The 1995 Mass Communication Campaign for theNational Childhood Immunisation Program:

An Overview of Research Conducted for the Development,Implementation and Evaluation of the Campaign

Tom Carroll, Senior Adviser,

Research and Marketing

Research and Marketing GroupPublic Health Division

Commonwealth Department of Health and Family ServicesLevel 2, 333 Kent Street

Sydney

April 1997

TABLE OF CONTENTS

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. CAMPAIGN DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1. Preliminary Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2.1.1 Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1.2 Service Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2.2. Logo Design Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.3 Exploratory Qualitative Research (September-October 1994) . . . . . . . . . . . . 3

2.3.1 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.3.2 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.3.2.1 Consumer Segmentation . . . . . . . . . . . . . . . . . . . . . . 52.3.2.2 Knowledge and Perceptions . . . . . . . . . . . . . . . . . . . . 62.3.2.3 Motivations for Immunisation . . . . . . . . . . . . . . . . . . 72.3.2.4 Barriers to Immunisation . . . . . . . . . . . . . . . . . . . . . . 72.3.2.5 Threats to Immunisation . . . . . . . . . . . . . . . . . . . . . . 92.3.2.6 Communication and Information Needs . . . . . . . . . . 10

3. CAMPAIGN DEVELOPMENT AND IMPLEMENTATION . . . . . . . . . . . . . . . . 113.1 Target Audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.2 Campaign Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.3 “Understanding Childhood Immunisation” Information Booklet Pre-testing

Research (February, 1995). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.4 Advertising Development Research (March-August 1995). . . . . . . . . . . . . 13

3.4.1 Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

4. CAMPAIGN IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5. CAMPAIGN EVALUATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165.1 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.2 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

5.2.1 Campaign awareness, processing and action . . . . . . . . . . . . . . . . . . 165.2.2 Support for Immunisation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.2.3 The Immunisation Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.2.4 Benefits of Immunisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.2.5 Problems and Difficulties with Immunisation . . . . . . . . . . . . . . . . . . 185.2.6 Behaviour and Intention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6. PERFORMANCE OF THE CAMPAIGN AGAINST ITS OBJECTIVES . . . . . . . 196.1 Campaign reach and communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196.2 Awareness objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216.3 Attitudinal objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.4 Intention objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

7. IMPLICATIONS FOR FURTHER CAMPAIGN ACTIVITIES . . . . . . . . . . . . . . . 23

8. REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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1. INTRODUCTION

Immunisation programs have been conducted in Australia since the 1920’s, with Australiangovernments being amongst the first in the world to recognize the public health benefits of massimmunisation and the value of financial investments of public funds in this field (NHMRC, 1993).The long-standing programs have included mass childhood immunisation against poliomyelitis,pertussis (whooping cough), diphtheria, tetanus, measles, mumps and rubella (ibid).

However, in 1993, the National Health and Medical Research Council (NHMRC) published itsNational Immunisation Strategy document (ibid). This document referred to data collected in the1989-90 National Health Survey conducted by the Australian Bureau of Statistics indicating that:

C only 53% of Australian children aged 0-6 years were fully immunised against all thediseases mentioned above;

C an additional 30% of children were partly immunised but had not completed the fullcourse of immunisations; and that

C nearly 20% of children were either totally immunised or had unknown immunisationstatus.

The strategy document suggested that improving immunisation coverage should be the prime goalof the 1990’s and at the same time noted the inadequacy of public and professional educationprograms. To address this deficit, NHMRC recommended, inter alia, that States, Territories andthe Commonwealth should agree to participate in strategies to improve public awareness,including regular information campaigns and telephone information lines for the public, health careworkers, child care facilities and schools.

In October 1995, stemming from this recommendation a national mass communications campaignwas launched by the Commonwealth Department of Human Services and Health with the goal ofcontributing toward the achievement of greater levels of full age-appropriate childhoodimmunisation coverage. The campaign was designed to raise community awareness of the needfor full immunisation and to generate a more favourable climate of acceptance and active supportfor this full age-appropriate child immunisation.

The purpose of this paper is to provide an overview of the various research studies which wereconducted for the development of the campaign strategy and communication materials, as wellas quantitative benchmark and tracking surveys carried out to assess the campaign reach,communication and initial impact.

2. CAMPAIGN DEVELOPMENT

A number of research stages were undertaken to provide direction for the National ImmunisationEducation Campaign and to guide the development of the campaign communication strategy andmaterials.

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2.1. Preliminary Literature Review

An initial literature review on childhood immunisation was completed in July 1994 (Bazeley andKemp, 1994 ). The review highlighted a range of groups which had been identified as being atgreater risk of incomplete immunisation than the general population including those:

C living in rental housing and who move frequently;C in families with very low income;C whose fathers are unemployedC whose mothers have not completed basic secondary education;C who have two or more older siblings;C whose older siblings are not fully immunised;C whose parents are recent immigrants to Australia;C who are from Arabic and Asian (other than Chinese) backgrounds; and C Aboriginal children.

At the same time the review noted the lack of research examining the dynamics of the relationshipbetween various risk factors and lower compliance, and of the association between particularconditions of disadvantage and specific beliefs or stated reasons for non-compliance.

2.1.1 Parents

The authors noted high levels of support for immunisation amongst parents, despite lowknowledge levels of specific diseases or vaccines. They also pointed to significant concernsamongst parents about potential ’side effects’ from vaccines (in many cases arousing more fearthan the actual diseases), particularly where an adverse reaction has been experienced in the pastand where ’vulnerable’ children are involved. This was reported as particularly so in the case ofPertussis vaccine. They suggested that parents’ attitudes, beliefs and behaviour with respect toimmunisation are strongly influenced by their contact with health professionals, with mediacoverage judged to be less influential. While the authors pointed to the need for consistent,comprehensive and multi-faceted communication strategies to be generated and implemented,they concluded that increased compliance will be achieved most effectively by improving accessto, and positive experience of, immunisation services.

2.1.2 Service Providers

The authors pointed to the particular need for continuing education of both service providers andinformation providers in light of indications of serious deficits in knowledge (particularly relatingto contraindications to immunisation), injecting in incorrect sites and inappropriate vaccinestorage. They concluded that opportunistic immunisation should be facilitated by convincingservice providers of the importance of immunisation and of their role in promoting compliance,and by ensuring the availability of free supplies of all vaccines.

The authors also pointed to the fragmented service delivery system in Australia, including lackof co-ordination in promotion, surveillance and distribution of vaccines, resulting in lack offollow-up of defaulters and missed vaccination opportunities. They further noted that whilesurveillance and reminder systems are important in prompting immunisation ’defaulters’, there are

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difficulties in implementing a comprehensive centralised system. They also observed that withoutsuch a surveillance system, immunisation requirements at school age can prompt completion ofpreschool immunisations. However, they cautioned that experience of such systems in othercountries has shown that reliance on this approach can result in a lack of age appropriateimmunisation.

