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Behavioral Journalism in Health and Risk Messaging

Summary and Keywords

Behavioral journalism is a term used to describe a theory-based health communication messaging strategy that is based on conveying “role model stories” about real people and how they achieve healthy behavior changes. The aim is to stimulate imitation of these models by audiences of their peers. Theoretical foundations for the strategy itself are in Albert Bandura’s social cognitive theory and Everett Rogers’s model of diffusion of innovations, but it can be used flexibly to convey various kinds of theory-driven message content. Behavioral journalism emerged as an explicit health communication technique in the late 1970s and was developed as a distinct alternative to the social marketing approach and its focus on centrally generated messages devised by experts. It has been used subsequently to promote smoking cessation, improvements in nutrition and physical activity, avoidance of sexually transmitted diseases and unplanned pregnancy, reduced intergroup hostility, advocacy for healthy policy and environmental changes, and many other diverse health promotion objectives. Formats used for behavioral journalism include reality television programs, broadcast and print news media, printed newsletters for special audiences, documentary film and video, digital and mobile communication, and new social media. Behavioral journalism is intended for use in concert with community organization and actions to prompt and reinforce the imitation of role models and to facilitate and enable behavior change, and its use in that context has yielded many reports of significant impact on behavior. With citations of use growing steadily in the past two decades, behavioral journalism has proven to be readily adaptable to new and emerging communication technologies.

Keywords: role model stories, peer modeling, diffusion of innovation, health communication, reality television

Origin and Philosophy

Behavioral journalism is a term coined by the author (McAlister, 1995) to describe a distinct, theory-based form of health communication designed to promote behavioral and social change. Also often labeled role model stories, this messaging strategy is explicitly contrasted with other approaches to health communication by a focus on telling factual stories about real people who are part of or relevant to the population that the communicator seeks to influence. This reflects the journalist’s or documentarian’s working methods rather than those based on creative advertising, celebrity endorsement, scripted “edutainment,” and other expert-created and centrally generated messaging strategies in the social marketing (Grier & Bryant, 2005) model of health communication. Instead of being based on a philosophy and methodology designed to sell products to consumers, the behavioral journalism approach is based on the philosophy and methodologies of communicators who seek to serve their audiences by telling real stories that are useful to them (McAlister, 1995). In the following sections of this article, the history of health behavior change messaging based on this approach will be presented and its theoretical foundations and overlapping concepts will be described. Next, some significant applications of behavioral journalism to cardiovascular disease and sexually transmitted disease will be presented in detail and subsequent developments up to the present will be noted. Finally, three diverse recent applications will be described briefly, followed by a summary and conclusions.

History

Testimonials and instructive storytelling have been used to influence behavior since prehistoric times and are part of many traditional cultures today. In the middle years of the 20th century, documentary films and journalism were frequently cited as effective modalities for health education and persuasive communication, but there are few references to the use of stories about real people changing behavior as a particular technique (e.g., Higby, 1940; Hovland, Janis, & Kelley, 1954; Griffiths & Knutson, 1960). The modern scholarly history of health promotion communications featuring real people succeeding in health behavior change begins with reports of televised group counseling for smoking cessation that began in the 1960s internationally and were first documented in English in the United States (Dubren, 1977). The first randomized study of this technique, in which participants either took part in a direct counseling program with copious group participation or viewed such a program via closed-circuit television and learned vicariously about how participants in the group were learning to quit smoking, was conducted by the author at Stanford University in his doctoral dissertation (McAlister, 1977). Observers of peers quitting smoking, in a context in which social reinforcement (i.e., prompting and praise) was used to stimulate imitation, achieved the same rates of smoking cessation as those who were directly involved in group counseling.

Although the preliminary study noted here was done of a very small scale, this approach was applied shortly after on a very large scale in Finland, where nationally broadcast television programs featured role models (ordinary people willing to make an effort at behavioral change) confronting the challenges of smoking cessation, weight loss, and cholesterol and blood pressure control (Puska et al., 1987). These early “reality television” programs were part of a highly successful 20-year project to reduce cardiovascular disease there, as described in more detail later in this article.

The peer role modeling approach to using documentary journalism for promoting behavior change was next explicitly applied in projects to promote smoking cessation and cancer screening in South Texas, beginning in 1984 (McAlister et al., 1992: Ramirez et al., 1995) and most recently replicated in Nevada (Ramirez et al., 2013). Theory- and evidence-based conceptual models were used to guide role model interviews and the selection of story content; examples include displaying specific factors and processes identified in research on smoking cessation in this population (Gottlieb, Galavotti, McCuan, & McAlister, 1990). In these projects, rather than following people as they changed over time in a reality television format, a traditional television, radio, and print news feature format was used to tell stories about persons who had previously quit smoking or obtained cancer-screening examinations.

