A Case Study In Public Health Social Marketing: The Immunise Australia program*

Tom E Carroll
Laurie Van Veen

Introduction
The application of social marketing principles in health promotion campaigns has gained increased acceptance within the public health field and by governments over the last two and half decades in Australia. During the 1980�s and 1990�s, Australia has undertaken state-wide and national campaigns targeting a range of health issues including tobacco prevention and cessation, alcohol abuse, illicit drug use, HIV/AIDS prevention, cervical cancer screening, breast cancer screening and discrimination against people with mental illness and people with HIV. The case study presented here represents the application of social marketing theory and practice to increase the levels of full age-appropriate childhood immunisation as part of the Immunise Australia Program.
The Challenge
Increasing the levels of age-appropriate childhood immunisation in Australia has proven a public health challenge. A significant proportion of Australian children were not being immunised in accordance with the schedule recommended by Australia�s National Health and Medical Research Council. In 1995, an Australian Bureau of Statistics survey found that only 33 per cent of Australian children aged up to 6 years were fully immunised according to the schedule being recommended at the time and 52 per cent assessed as being fully immunised according to the previous schedule (ABS, 1996).
The Response
In response to this situation, the Australian Government formulated the Immunise Australia Program. This Program comprised a number of initiatives including:

■ improvements to immunisation practice and service delivery;
■ establishment of a National Centre for Immunisation Research and Surveillance;
■ negotiation with State and Territory Governments to introduce requirements for immunisation prior to commencing school;
■ financial incentives for doctors and parents/guardians;
■ a national childhood immunisation education campaign; and
■ a specific Measles Control Campaign.

While recognizing the key role played by structural and policy reform within the formulation and implementation of a national population health strategy, this case study will primarily focus on the social marketing components of this strategy.
A Social Marketing Approach
Reported effectiveness of mass-media campaigns to promote immunisation has varied (Bazeley and Kemp, 1994). Campaigns supported by community level activities, longer-term reminder systems, and incorporating service provider strategies, appear to offer greatest potential (ibid). The contribution of a social marketing approach to designing strategies to increase population immunisation levels has been previously recognised in the Australian context (Nutbeam, 1991; Donovan and Robinson, 1991). The application of these social marketing principles and particularly the role of formative research, is illustrated through the development of the Immunise Australia Community Education Campaign, and in its comprehensive integrated approach.
Formative Research
Extensive formative research was carried out to guide the development, implementation and evaluation of Australian campaigns to promote greater levels of child immunisation in 1995, 1997 and 1998.

One of the key roles for formative research was to gain an understanding of the perceived costs and benefits associated with parents taking their children along to be immunised. In social marketing terms this of course relates to understanding the dynamics of the exchange that the social marketing program will be seeking to achieve. That is, what will be the range of costs, including psychological, emotional, time and financial costs, and what are the most salient perceived benefits of �paying these costs� and undertaking the behaviour of taking your young child to the doctor or the clinic to have him or her immunised?

Because of the greater likelihood that mothers take primary responsibility for children�s health care in Australian families, the primary target audience for the campaign, and consequently samples for campaign formative research, were designated as mothers of children up to the age of five years.

Qualitative research methodologies were employed in pre-campaign formative research because of their strength in allowing in-depth exploration of attitudes and motivations. Recognising a number of sub-segments within this target audience, the qualitative sample structure was designed to include first time mothers, mothers with additional children, and mothers from a range of socio-economic backgrounds in metropolitan and regional areas throughout Australia.
Key Findings from Formative Research
From developmental formative research (Carroll, 1997), it was evident that while most people do in fact express their support for childhood immunisation when asked, many did not perceive a high level of personal relevance or urgency in the issue for them. This was related to the fact that many parents had not ever seen children suffering the diseases which the vaccinations were designed to protect their children from.