2.2. Logo Design Research

During October 1994 a qualitative research study was undertaken (Blue Moon Research andPlanning, 1994a) to explore a number of possible logo designs for the education campaign. Aseries of focus groups were conducted with mothers of children aged under five years in NSW,Victoria, Queensland and the Northern Territory in both urban and rural location. The groupsamples reflected a range of experience of social disadvantage, family sizes and immunisationcompliance. Additional groups were conducted with Arabic mothers and Vietnamese mothers.

The findings of this research indicated a high level of consistency of response across the studysample. Designs which were perceived to portray positive aspects of the Immunisation Programand the loving concern they showed as parents in immunising their children were receivedpositively. The most popular design, “mother and child”, was seen to symbolise the caring parentwho was choosing to protect his or her child though immunisation . Importantly, the child lookedto be happy and healthy, while the parent was perceived to be loving and protective, and therewas no reference to needles as in other designs. The critical implication of this research was thatbecause most parents already feel a level of discomfort about their children receiving an injectionand the child's potential negative reaction to this, let alone the concern of the potential reactionto the vaccine and any resulting side effects, any aspect of the campaign which refers to theinjection aspect of immunisation should be avoided. The study also confirmed the findingsreported earlier of the fundamental support for immunisation amongst parents.

2.3 Exploratory Qualitative Research (September-October 1994)

To provide a greater understanding of current knowledge, beliefs, attitudes and behaviourtowards childhood immunisation for the development of the campaign strategy, Blue MoonResearch and Planning were commissioned to undertake an exploratory qualitative research studywith a range of Australian mothers of children aged under five years (Blue Moon Research andPlanning, 1994b). The research was designed to:

C identify and explore the factors which influence childhood immunisation behaviour andattitudes, and to understand their relative importance in relation to different sectors of thetarget audience; and

C determine the key barriers to appropriate immunisation practices and to provide guidanceas to the kinds of messages, activity and approaches which will be most effective inremoving these barriers.

The target audience of Australian mothers of young children was divided into three segments forthis study:

C mothers with mainly English speaking background;C mothers with particular non-English speaking backgrounds; andC Aboriginal mothers.

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2.3.1 Method

The research was undertaken in New South Wales, Victoria, Queensland and the NorthernTerritory. In each of the group discussions:

C each participant was a mother of a child aged under five years;C some participants were first time mothers while others had additional children;C there was a range of ages represented from infancy to four years amongst the

participants’ children;C there was a range of ages amongst the mothers; andC there was a spread of residential types within each location.

Furthermore for mothers from lower socio-economic backgrounds, participants were screenedin order to ensure representation of mothers:

C who were working, non-working and working part-time;C who were living in areas of social disadvantage;C who were from families with very low incomes;C whose husbands were unemployed;C who had not completed basic secondary education; andC whose older children were not fully immunised.

The English-speaking mothers were recruited to reflect a representative cross-section of mothersin terms of their attitudes and behaviour towards immunisation, the areas in which they lived andtheir socio-economic backgrounds. Two focus groups per location were conducted in NewSouth Wales, Victoria, Queensland and the Northern Territory, in areas broadly reflecting a rangeof factors potentially contributing to immunisation non-compliance, such as socio-economics,geography, population density and type of service delivery. In each area, one group wasconducted with compliers and one with non-compliers. Four further groups were conducted inrural areas, two groups in lower socio-economic areas, and finally two ’conflict’ groups wereconducted with a mixture of ’pro-immunisers’ and ’anti-immunisers’.

Reflecting earlier research which indicated that levels of immunisation amongst Arabic and South-East Asian (non-Chinese) communities tended to be lower, the study also included samples fromthese communities (Blue Moon Research and Planning, 1994c). Six groups comprising mothersfrom Middle Eastern and Asian backgrounds were conducted at community venues in the Auburnand Cabramatta areas of Sydney by researchers from Blue Moon Research and Planning and bi-lingual moderators. Following these groups, a discussion group was conducted with the bi-lingual moderators to compare their findings. In addition, a number of Aboriginal interviewerswere employed to gather information from Aboriginal mothers in a range of NSW locations usinga semi-structured interview schedule. These interviewers in turn reported on their findings in agroup discussion with a moderator from Blue Moon Research and Planning.

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2.3.2 Findings

2.3.2.1 Consumer Segmentation

Blue Moon Research and Planning (Blue Moon) identified six consumer types within the groupparticipants. These were:

C advocates - who are actively, conspicuously pro-immunisation, well informed aboutimmunisation and most likely to be compliant;

C acceptors - who are more passive in their attitudes toward immunisation, hold strongbeliefs in social norms and are firm in their acceptance of immunisation;

C defaulters - who are basically pro-immunisation, but fairly uninvolved in the subject, andwhose failure to immunise usually related to ’not getting around to it’, forgetting or beingunaware of timing and schedules;

C questioners - who are interested in both sides of the immunisation debate. Most are likelyto try to comply if possible, but are looking for ’proof’ to decide the argument one wayor the other;

C lapsed immunisers - who have essentially stopped believing in immunisation, but typicallyfelt uncomfortable and vulnerable about deciding not to immunise. Many now believedthat the risks of immunisation exceeded the risks of the diseases; and

C rejectors - who were similar to the lapsed immunisers, but had found alternativeapproaches to immunisation such as homeopathic or naturopathic approaches. Somewere quite actively anti-immunisation.

Apart from ’rejectors’ who had found alternative immunisation approaches, support for theconcept of immunisation was virtually universal across these groups.

The researchers commented that it was only the rejectors with an absolute belief in theiralternative practices to immunisation who were free of the fear that their child could become illwith a disease that they could have prevented but didn’t.

The majority of pro-immunisation mothers were judged to be ’acceptors’, with ’advocates’comprising a smaller but more influential group. ’Questioners’ appeared to be more prevalent inrural areas. Many ’rejectors’ and ’lapsed immunisers’ had immediate experience of the possibleside effects related to immunisation. This segmentation of consumer types was subsequently usedin further defining the target audience for the campaign and for formulating sample structures fordevelopment and testing of communication materials.

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2.3.2.2 Knowledge and Perceptions

Many spontaneous associations with immunisation were found to be negative (needles, pain,screaming children, possible side effects). Furthermore there was a general concern over whatwas perceived to be an ever increasing number of immunisation injections for children.

Most mothers were reported to prefer having their children immunised at a GP practice ratherthan at a local council clinic where they encountered many screaming children. However, whilesome mothers strongly praised their GP’s approach to immunising their children, others were verycritical. There were perceptions of a wide degree of variation in the advice and guidanceprovided by GPs with respect to:

C the importance of the timing of vaccinations;C contra-indications;C potential side-effects;C location of injections; andC the actual need to immunise.

