboard Target Groups (Female n= 74, Male n=65)

All Females #,%

All Males #,%

Females 64, 86% 41, 63% Males 58, 78% 40, 62% Children 51, 70% 32, 49% Youth/Students 57, 77% 36, 55% Seniors/Elders 56, 76% 38, 58% Leaders 53, 72% 34, 52% People like me 60, 81% 40, 61% People different from me 48, 65% 32, 49%

When asked who the cancer prevention billboards were for, most females felt they were being targeted and that the billboards were for “people like them”. Males also related to the billboards. Unlike the females, males felt the billboards were targeting males and females equally. Two thirds of females and half of males felt the billboards were not targeting them personally, but were for “people different from me.” Amongst the primary target audience, two thirds of males 40‐49 and females 50 and older related to the billboards. Nearly all of males 50 and older related to the billboards.

Gender/ Age Group

BB are for People Like Me

Females 40‐49 84% Males 40‐49 67% Females 50+ 67% Males 50+ 90%

One goal of social marketing messages is to motivate interpersonal discussion about health issues. Most survey respondents said they saw the billboards but they did not discuss them with others. This presents an opportunity for follow‐up initiatives to elevate the importance of cancer prevention and screening via informal and formal dialogue.

Discussed Billboards with Others (n saw any billboard)

Yes #,%

All Females(n=75) 36, 48% All Males(n=65) 20, 31% All <20 (n=30) 10, 33% All 20‐29 (n=28) 8, 29% All 30‐39 (n=30) 12, 40% All 40‐49 (n=32) 15, 47% All 50+ (n=21) 11, 52% All Lower Education (n=87) 42, 48% All Higher Education (n=47) 13, 28%


20

About half of all females, all respondents 50 years and older, and all with lower education levels talked to others about the billboards. Most of these respondents discussed the billboards with family and friends. Family and friends may prove to be influential in helping others adopt healthy behaviors and can also be targeted more specifically.

Billboard Opinion Results The majority of survey participants had positive opinions about the cancer prevention billboards. However, the billboards no longer seem to be attracting the attention of nearly one third of respondents after being up for over a year. Interestingly, people felt the billboards were easy to read, although “difficult to read” and “font too small” was a frequent area of improvement listed as well. Similarly, most males and females “think there should be more billboards” which was contrary to several written recommendations and anecdotal evidence against the use of any billboards. (See Survey Respondent Recommendations for Billboard Improvements.)

Statements Number Respondents

Agreement (#,%) Females Males

I like the cancer billboards I have seen. F=74 M=64 57, 77% 51, 80% The cancer billboards look nice. F= 72 M=65 54, 75% 47, 72% The cancer billboards attract my attention. F=74 M=65 50, 68% 43, 66% The cancer billboards are easy to read. F= 74 M=64 62, 84% 53, 83% The cancer billboards give me useful information. F= 73 M=64 59, 81% 47, 73% The cancer billboards make me think about my health. F= 74 M=65 58, 78% 46, 71% I think there should be more cancer billboards. F= 74 M=65 60, 81% 47, 72%

051015202530354045

Discussed Billboards With Others

All Females

All Males


21

Billboard Behavior Change Results The best measure of target behavior uptake—cancer screening and smoking Quitline calling—would be data showing an increase in service utilization after the billboards were erected. Unfortunately, this information is not available for assessing the potential impact of the billboards, so self‐reporting was used.

Survey respondents were asked if they had ever smoked and if so did the Stop Smoking billboards motivate them to quit. This may be an inadequate question because people could have quit smoking long before the billboards were put up. Yet, about one fourth of male and female smokers claim the Stop Smoking billboards helped them do just that. Similarly, one fourth of males and one fifth of females ever screened for cancer claim they did so partly due to seeing a Screen for Your Life! billboard. More than five times more females have been screened for cancer (mammogram, pap smear) than males. Interestingly, some men stated they have had a mammogram or pap smear and some women claim to have had a PSA test.