Parents were generally aware of the diseases against which children could be immunised, but had low levels of specific knowledge and perception of seriousness regarding these diseases, and the particular details of the recommended immunisation schedule. Many mothers reportedly were not immunising against measles because it was often thought of as a fairly benign disease. The danger of pertussis (whooping cough) was typically underestimated in comparison to the perceptions of the risks of immunisation. Parents� perception of the seriousness of polio was partly due to memories of common permanent disabilities in the previous generation. Diphtheria was perceived as a frightening disease but knowledge of what the disease actually entailed was very low.

Furthermore, parents� spontaneous associations with immunisation were quite negative � needles, pain, screaming children, possible side effects. In addition there was a general concern over what was perceived to be an ever-increasing number of immunisation injections for children and significant variation in advice and guidance on immunisation issues from doctors.
Motivations
Immunising children was perceived to be the accepted norm and the key motivators toward immunisation were identified as emotional ones:

■ fear of not being a good mother;
■ potential guilt if their children did contract a disease and were not immunised; and
■ fear of being socially alienated.

Strategically important was the fact that while the majority of mothers reported �feeling� that immunising their children was the �right thing to do,� they also claimed that they lacked the rational arguments to support this fundamental belief and reassurance that their actions were in fact the most responsible for their children.

Barriers
Three types of barriers to full immunisation were identified in this formative research.
Practical barriers appeared to mainly affect mothers with lower socio-economic backgrounds, and those with more than two children. These included:
■ difficulty in remembering whether the children have been immunised or not;
■ difficulty in attending venues for immunisation at the appropriate times;
■ lack of belief in the importance of the precise timing and number of vaccinations; and
■ lack of awareness of the exact details of immunisation schedules.

Medical factors were also observed to affect some mothers. These factors included:
■ postponing vaccinations because of a perception that their children are too sick to be immunised;
■ lack of belief in the seriousness of particular diseases; and
■ disillusionment when a child still contracts a disease despite being immunised.

Emotional factors operating as barriers to immunisation included:
■ fear of retribution as a result of having missed vaccinations; and
■ fear of possible side effects.

The greatest concerns related to the perceived potential side effects of vaccination, which for some mothers included the frightening risk of long-term, serious disability.
Aim
The aim of the 1997 Immunise Australia campaign was to increase the level of full age-appropriate immunisation by creating a climate of support from both parents and service providers. The key message of the campaign was that full age-appropriate childhood immunisation provides the best protection against diseases still causing death and illness in Australia.
Target Audiences
The primary target audience for the campaign comprised parents (in particular, mothers) of children aged up to five years. Secondary target audiences included family and friends of parents, immunisation service providers and immunisation information providers.
Target Audience Segmentation
Six segments were identified amongst these mothers, according to their attitudes toward immunisation. These were:

■ advocates � who are actively, conspicuously pro-immunisation, well informed about immunisation and most likely to be compliant;
■ acceptors � who are more passive in their attitudes toward immunisation, hold strong beliefs in social norms and are firm in their acceptance of immunisation;
■ defaulters � who are basically pro-immunisation, but fairly uninvolved in the subject, and whose failure to immunise usually related to �not getting around to it�, forgetting or being unaware of timing and schedules;
■ questioners � who are interested in both sides of the immunisation debate. Most are likely to try to comply if possible, but are looking for �proof� to decide the argument one way or the other;
■ lapsed immunisers � who have essentially stopped believing in immunisation, but typically felt uncomfortable and vulnerable about deciding not to immunise. Many now believed that the risks of immunisation exceeded the risks of the diseases; and
■ rejectors � who were similar to the lapsed immunisers, but had found alternative approaches to immunisation such as homeopathic or naturopathic approaches. Some were quite actively anti-immunisation.

Apart from �rejectors� who had found alternative immunisation approaches, support for the concept of immunisation was virtually universal across these groups. Campaign communication was primarily directed toward the �acceptors�, �defaulters� and �questioners� while also providing information for the advocates to confirm their position and to challenge the position of �lapsed� immunisers.