Furthermore some mothers were suspicious of the government’s motives in actively promotingimmunisation, including consideration of the role of drug companies in influencing thisgovernment initiative for their own profit motives.

The study found that awareness of the diseases against which children could be immunised wasquite high, with ’advocates’ and ’acceptors’ tending not to distinguish between them. ’Questioners’and ’lapsed’ mothers, who were more involved in the immunisation decision-making process, oftenmade distinctions between the diseases according to the perceived risk of contracting the diseaseversus the perceived risks associated with immunisation. Further, Blue Moon reported that “thefacts”, (i.e. that diseases:

C are genuinely capable of causing death, permanent damage;C could strike in Australia at any time;C are much harder to treat without prior immunisation;C will be much more benign if they affect immunised children; andC will return if we don't immunise).

were not broadly known, genuinely believed or top of mind.

With respect to specific diseases, many mothers reportedly don't immunise against measlesbecause it is often thought of as a fairly benign disease. The danger of whooping cough wastypically underestimated in comparison with perceptions of the risks of immunisation. Polio'sperception of seriousness was partly due to memories of common permanent disabilities in theprevious generation. Diphtheria was perceived as a frightening disease but knowledge of whatthe disease actually entailed was very low. Meningitis was well known, perceived as “a modernkiller which strikes quickly and indiscriminately”. Support for immunisation against Hep B wasweak.

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Interestingly, a number of mothers who initially claimed that their children were fully immunised,later acknowledged that this was not the case once they realised the full extent of theimmunisation schedule.

A number of issues were cited as confusing for mothers and clouding ’the truth’ aboutimmunisation. These included perceptions that:-

C immunisation procedures differed between States;C different experts offered different advice;C advice about immunisation and requirements of the schedule changed from year to year;

and thatC it was difficult to find reliable information about the risks of immunisation, arguments

against immunisation, the validity of homeopathic approaches and the ’normal’ range ofside effects of immunisations.

2.3.2.3 Motivations for Immunisation

The vast majority of respondents openly supported child immunisation. Immunisation wasperceived to be the accepted norm and key motivators toward immunisation were identified asemotional ones:

C fear of not being a good mother;C potential guilt if their children did contract disease and were not immunised; andC fear of social ostracism.

Blue Moon also concluded that peer pressure was a powerfully influential factor in immunisationbehaviour. While the majority of mothers were reported to ’feel’ that immunisation is right, theywere also reported to claim that they lacked the rational arguments to support this fundamentalbelief and reassurance that their actions are for the best.

First children seemed to be the most fully immunised as a result of:

C heightened health concerns of new mothers generally;C the influence of authority figures over new mothers;C the strong desire to do ’the best for my child’; andC less experience of side effects.

2.3.2.4 Barriers to Immunisation

Three types of barriers to immunisation emerged from the study:

C practical factors;C medical factors; andC emotional factors.

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Practical Factors

Blue Moon reported that practical barriers appeared to mainly effect mothers with lower socio-economic backgrounds and those with more than two children. These included:

C difficulty in remembering whether the children have been immunised or not;C difficulty in attending venues for immunisation at the appropriate times;C lack of belief in the importance of the precise timing and number of vaccinations; andC lack of awareness of the exact details of immunisation schedules.

Medical Factors

Medical factors were also observed to affect mothers from lower socio-economic backgrounds.These factors included:

C postponing vaccinations because of a perception that their children are too sick to beimmunised;

C lack of belief in the seriousness of particular diseases; andC disillusionment when a child still contracts a disease despite being immunised.

Emotional Factors

Emotional factors operating as barriers to immunisation include:

C fear of retribution as a result of having missed vaccinations; andC fear of possible side effects.

Blue Moon also commented the emotional reactions to the immunisation injections can varyamongst mothers but is usually considerable, especially with young babies.

The research suggested that the combination of these factors may lead to partial or selectiveimmunisation, especially among ’defaulters’.

Specific Concerns

The primary concerns about immunisation expressed by respondents in this research were:

C the risk of side effects;C concerns about the vaccines;C lack of trust in the medical profession;C suspicion of the Government’s motives;C interference with natural immunity; andC confusion about the facts.

The greatest concerns related to potential side effects, which for some mothers were perceivedas the frightening risk of long-term, serious disability. In the research groups many respondentsappeared to know someone whose child had been seriously affected. Approximately half of

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respondents had experienced short-term side effects, ranging from prolonged screaming and feverthrough to uncomfortable swellings and temporary paralysis. Because many of these side effectswere unexpected by mothers, there was often emotional stress associated with them, and aconcomitant questioning of their doctors and the immunisation process generally.

Amongst the sample of mothers from Middle Eastern and Asian backgrounds, Blue Moonreported little evidence of any significant cultural barriers to immunisation. Overall, they foundthat these mothers were more pro-immunisation than their English-speaking backgroundcounterparts, and were more focused upon the risks of the diseases and valued the opportunityoffered by health services in Australia to immunise their children. It appeared that with thesemothers, one of the key reasons for not fully immunising their children relates to communicationproblems, and lack of awareness or confusion related to timings, schedules and contraindications.

Amongst the small sample of Aboriginal mothers included in the study, non-compliance appearedto be related to practical difficulties associated with visiting immunisation centres, such ascomplications of large families and complexities of schedules. In addition to physical difficultiesof accessing services, Blue Moon also reported indications that there could be problems ofcompliance if trust did not develop between Aboriginal mothers and particular service providers.

2.3.2.5 Threats to Immunisation

In terms of potential threats to high national immunisation levels, the study indicated that despitevery high levels of support for immunisation, mothers had very few rational arguments to supportthis fundamental belief. Blue Moon suggested that there was a real danger that the argumentsagainst immunisation would become more and more compelling unless they were counteredeffectively and quickly. In support for this concern, they pointed to:

C the increasing numbers of immunisations;C the tendency to become selective, to partially immunise;C the more immediate, emotional, threat of side effects; andC confusion, misunderstanding and misinformation regarding immunisation procedures and

effectiveness.

It also appeared that the more experienced with immunisation that mothers became, the morelikely they were to have experienced or heard about side effects, and to have heard differentversions of “the truth” about immunisation over time. Experienced mothers became more of anon-compliance risk as additional children increased the practical problems of complying, and asthe chances of side effects multiplied and the risk of disease appeared more remote.

In addition it seemed that anti-immunisation stories were perceived as more compelling anddisturbing than pro-immunisation ones.

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2.3.2.6 Communication and Information Needs

In discussing their sources of information about immunisation, mothers most commonly cited:

C hospital information packs;C infant welfare centres;C GP’s and other practitioners;C media (particularly television and magazines); andC their own mothers and other mothers.