0

10

20

30

40

50

Ever Smoked

BB Motivated Me to Quit

Ever Cancer Screened

BB Motivated Me to Screen

44

128

2

41

10

44

9

Behavior Change Motivation

All Males

All Females

05

10152025303540

Self‐reported Cancer Screening History

All Females

All Males


22

Billboard Design Evaluation Overall, the Screen for your Life! billboards scored low on the criteria for effective design while the Stop Smoking billboards reached a medium level of achievement.

1) Visibility Can the message be read easily? Are the fonts easy to read and large enough (from moving vehicle at 500‐1,000 feet in less than 5 seconds)? Are the words properly spaced?

Screen For Your Life! BBs Stop Smoking BBs High

Medium Low

High Medium Low

2) Color Are contrasting colors used? Does the billboard stand out from the surroundings? Do the colors appeal to the TA?


Medium Low

High Medium Low

3) Copy Are short and simple words used? Are the words memorable and culturally appropriate? Screen For Your Life! BBs Stop Smoking BBs

High Medium Low

High Medium Low

4) Images Are images attention getting? Does the TA relate to pictures? Do images reinforce the message?


Medium Low

High Medium Low

5) Layout Is there are balance between copy and images? Are contrasting colors balanced? Is the design simple and not cluttered?


Medium Low

High Medium Low

6) Message Is a single, behavior‐oriented message conveyed? Is enough information given to adopt the behavior?


Medium Low

High Medium Low

7) Intrigue Does the billboard message and image grab the TA’s attention? Does the billboard prompt informal discussion of the target behavior?


Medium Low

High Medium Low


23

Billboard Recommendations Survey Respondent Recommendations for Billboard Improvements

Design Message Location Bright colors Include local cases, statistics Put in all villages, near schools,

churches and workplaces Bigger size New message yearly, catchy and

memorable mottos Do not place in busy intersections where people can’t see them

More graphics and pictures: Polynesians, before and after smoking

Provide easy to read phone numbers, update numbers and contact information

Put in Bingo Hall, malls, and where people walk

Make visible at night Target to specific groups, ages, genders

Other

Fewer and simpler words, don’t waste space on sponsor advertisement

State screening location clearly

Need more billboards

Decorate Single message, motivate action and behavior change

Need less billboards/none, they make the island look messy

Change designs often Provide more useful information (what diseases result from smoking)

Use other forms of media: posters or signs that can be put on lawns, in businesses, churches, schools

Pictures of survivors and age groups most affected

Dispel myths and describe symptoms Protect them from vandalism and damage

More community involvement in design, message

Messages about risk factors and prevention: diet, exercise

Don’t rely only on billboards, have events and outreach to back up message and get people’s attention

Larger fonts What is screening? Rephrase or explain why screening would help

Avoid addressing cancer as a “battle”, “fight” or that it can be “beat” so as to not stigmatize people who do not reach a cure as “failing” or “losing”

Evaluator Recommendations • Include billboards as part of larger social marketing/outreach and service provision

programming and do not rely on them solely to prompt behavior change. Or, replace billboards with smaller communications such as posters and signs in new locations of high traffic such as at bus stops or in workplaces. Fully develop a social marketing campaign: product, price, placement and promotion

• Develop billboard messages and designs in cooperation with the target audience(s) and always pre‐test before construction. Make sure messages encourage to realistic actions taking into account known barriers to behavior change.

• Establish measureable goals for billboards. If the aim is to increase service utilization, ensure means to measure uptake of this behavior other than self‐reporting.

• Billboards should have specific target audiences. Research the needs and preferences of specific audiences to craft the most appealing and motivating messages and designs.

• Change current billboards as soon as possible as they have outlived their attention‐grabbing lifespans. Change billboards at least every six months with new messages and designs and updated contact information.

• Provide phone numbers and locations of services in large fonts.

• Billboards need relevant pictures to attract attention.

• Do not place billboards in busy intersections or in scenic areas (parks, coastal drives). Instead use billboards to beautify public spaces/buildings.

cancer prevention billboards evaluation in american samoa, sara krosch

Documents