Objectives
The campaign was designed to operate as an integral facet of the Immunise Australia Program in seeking to achieve an increase in age-appropriate childhood immunisation levels. The campaign was designed to increase parents� awareness of the benefits of full childhood immunisation and that the risks associated with the diseases are much greater than risks associated with vaccinations. Further, it sought to reinforce existing positive attitudes toward immunisation, and to reduce fears about possible side-effects that could be operating as barriers to parents immunising their children. Finally it sought to stimulate parents to check the immunisation status of their children, to seek further information if required and to undertake any necessary action to fully immunise their children.
Theoretical framework and strategy
The earlier literature review and findings of formative research suggested that the Health Belief Model (Rosenstock, 1974) would provide a useful theoretical framework within which to conceptualise how the campaign could operate to achieve these objectives at an individual level. Initially the campaign would need to reach its target audience of parents of 0-5 year old children and communicate with them in such a way as to generate a sense of personal relevance and identification. It would then need to generate an awareness of their children's susceptibility to these childhood diseases and the severity of the consequences of their children experiencing these diseases. This latter point was a central component of the campaign strategy, given that formative research had indicated an alarming level of complacency about these diseases amongst some parents, driven primarily by the fact that most of this generation of parents had never seen children suffering from many of these diseases.

Knowledge deficits relating to which diseases to have children immunised against would also need to be addressed. However, formative research suggested that knowing when to take children to be immunised according to the recommended schedule was probably a more important factor in predicting appropriate immunisation practices than knowledge about specific diseases which the various vaccinations actually protected against. The campaign needed to increase knowledge levels about these particular ages at which immunisations fell due within the recommended schedule. The campaign would further need to reduce the barrier of concern about possible side-effects of the vaccinations by clearly communicating the relative seriousness of the consequences of experiencing the diseases in comparison with any risks associated with the vaccinations.

Three stages of formative research were undertaken to develop and pre-test communication materials for the campaign.
Implementation
Whilst immunisation service providers were a secondary target audience, the first phase of campaign activity was directed at this group to increase and reinforce their knowledge levels and support for immunisation, with the goal of increasing opportunistic recruitment by general practitioners. Further, as research indicated that parents would be likely to seek information from their general practitioner or immunisation service provider, it was important to inform these health professionals that a campaign targeting parents would soon be initiated and to assist them in being able to meet these requests.

The service provider component of the campaign commenced in February 1997 with the launch of the 6th edition Australian Immunisation Handbook (NHMRC, 1997). The Handbook was distributed to over 60,000 immunisation providers. Other components of the strategy included a regular column in Australian Doctor (a peak provider publication); an interactive satellite program for rural and remote providers; development and distribution of a regular newsletter updating specialist media on the progress of the campaign or any emerging issues for providers; development of the Australian Childhood Immunisation Charter which outlines key principles and practices of immunisation and includes signatories from professional and community organisations; a public relations strategy; and the development and distribution of a range of resource materials.

The community education campaign advertising launched in August 1997 with two weeks exposure of the 60 second version of the �Whooping Cough� television commercial, designed to unashamedly show Australian parents exactly what it is like for a child to experience whooping cough. Television advertising continued over the next seventeen weeks with a pattern of one week on-air followed by two-weeks off-air. The initial period of the �Whooping Cough� commercial was followed by introduction of the �Amy/Hospital� commercial in week eight of the campaign. This commercial was particularly targeted at parents with more than one child, and added a focus on the potential seriousness of a disease that many parents had become quite complacent about, measles. The final seven weeks of television advertising featured a rotation of the 30 second version of �Whooping Cough� and �Amy/Hospital�. Supporting communication was undertaken through advertising in women�s magazines and through posters in health clinics, hospitals and doctors� surgeries.

Other components of the integrated campaign strategy entailed three immunisation awareness days conducted in August, October and December at selected locations in each State and Territory, a national telephone information line, and distribution of a booklet, �Understanding Childhood Immunisation� developed for parents through the formative research process. Extensive public relations activities underpinned these various campaign elements, including publicity strategies, media monitoring, issues management, stakeholder management and an expert spokesperson program.