The hospital books were seen as an invaluable resource in the baby’s early months but werereported to be consulted less often and forgotten over time.

Blue Moon concluded that mothers were generally looking for a consistent, credible statementof the facts to re-assure them about immunisation and to give them sufficient information onwhich to base their decisions. In addition to addressing issues around the immunisation debate,there was a need for clear information about when and how to ensure that children are fullyimmunised, the risks of not complying and typical short term side effects from vaccinations.

Blue Moon reported that much of the information about immunisation that was available at thetime of the study was regarded by mothers as “inadequate, confusing and biased (according towhich side you're on)”. Medical sources tended to be accepted by inexperienced mothers, butbecame questioned more often as mother's own experience with immunisation grew and theyencountered contradictory advice and, at times, a lack of knowledge of the diseases andcontraindications. Many mothers reported irritation with practitioners who failed to respect theirconcerns and insisted on telling mothers what to do but not giving them reasons to justify thisadvice.

It did appear from the research that there was a strong interest in, and desire for, moreinformation to respond to the concerns, and numerous questions respondents had aboutimmunisation. Of the six consumer type segments outlined earlier, Blue Moon pointed to threekey segments for targeting with communication activities: defaulters, questioners and acceptors.Importantly, defaulters and acceptors may fail to fully immunise essentially because of lack ofinvolvement and lack of awareness of immunisation requirements.

The different consumer types reflected differing communication needs. Blue Moon reported thatthe following emerged as key communication considerations for each of the consumer segments:

Advocates: Clear, concise information and arguments would support advocates in theirpromotion of immunisation.

Acceptors: While some acceptors were not interested in anything more about immunisation otherthan reassurance that they were acting appropriately and were up to date, they nevertheless wouldbenefit from encouragement not to default. Useful information would include details of theschedule and timing of individual vaccinations in a clear, concise format.

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Defaulters: In addition to generating greater awareness of opportunities for immunisation andfacilitating the role of practical reminder systems, communication to defaulters should seek tocreate a greater level of involvement in the subject and provide greater encouragement to fullyimmunise.

Questioners: Both pro-immunisation and anti-immunisation arguments need to be presented ina constructive and balanced way for questioners. What is important with this segment is toaddress the immunisation debate, affording the two sides of the debate the appropriate weightingaccording to the facts.

Lapsed Immunisers and Rejectors: Many lapsed immunisers and rejectors tended to view pro-immunisation information and arguments as being biased. These mothers always wanted to hearthe other side of the argument, and would invariably support this alternate argument.Presentation of these counter-arguments to immunisation risks inadvertently reinforcing suchalternate views. Blue Moon suggested that while communication activities may have little impactin achieving greater understanding of the benefits of immunisation amongst these mothers, theincreased focus and immunisation compliance amongst the community generally may exert suchan influence.

The recognition of the propensity for mothers to selectively attend to and interpret particularinformation about immunisation according to their own current beliefs and attitudes became a keyconsideration in determining the campaign strategy, media mix and communication materials.

3. CAMPAIGN DEVELOPMENT AND IMPLEMENTATION

3.1 Target Audience

The target audience for the communication campaign was designated as parents, particularlymothers, of children aged 0-5 years.

3.2 Campaign Objectives

Within the framework of The National Immunisation Strategy and in light of the findings of thedevelopmental research, a number of communication objectives were set for the campaign asfollows:

Awareness

To increase and reinforce awareness:

C of the benefits of immunisation in protecting children from diseases;C that the risks associated with the diseases are dramatically greater than the risks of side

effects from the vaccines;C of the need for full immunisation to maximise protection; andC that standard children’s vaccines are free.

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Attitudes

C to increase and reinforce the existing positive attitudes to childhood immunisation byindicating that immunisation is both the appropriate way to care for children and animportant aspect of being a “responsible” parent as well as the rational thing to do; and

C to undermine negative attitudes towards immunisation and reduce fears of possible sideeffects of vaccines.

Intentions

To encourage and reinforce intentions to:

C review their children's current levels of immunisation coverage;C initiate and complete age-appropriate childhood immunisation; andC obtain more qualified information on childhood immunisation from appropriate service

and information providers.

3.3 “Understanding Childhood Immunisation” Information Booklet Pre-testing Research (February, 1995)

As part of the National Immunisation Education Program, an information booklet was producedfor parents and their extended family. The booklet was planned as a full colour, illustrated A5information and reference booklet.

The booklet was designed to answer the questions and address the concerns about childhoodimmunisation identified in the pre-campaign developmental research (Blue Moon Research andPlanning, 1994b). In line with the communication objectives of the proposed educationcampaign, the content of the booklet was written to inform parents about childhoodimmunisation, increase positive attitudes towards immunisation and to prompt parents to reviewtheir children’s immunisation status.

Using the six consumer type segments identified in their earlier research, Blue Moon Researchand Planning were commissioned to undertake a qualitative research study with Australianmothers of children aged five years and under to evaluate the draft (mock-up) booklet in termsof its overall appeal and usefulness, accessibility, credibility, presentation and layout, andlanguage appropriateness in line with these objectives. The study also sought to explore the mostappropriate method of distribution for the booklet (Blue Moon Research and Planning, 1995a).

While the draft version of the booklet was generally assessed as performing well against theseobjectives and showing potential to be a key resource for the future campaign, the researchersprovided direction for a range of both minor and more significant changes to improve the draft,as well as recommendations for distribution channels. The research also led to the title of thebooklet becoming “Understanding Childhood Immunisation.”

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3.4 Advertising Development Research (March-August 1995)

Four separate stages of advertising development research were undertaken for the communityeducation campaign by Blue Moon Research and Planning (1995b). There were as follows:

i) Assessing creative submissionsThe campaign was the subject of a competitive pitch by five advertising agencies. This initialstage of research was designed to identify the most effective creative concepts in terms of theirperformance against campaign communication objectives.

ii) Further development of campaign television commercialsFollowing the identification of the most effective creative concepts, further research wasundertaken to refine these concepts for production.

iii) Development of 1800 telephone message and further development of print conceptsAdditional research was required to explore consumer reaction to a proposed script for a 1800telephone message and to three print concepts designed to support the television commercials.

iv) Final testingA final stage of research was undertaken to test and guide any fine-tuning of the television andprint advertisements. In each of the four stages of research the ’consumer type’ segments wereused to design study samples and to explore particular reactions to the concept materials andadvertisements. However, as it was felt that the ’rejector’ group would not be significantlyaffected by the communication campaign, this group was not included in study samples.

In each stage, these samples included a range of mothers with children aged five years andyounger, including:

C first time mothers as well as mothers of two or more children;C working, non-working and part-time working mothers;C mothers utilizing different health advisers and service providers; and C disadvantaged mothers (e.g. unemployed, low income, single parent, low education).

Two specific target groups were also included in particular stages of the research. Aboriginal andTorres Strait Islander mothers with children aged five years or younger were included in stage(i), while health professionals with regular contact with mothers and young children wereincluded in stages (i) and (ii).

A detailed outline of samples for each stage of research are provided in the report on these studiesprepared by Blue Moon Research and Planning (1995b). A focus group methodology wasemployed throughout these advertising development research studies.

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3.4.1 Outcomes

In stage (i) seven campaign concepts were researched (rotated through the research groups). Inassessing concepts, Blue Moon were cognisant of the need for a successful concept to performagainst the designated communication concepts across the range of consumer types. Ideally itshould represent a campaign idea which:

C advocates would champion;C acceptors would be reassured by;C defaulters would be spurred into action by;C questioners would find useful and accept; and that C rejectors would find difficult to dispute.

In terms of consumer response, an effective concept was viewed as needing to provide:-

C impact;C identification;C a sense of urgency;C a sense of danger and risk for non-immunisers;C a motivation and opportunity to respond positively; andC a demonstration that immunisation is the best option.

Throughout the four stages of research, a significant level of development and refinement ofcommunication materials took place. At the conclusion of the final stage, Blue Moon reportedthat the proposed campaign had the potential to fulfil its designated campaign communicationobjectives. The key messages from the advertising which the researchers judged to be operatingas clear, powerful and motivating for target audience mothers in the studies were:

C these diseases pose a real threat to our children;C immunisation offers the best protection against these diseases; and thatC the time to act is now.

The key strengths of the proposed campaign were identified by the researchers as:

C its impact;C its clear, powerful call to action;C its communication that the diseases threatening children are real and that immunisation

is the best protection; and C its ability to raise concern but also offer hope and solutions.

The campaign was implemented without further modification following the final stage of thisresearch. A step by step outline of the studies is provided in Blue Moon Research and Planning(1995b).

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4. CAMPAIGN IMPLEMENTATION

The national mass media community education campaign was implemented from October 22,1995 to 31 January, 1996. The campaign comprised five main components as follows:

C television commercials which ran nationally from 22 October, 1995 to 8 November, 1995;C print advertisements which appeared in national women’s magazines from 29 October,

1995 to 29 January, 1996;C advertisements appearing on capital city bus and tram exteriors and interiors from 1

November, 1995 to 31 January, 1996 (excluding Darwin where outdoor posters wereplaced);

C a ’Superbus’ (totally painted as a campaign advertisement) commissioned in each ofSydney, Melbourne, Brisbane, Adelaide and Perth;

C posters distributed through doctors surgeries and baby health clinics; andC advertisements and “infomercials” appearing on Good Health Television, a video

presentation which appears in waiting rooms in 1,300 doctors surgeries around Australia,from 1 November, 1995 to 31 January, 1996.

The total cost of the media was approximately $1.1 million.

Supplementing the campaign was the distribution of the booklet “Understanding ChildhoodImmunisation”. The booklet was promoted through the campaign and distributed via doctors'surgeries, baby health clinics and a 1800 telephone number which appeared on the advertisingmaterial.

In addition to the mainstream media buy, there was a component of the community educationcampaign which targeted people from non-English speaking backgrounds (NESB), includingradio advertising and brochure production. A separate report on this component has beenprepared by Cultural Perspectives, the agency responsible for its implementation (CulturalPerspectives, 1996). The report covers campaign development, implementation and evaluationof the campaign and recommendations for future campaign strategies, including the key role ofethnic radio.

5. CAMPAIGN EVALUATION

A national quantitative study was carried out in October 1995, prior to the launch of campaignactivity. This study served as a benchmark against which a later tracking study could comparechanges in community attitudes, knowledge and behaviour. This tracking study was undertakenin February 1996 and adopted an identical methodology to the benchmark survey, but includedadditional campaign awareness and processing measures.

5.1 Method

Each study was conducted by telephone with a national systematic probability sample ofhouseholds containing children aged 0-6 years (benchmark n=804; tracking n=806). The personin the household mainly responsible for the child/children's health care was interviewed. Thecurrent CD-ROM white pages listing served as the initial sampling frame. Within each

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metropolitan and non-metropolitan region, geographic coverage of the target population wascontrolled through a stratification by postcode based on the ABS CDATA91 reports of theproportion of the population age 0-5 years within each post-code. This design provided acomplete national coverage, allowing for some over-sampling within postcodes where 0-5 yearolds comprise 9% or more of the population, with subsequent under-sampling within postcodeswhere 0-5 year olds comprised less that 9% of the population. Survey results were thenreweighted in line with the sample stratification to reflect the overall distribution of children aged0-6 years, and of households with children aged 0-6 years. Both the benchmark and trackingstudies were carried out by The Wallis Consulting Group.

Further methodological details are available in the separate reports from the two studies(benchmark: Research and Marketing Group, 1996a; tracking: Research and Marketing Group,1996b).

5.2 Findings

5.2.1 Campaign awareness, processing and action

Indicating an overall campaign awareness effect, the proportion of respondents who reportedrecently seeing, hearing or reading something about child immunisation increased from 64% inthe benchmark study to 79% in the tracking study. Respondents reporting this awareness overthe last three months (the period of the campaign) also increased (from 42% in the benchmarkto 58% in the tracking study). The most commonly cited sources of information were television(49%) and newspapers (19%). The television awareness figure had increased from 26% in thebenchmark study.

Unprompted awareness of the television commercial was 30%, with prompted awarenessreaching 49%. The most frequently reported message from the commercial was “because fewerchildren are being immunised, childhood diseases are returning” (25% of those aware of thecommercial).

In terms of processing the campaign communication, 59% of those aware of the commercialreported that seeing it had made them think about their child/children's immunisation, with themost common responses being “determined to ensure my child is up to date” (28%) and“concerned about the risk of my child catching the disease” (16%). Furthermore, 5% ofrespondents who reported seeing the television commercial also reported that they had arrangedfor immunisations as a result of this. (At a national level this proportion represents approximately19,000 households).

Prompted awareness measures for other media were 13% for the magazine advertisement, 9%for transit advertising, and 26% for the campaign poster. Considering the campaign activities asa whole, 63% of respondents reported awareness of at least one campaign element. Similarcommunication messages to that reported from the television commercial were reported for othermedia.

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Consistent with the benchmark study, approximately one-third of respondents in the trackingstudy (32%) indicated that they had looked through or read the “Understanding ChildhoodImmunisation” booklet. Only three respondents in the tracking survey, however, indicated thatthey had received the booklet by calling the 1800 telephone number promoted in the campaign.

The majority of respondents in both surveys reported that it was easy to obtain information onchildhood immunisation (93% benchmark, 92% tracking) and that they were confident that theyhad enough information about childhood immunisation (87% benchmark, 86% tracking).