In addition, a non-English language component of the campaign was launched in August, 1997. This strategy targeted parents from non-English speaking backgrounds and included advertising, public relations and education strategies in thirteen spoken languages.
Evaluation
In order to assess the impact of the campaign, two national telephone surveys were conducted with parents/guardians of children aged up to six years. The pre-campaign survey in July 1997 and the post-campaign survey in November/December 1997 comprised nationally representative samples of 802 and 804 parents/guardians respectively (Cramer and Carroll, 1998).

Survey results indicated that the campaign effectively reached and communicated with its target audience. Recognition level for �Whooping Cough� was 80 per cent, with appropriate message recall amongst these respondents of 97 per cent. The �Amy/Hospital� commercial showed a lower recognition rate at 49 per cent, possibly reflecting its lower media weight, but a similarly very high level of appropriate message recall amongst these respondents of 93 per cent.

Consistent with the agenda setting function of mass media campaigns, there was an increase in reported discussion about immunisation in the home. Key findings from the study indicated that between the two surveys there was an increase in the proportion of respondents reporting correct ages for immunisation. In addition, there were increases in the proportion of respondents who believed it would be very serious to a child's health if the child caught whooping cough (49per cent to 69 per cent) and measles (31 per cent to 43 per cent). There were also increases in the proportion of respondents who believed that a child not immunised against whooping cough would catch whooping cough (78per cent to 82 per cent), and a child not immunised against measles would catch measles (84 per cent to 88 per cent).

The proportion of parents who reported they had checked their child's immunisation status in the last three months also increased (36 per cent to 43 per cent) as had the number of parents who had reported they had taken their child to be immunised during this period (22 per cent to 33 per cent). Overall the survey found that 99 per cent per cent of parents in the target group supported immunisation, with 91 per cent now strongly supporting it.

Consistent with the direction of these results, data from the Australian Childhood Immunisation Register, which was established in January 1996 and provides a comprehensive database of children�s immunisations in Australia, has indicated that levels of full age-appropriate childhood immunisation have consistently been rising since the campaign and the implementation of the range of Immunise Australia Program parent and service provider initiatives.
At the end of June 1997, prior to the commencement of the 1997 campaign, the proportion of children aged twelve months who were assessed as fully immunised for their age was 76 per cent (Department of Health and Family Services, 1998). April 1998 marked the commencement of the Immunise Australia Program initiative of linking the eligibility for Childcare Rebate to the child�s immunisation coverage rate. By the end of December 1998, the comparable figure had increased to 85 per cent (Department of Health and Aged Care, 1999). The combination of communication campaigns and such policy initiatives has resulted in a significant increase in the full immunisation coverage rates among this age cohort. By June 2000 the level of full immunisation for this group had reached 88 per cent (Department of Health, 2000), and by June 2004, 91 per cent (Department of Health and Ageing, 2004).
Service Providers
Two national telephone surveys were conducted with immunisation providers. One survey was conducted at the beginning of the campaign, the other one year later. The research found that there was an increase in the number of service providers accessing the latest handbook and a high degree of satisfaction with the handbook.

The 1998 Measles Control Campaign
Building on the achievements of the 1997 campaign and the favourable community environment for child immunisation that it had achieved, the Immunise Australia Program then initiated the National Measles Control Campaign in 1998 as a first step toward eliminating measles in Australia. The marketing objective for this strategy was to increase the proportion of 5-12 year old Australian children who have received their second measles, mumps and rubella vaccinations to 95 per cent. The strategy entailed a national mass media and direct marketing campaign to the parents of 1.75 million children to gain their consent for their children to be vaccinated at school by visiting teams of nurses. In addition, an extensive range of information kits were distributed to schools and local doctors as well as a comprehensive public relations campaign promoting the purpose of the program and mobilising a firm issues management campaign answering concerns raised in the press by anti-immunisation groups. Extensive consultation processes in the health and education sectors were initiated and maintained throughout the campaign.