The most popular place to receive more information amongst respondents was their own doctor(67% benchmark, 73% tracking), followed by a baby health clinic (19% benchmark; 29%tracking).

5.2.2 Support for Immunisation

Stated support for immunisation was almost universal in both surveys (98%, 97%), with 16% ofrespondents in both surveys reporting that they 'supported' childhood immunisation and 82% and81% in the benchmark and tracking studies respectively reporting that they 'strongly supported'childhood immunisation.

Changes in agreement to two attitude statements included in the questionnaire suggest thatacceptance of childhood immunisation as the community norm has increased over the campaignperiod. The proportion of respondents 'strongly agreeing' that “parents who don't have theirchildren fully immunised are irresponsible” increased from 28% in the benchmark to 36% in thetracking survey. Overall agreement (agree and strongly agree) increased from 68% to 75%.

Consistently, while overall agreement with the statement “it is difficult to decide whether youshould have your children immunised or not” remained consistent between the two surveys(86%), the proportion of respondents 'strongly disagreeing' with the statement increased from39% in the benchmark to 49% in the tracking survey.

5.2.3 The Immunisation Schedule

There was quite a range of responses in both surveys regarding awareness of particular childhooddiseases. In terms of the recommended schedule for childhood immunisation (which featured inthe campaign magazine advertising), there was an increase in respondents correctly reporting theneed for immunisation at six months (from 58% in the benchmark to 64% in the tracking) and attwelve months (50% to 58%) and at five years (45% to 56%), but a decrease in respondentscorrectly reporting the need for immunisation at two months (51% in the benchmark to 45% inthe tracking study). While the most commonly reported source to check or find out about theschedule in both surveys was 'own doctor', there was an increase between the two surveys in theproportion of respondents reporting 'childhood immunisation booklet' (14% to 21%), 'baby healthclinic' (16% to 23%), 'child's personal health record' (25% to 30%) and 'own doctor' (33% to44%). This general increase in reporting options is consistent with an increased salience of theissue and consequent discussion of immunisation matters during the campaign.

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Between the two surveys there was also an increase in the proportion of respondents whoconsidered that all diseases on the current schedule were essential (from 35% in the benchmarkto 54% in the tracking survey). Similarly, there was an increase in the proportion of respondentsagreeing with the statement ’if you miss a particular immunisation, it is never too late to catch up’(from 79% to 83%). Other knowledge measures showed no change between the surveys.

5.2.4 Benefits of Immunisation

When asked about their perceptions of the major benefits of immunisation, the most commonlyreported responses were “protect the child against disease” (increased from 75% in thebenchmark to 83% in the tracking study) and “protect the community against disease/epidemics”(decreased from 36% in the benchmark to 26% in the tracking study).

5.2.5 Problems and Difficulties with Immunisation

Respondents were similarly probed about their perceptions, if any, of problems or difficultiesassociated with childhood immunisation. The most frequently reported issue (consistent with thedevelopmental study outlined earlier) was “side effects of vaccines” (43% in the benchmark studyand 42% in the tracking study). The second most commonly reported aspect of immunisationwas “irritability/pain as a result of the injection” (20% in the tracking study and 19% in thebenchmark). Also consistent between the two surveys was the fact that one in ten respondentsreported that there were no problems or difficulties and approximately one in five respondents(18% in the benchmark and 20% in the tracking study) reported that they didn't know if therewere any such problems.

Overall there was an increase in the proportion of respondents who expressed concern aboutserious ill-effects associated with immunisation (from 30% to 37%). The proportions ofrespondents who reported being 'very concerned' or 'extremely concerned' were 13% in thebenchmark and 16% in the tracking study.

In terms of specific barriers to immunisation, there was an increase between the two surveys inthe proportion of respondents agreeing that “having a child immunised can be as distressing forthe parents as it is for the child” (from 56% to 61%) and “I find it difficult to remember when mychild's immunisations are due” (from 20% to 26%). As in the benchmark survey, respondentswho had missed or were late for an immunisation were more likely than those who hadn't missedone to agree with the distressing nature of immunisations for the parents.

5.2.6 Behaviour and Intention

The majority of respondents reported taking their children to be immunised at a doctor's surgery(62% benchmark; 59% tracking). There was an increase from 22% in the benchmark to 29% inthe tracking study in the proportion of respondents who reported taking their child to beimmunised in the last three months. However, the proportion of respondents reporting that theirchild/ren were immunised in the last twelve months was consistent between the two surveys (65%benchmark; 62% tracking).

In both surveys, 79% of respondents reported that they would be “extremely likely” to catch-upif their child missed an immunisation. A further 14% reported that they would be “very likely”

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to catch up (16% in the benchmark). The proportion of respondents who indicated that theywould do this within two weeks increased from 66% in the benchmark to 73% in the trackingsurvey.

Very high proportion of respondents in both the benchmark survey (94%) and the tracking survey(92%) reported that their child/ren were up-to-date with immunisations. This perceptioncontrasts strongly with the 33% proportion of children who were reportedly fully immunised inthe 1995 National Health Survey according to the current schedule. In comparison with schedulein place during the 1989-90 National Health Survey when 53% of children were reported to befully immunised, the 1995 National Survey immunisation level was 52%.

6. PERFORMANCE OF THE CAMPAIGN AGAINST ITS OBJECTIVES

A number of communication objectives were set for the campaign as indicated earlier at 3.2.However, after the considerable input from the various stakeholders in the campaign, directquantification of the achievement of these final objectives through the final benchmark andtracking survey instruments becomes difficult. Nevertheless, this section will present a generalassessment of the campaign’s performance against the objectives.

The campaign evaluation adopted an advertising model (e.g. Flay and Cook, 1989) with twonational quantitative surveys, conducted prior to commencement of campaign activity, (October1995) and at the conclusion of the initial wave of this activity (February 1996). The timing inthese surveys is, in itself problematic with respect to interpretation of survey findings since thecampaign was staged at the time of year when it may be most likely that increased immunisationbehaviour could be stimulated. A second tracking study was planned for August 1996, when themaintenance of campaign effects could be measured, but a decision was made not to proceed withthis survey once the campaign was suspended in February.

6.1 Campaign reach and communication

Assessing campaign effects within an information processing paradigm (e.g. McGuire, 1985)requires an initial focus on proximial measures of effect such as exposure, attention andcomprehension. The benchmark survey measured the ’background’ level of exposure toimmunisation issues, with 64% of respondents indicating that they had recently ’seen, heard orread something about child immunisation.’ In the tracking survey following this initial wave ofcampaign activity four months later, this level of reported exposure to immunisation issues hadincreased to 79%, with television being cited as the primary source of this exposure.

An unprompted awareness level of 30% and prompted awareness level of 49% for the campaigntelevision commercial is quite reasonable given that the commercial was only broadcast ontelevision for a total period of eighteen days (22 October to 8 November, 1995), three monthsprior to the tracking survey. Exposure of the commercial was, however, supplemented throughinclusion on Good Health Television in 1300 doctors’ surgeries. Nevertheless this televisioncomponent of the media campaign was very brief and relatively light in media terms(approximately 300 Target Audience Rating Points for the total television buy).

Awareness levels for other support media, magazine (13%) and transit (9%), were predictablylower, although awareness of the campaign poster was unexpectedly high (26%). This poster

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This is something of an imperfect science on Australian television, however, since the 1

commercial breaks on the three networks are not synchronised as is the case in some other countries like the United Kingdom.

Within a long term campaign, such a high reach launch strategy may be very 2

productive in quickly establishing awareness levels which can then be effectively reinforced.

awareness figure was prompted by describing the distinctive yellow handprint from the poster,and given that the creative styles of this poster and the magazine advertisement were virtuallyidentical, there may have been some positive generalization across these media (as intended withinthe campaign creative strategy). Overall, with approximately two-thirds of respondents reportingawareness of some aspect of the campaign for a media spend of $1.1 million, the campaign’sperformance on audience reach was quite reasonable for this parent target audience. [Higherawareness levels can be achieved more easily with teenage target audiences, as evidenced in thealmost universal reach of some Drug Offensive campaigns (e.g. see Carroll, 1996)].

The most commonly reported message from the television commercial (“because fewer childrenare being immunised, childhood diseases are returning”) was consistent with the content of thecommercial. The fact that 72% of respondents who recalled the television commercial could notreport a specific message embodied in it, may at first suggest a deficiency in the commercial's callto action. However, it should be noted that the strategic role of the commercial in this first phaseof what was planned as a longer term campaign was to increase the position of immunisationissues on the public agenda, with support media and the booklet “Understanding ChildhoodImmunisation” playing the role of providing more specific information to meet the needsindicated in the pre-campaign developmental research. Nevertheless, when assessing cognitiveeffects of the communication, the fact that 59% of those aware of the commercial reported thatit had made them think about their child/ren's immunisation [most common responses: 'determinedto ensure my child is up to date' (28%) and 'concerned about the risk of my child catching thedisease' (16%) ] suggests that this component of the campaign has had a reasonable impact,despite the poor information storage of the commercial's content or specific message.

The media scheduling for the television component of the campaign also needs to be consideredin interpreting these findings. A Sunday night 'roadblock' strategy (buying spots across each ofthe commercial networks at the same time ) was adopted to launch the campaign. As buying1

spots in each of the Sunday night movies is expensive (28.5% of the total television buy) such astrategy sacrifices duration of an effective buy for very high initial audience reach [i.e. repetitionof exposure (frequency) for reach]. Effective communication may have occurred, includingagenda setting effects resulting from exposure to the commercial and consequent and contextualexposure to discussion of immunisation, but this exposure was short-lived owing to the very brieftelevision schedule.2

The content of message recall from the magazine component of the campaign was consistent withthat reported for the television commercial, and suggests that the campaign components wereworking together as a whole campaign.

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6.2 Awareness objectives

The awareness objectives for the campaign sought to address the key issues of:

C the benefits of immunisation;C risks of immunisation versus risks of disease;C the need for full immunisation; andC the lack of cost for immunisation.

With respect to the benefits of immunisation, there appears to have been a shift in parentalperceptions from the community level to the personal, individual level over the period of thecampaign. The increase in perception that the major benefit of immunisation was “to protect thechild against disease” from 75% to 83% may suggest an increase in personal relevance of theimmunisation issue, a positive indicator in behaviour change processes (e.g. The Health BeliefsModel, Rosenstock 1974).

At the same time there appears to have been an increase in the salience of the potential side-effects associated with immunisation. Not surprisingly, the two most commonly citedproblems/difficulties associated with immunisation in the pre-campaign developmental research,'side effects of the vaccines' and 'irritability/pain as a result of the injection' remain as the principleconcerns reported in both the benchmark and tracking studies. The proportions of respondentsconfirming these as the key concerns are consistent in these two surveys. However, the levelsof concern about serious ill-effects associated with immunisation actually increased between thetwo surveys form 30% to 37% of respondents reporting such concern (and levels of 'extremelyconcerned' rose from 13% to 16%). The increase in reporting that “having a child immunised canbe as distressing for the parents as it is for the child” between the surveys (56% to 61%) is alsoconsistent with the increased salience of these concerns.

This potential increase in salience of such concerns was foreshadowed in the pre-campaigndevelopmental research. Blue Moon (1994b) pointed to the risk that if the issue of side-effectsof vaccinations (which could easily be sensationalised) received more focus without beingcountered effectively and quickly, then these anti-immunisation arguments could become morecompelling. In weighing up the implications of this finding, it is useful to review the levels ofsupport for immunisation in the two surveys. This level of support for immunisation was virtuallycomplete (98%) in the benchmark survey, with 82% 'strongly supporting' immunisation. If theraised level of concern about side effects of immunisation was resulting in parents losingconfidence in the immunisation process, it would follow that levels of support for immunisationshould diminish. This was not in fact the case, with the level of overall support for immunisationand 'strong support' both remaining consistent (97% and 81% respectively).

The campaign appears to have performed well in its attempts to increase awareness of the needfor full immunisation with a strong increase in the proportion of respondents indicating theybelieved that all diseases on the current schedule were essential (from 35% to 54%). Thisincrease in perception of the essential nature of immunisation was also demonstrated for specificdiseases (tuberculosis, mumps, rubella and measles). The increase in respondents reporting thatthey find it difficult to remember when their child's immunisations are due (20% to 26%) reflectthis increased awareness of the full extent of the immunisation schedule. The issue of cost ofimmunisation was not included in the final campaign strategy and hence perceptions of the cost

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of immunisation were not measured in the surveys.

6.3 Attitudinal Objectives

The attitudinal objectives of the campaign focused on:

- normalising immunisation as a key aspect of responsible parenting; and- undermining negative attitudes towards immunisation and reducing fears of

possible side effects of vaccines.

The significant increase in parents 'strongly agreeing' that “parents who don't have their childrenfully immunised are irresponsible” (28% to 36%) and overall increase in agreement (68% to 75%)with this statement, can be seen as an indication of performance against the objective ofnormalising immunisation as a key aspect of responsible parenting. Consistent with this was theincrease in parents who 'strongly disagreed' that it is 'difficult to decide whether you should haveyour children immunised or not' (39% to 49%).

As discussed earlier, it appears that over the course of the campaign levels of concern aboutpossible side-effects of vaccines actually increased. While this increase in concern does notappear to have eroded support for immunisation in the community, the campaign could not bejudged to have performed well against the objective of reducing fears of possible side-effects ofvaccines.