In contrast to the 1997 campaign where formative research had clearly indicated the need to raise perceptions of the seriousness of the diseases children were being immunised against, the Measles Control Campaign creative strategy reflected a positive, modelling approach (Bandura, 1986). Developed and refined through further formative research, this approach was premised upon, and reflected, the greater support for child immunisation achieved by the previous campaign, and adopted the voices of children themselves calling on parents, schools and the community at large to �Work Together To Beat Measles�.

Evaluation research for this campaign indicated that the target for the campaign was achieved, with 96 per cent (1.7 million) of the 1.78 million Australian school children aged 5-12 years receiving a dose of MMR vaccine during the campaign. A serosurvey conducted after the campaign showed that 94 per cent of children aged 6-12 years were immune to measles, an increase from 84 per cent before the campaign (Commonwealth Department of Health and Aged Care, 2000). The campaign was assessed as averting an estimated 17,500 cases of measles (NCIRS, 1999).
Conclusion
Australia clearly faced a significant challenge in light of the levels of complacency about immunisation that had become evident amongst Australian parents. The response of the Australian Government to this situation was comprehensive and multi-faceted. Designed within a social marketing framework the community education campaigns performed well in line with their designated objectives. The levels of campaign reach and effective communication were very satisfactory and changes in knowledge and attitudes between the pre-campaign and post-campaign surveys were consistent with the self-reported behaviour. It must of course be recognised that the campaigns operated as part of the broader Immunise Australia Program and that the various elements of the Program, both consumer aspects and service provider aspects, are inextricably linked. It is clear that social marketing has played a strong role in increasing the protection of Australian children against vaccine preventable diseases.
implications for social marketing
This case study has illustrated the critical role played by formative research in both the development of social marketing strategy and in design and refinement of communication materials. It is, of course, only by adopting a consumer orientation and understanding the range of perceived costs and benefits of the behaviour we are seeking to increase, through the eyes of our target audience, that we can hope to generate identification with our message and a sense of personal relevance in our communication. This case study illustrates that the application of social marketing can, and has, achieved significant positive gains in improving levels of childhood immunisation and consequently protection against preventable disease for Australian children. Critical to the sustainability of the social marketing intervention were the policy initiatives of providing ongoing incentives to doctors and parents, particularly the linking of eligibility for the Childcare Rebate to the child�s immunisation coverage rate. This is a useful example of how a public education campaign can help create an environment, which facilitates the implementation of policy initiatives, which in turn, create structural support for the achievements of the campaign.

Agencies
Social marketing and research consultant: Carroll Communications, Sydney.
Advertising agency: Singleton Ogilvy and Mather, Sydney.
Formative research agency: Market and Communications Research, Brisbane.
Evaluation research agency: The Wallis Consulting Group, Melbourne.
About the authors
Tom E. Carroll, BSc (Psych) Hons, PhD, is a social marketing and research consultant and principal of Carroll Communications. Over the last two decades he has consulted on state-wide and national social marketing strategies across a range of public health areas, including alcohol, tobacco, pharmaceutical and illicit drug use, HIV/AIDS, mental health, breast, cervical and bowel cancer screening, and childhood immunisation. He is a member of the Advisory Board of The Australian Centre for Health Promotion, University of Sydney, and lectures on social marketing within the Master of Public Health and Master of International Public Health programs. In recent years he has also consulted on social marketing strategies for promoting environmental sustainability.

Laurie Van Veen, Dip Advtg. & Pub. Rel. is the Director of the Strategies & Social Marketing Unit, in the Information & Communications Division of the Australian Department of Health and Ageing. Over the last two decades she has been a practitioner in field of marketing and communications. During the last 12 years she has been directing Commonwealth Government national social marketing campaigns across a range of public health issues including alcohol abuse, illicit drug use, discrimination against people with HIV/AIDS, childhood immunisation, tobacco prevention and cessation and cervical and breast cancer screening.