6.4 Intention Objectives

The intention objectives set for the campaign focused on:

C reviewing children's current levels of immunisation coverage,C initiating and completing age-appropriate childhood immunisation;C obtaining more qualified information on childhood immunisation.

On the measure of ease in obtaining information about immunisation (93% benchmark, 92%tracking) and confidence in having enough information about childhood immunisation (87%benchmark, 86% tracking), the majority of respondents reported high levels of satisfaction in bothsurveys. The campaign did not appear to affect these measures which seem higher than wouldhave been predicted from the pre-campaign developmental research.

There was however, some indication of a greater sense of urgency about immunisation after thecampaign with an increase in the proportion of parents who indicated they would 'catch-up' withintwo weeks if their child missed an immunisation (66% to 73%).

While the proportion of parents reporting that their children were immunised in the last twelvemonths was consistent between the surveys (65% benchmark, 62% tracking), there was areported increase in those taking their children to be immunised over the period of the campaign(last three months, 22% to 29%). This reported increase is certainly consistent with otherfindings of this campaign assessment (despite the increase in concern about possible side effects),however any direct causality cannot be confidently attributed to specific campaign effects. Giventhe agenda setting nature of this campaign approach and the consequent stimulation of discussion

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and debate about the immunisation issues stimulated by the campaign, a simple comparison ofthose aware or unaware of a component of the campaign (e.g. television commercial), in orderto assess a direct campaign effect, would be clearly flawed. Indeed, such an approach has beenlong discredited in the communication literature (e.g. Klapper, 1960). Independent examinationof immunisation data needs to be undertaken over a longer period to compare the campaignsurvey trend in reported behaviour with this service provider data, to both measure consistencyand to compare trends over this period in previous years (including consideration of othercontemporaneous influences which could also have affected these trends over the campaignperiod). It is understood such an assessment will be made within the National ImmunisationProgram Evaluation.

7. IMPLICATIONS FOR FURTHER CAMPAIGN ACTIVITIES

There are clearly very high levels of public support for childhood immunisation, and there appearsto be increasing public pressure for immunisation to be seen as the ’responsible’ practice forparents to undertake.

While knowledge of the particular diseases which need to be covered in a child’s immunisationschedule, and of the schedule itself, is relatively low, support for immunisation against all diseaseson the schedule has grown over the course of the campaign. Of particular concern though, is thesignificant discrepancy between perceptions of children being fully immunised among respondentsin these surveys and the findings of the National Health Surveys. While a demand characteristicof reporting immunisation compliance may well be present in the campaign survey, the findingssuggest that there may be real deficits in understanding of what full immunisation actually entails.This of course has clear implications for the next stage of education activity.

It would seem from the campaign developmental research, perceptions of the severity ofchildhood diseases provides a strong motivation toward child immunisation and this is reflectedin the high levels of support for immunisation evidenced in the campaign evaluation surveys.Increased indications of acceptance of childhood immunisation as a community norm is also apositive finding. Furthermore, while approximately one out of six parents/guardians (16%)expressed strong concern about serious side effects associated with immunisation, the high levelof support for immunisation would seem to suggest that the majority of parents/guardiansbelieve that the risk of the diseases outweighs the risks of immunisation and the trauma associatedwith it. In addition, there appears to be significant motivation for parents’/guardians to want to“catch-up” quickly where their child has missed an immunisation.

The challenge then, and the opportunity, for the next phase of public education would seem tolie in increasing awareness of the importance of full immunisation and what full childhoodimmunisation actually entails, thereby capitalizing upon this motivation. Nevertheless, thesignificant level of emotional distress which parents associate with the immunisation experiencemustn't be ignored. This emotional barrier has potential to override the cognitive decision toimmunise and generate reasons why not to undertake the immunisation today. This should becounterbalanced by a greater level of emotional arousal in the campaign which should seek togenerate a greater sense of urgency surrounding immunisation. There may also be a strategic rolefor modelling positive emotion associated with carrying out this protective parenting behaviourfor your child/children.

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At the same time, education efforts with service providers regarding the latest immunisationschedule and recommendations, and strategies to increase opportunistic immunisation, are clearlynecessary. This could include promoting awareness amongst service providers of the high levelsof community support for childhood immunisation. It would appear that development of acombination of complementary strategies which would both increase consumer motivation toexamine whether a child really is fully immunised and at the same time promote accurateopportunistic immunisation amongst service providers should be considered.

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References

Bazeley, P. and Kemp, L. (1994). Childhood Immunisation: The role of parents and service providers.A review of the literature. July 1994.

Blue Moon Research and Planning (1994a) Immunisation Education Campaign. Exploratory QualitativeResearch with Mothers of Children Under Five. Logo Design Research Report. October, 1994.

Blue Moon Research and Planning (1994b). Immunisation Education Campaign. Exploratory QualitativeResearch with Mothers of Children Under Five. November, 1994.

Blue Moon Research and Planning (1994c). Immunisation Education Campaign. Exploratory qualitativeresearch with NESB and Aboriginal Mothers of Children Under Five. November, 1994.

Blue Moon Research and Planning (1995a). National Childhood Immunisation Program. Booklet Pre-Testing Research Report. February, 1995.

Blue Moon Research and Planning (1995b). National Immunisation Education Campaign. Advertisingdevelopment from pre-testing creative submissions through to testing finished advertising final researchreport. September, 1995.

Carroll, T. (1996). The Role of Social Marketing Campaigns Within Australia’s National Drug Strategy.A submission to the National Drug Strategy Evaluation 1996. Commonwealth Department of Health andFamily Services, November, 1996.

Cultural Perspectives, (1996). Department of Human Services and Health. Immunisation Evaluation. VolsI and II. February, 1996.

Flay, B.R. and Cook, T. D. (1989). Three models for evaluating prevention campaigns with a mass mediacomponent. In R.E. Rice and C.K. Atkin (eds) Public Communication Campaigns (2nd edition) NewburyPark: Sage: 175-196.

Klapper, J. T. (1960). The Effects of Mass Communication. Glencoe, Illinois: The Free Press.

McGuire, W.J. (1985). Attitudes and attitude change. In: G. Lindzey and E. Aronson (eds.), Handbook ofSocial Psychology, (3rd edition) Vol 2. New York: Random House: 233-346.

National Health and Medical Research Council, (1993). National Immunisation Strategy. AGPS. April,1993.

Public Affairs and International Branch Research Report, (1996a). Immunisation Campaign BenchmarkSurvey. January, 1996.

Public Affairs and International Branch Research Report, (1996b). Immunisation Campaign TrackingSurvey. April, 1996.

Rosenstock I.M. (1974). The health belief model and preventive health behaviour, Health EducationMonograph, 2(4), 1974.