The notion of combining mass media communication of stories about peer models succeeding in changing health behavior with community organization and policies to reinforce and enable that change was explicitly described in the late 1970s McAlister, Puska, Salonen, Tuomilehto, & Koskela (1982). But the term behavioral journalism was not used to describe that media strategy in scholarly literature until the early 1990s (McAlister, 1991, 1995). The first publication explicating the concept appeared in 1995 (McAlister, 1995) when it was being applied in the AIDS Community Demonstration Projects (ACDP) by the U.S. Centers for Disease Control and Prevention (CDC), which are described in detail later in this article (O’Reilly & Higgins, 1991; McAlister et al., 2000). In publications from this work, the term role model stories (McAlister, 1991) was often used as a label for messages produced by use of the behavioral journalism technique (Pulley, McAlister, Kay, & O’Reilly, 1996; Corby, Enguídanos, & Kay, 1996). While previous applications featured retrospective stories in television or print news aimed at broad audiences, in these projects the stories were presented in printed tabloid newsletters produced at each site and distributed directly to selected audiences.

In the late 1990s, an application of the behavioral journalism approach was developed to reduce intergroup hostility in Texas (McAlister et al., 2000). It was rigorously evaluated in a randomized experimental study of a project designed to decrease hostility toward growing immigrant communities in Finland (Liebkind & McAlister, 1999). This was labeled extended contact because it is based on the idea that the prejudice- and hostility-reducing effects of positive contact with persons from other groups can be produced vicariously by having group members tell stories about their own positive contacts to extend the influence of these contacts to other members of their group. The modest but positive results from this study have led to several notable replications (e.g., Cameron & Rutland, 2006) and it is widely cited as a potentially effective way to improve group relations, at least modestly.

Demonstrating the diversity of topics and theoretical frameworks to which it can be applied, another small-scale experimental application of behavioral journalism was developed following the September 11, 2001, attack on the World Trade Center and Pentagon in the United States. This was designed to reduce international hostility and support for military action, employing theory- and evidence-based peer modeling messages in an online self-test and tailored, interactive learning experience to psychologically inoculate” young adults against war fever (McAlister & Wilczak, 2015). In an online pretest-posttest experiment that obtained close to 10,000 website visits and yielded small but significant reductions in support for military action (Howard et al., 2007), theory and research on the social cognitive theory construct termed moral disengagement were used to guide the elicitation and presentation of corresponding role model story content (McAlister, Bandura, & Owen, 2006).

Summarizing the history of behavioral journalism and role model stories in scholarly literature as revealed on Google Scholar, 11 publications containing these terms can be found before 1995—all based on the ACDP or other work by the author. Between 1995 and 1999, another 86 publications with these terms appeared, with 125 more in the next five-year interval, 151 between 2005 and 2009, and 247 from 2010 to the end of 2016. During 2015–2016, 92 publications cited the use of behavioral journalism in extended contact to improve intergroup relations (Liebkind & McAlister, 1999).

Theoretical Foundations

The primary theoretical foundation for this health communication strategy comes from Albert Bandura’s social cognitive theory (Bandura, 1986, 2001; McAlister, Perry, & Parcel, 2008) and the concept of peer modeling (i.e., observational learning of new behaviors through imitation of one’s peers). Social cognitive theory identifies observation and imitation, increasingly mediated by communication technologies, as the primary human learning process. A second conceptual foundation comes from the Rogers (2010) “Diffusion of Innovation” model and the phenomenon of early adoption by innovators being imitated by their peers as new behaviors, technologies, and ways of thinking spread through societies.

Social cognitive theory postulates that behavior change occurs when peer models are presented and the imitation of those models is reinforced and facilitated by actions that influence people directly (i.e., by prompting and praise for imitation and by arranging environmental conditions that make the modeled behaviors easy to imitate). For this reason, behavioral journalism is not intended or expected to have a significant impact on behavior unless it is accompanied by actions to prompt and facilitate imitation. As Bandura (2001) describes it, media communications elicit behavior changes when they are part of a dual link combining mediated displays of peer modeling with directly reinforcing and enabling actions in the form of prompts, praise, and environmental changes that make the modeled behaviors easy to imitate (McAlister, 2013). The systematic combination of peer modeling via behavioral journalism, prompting and social reinforcement organized through community networks, and policy/environmental changes to facilitate modeled behaviors has been labeled a “diffusion accelerator” (McAlister, 1997, p. 32) and as the behavioral journalism approach was developed by the author, it was always seen as only part of broader actions that are needed to achieve population-level change in health behaviors (McAlister, 1991; McAlister & Fernandez, 2002). In the case studies of this method described next, behavioral journalism was usually combined with community organizing and policy or environmental changes. Presently recommended best practices for the use of peer modeling in health communication call for it to be integrated into broader actions, such as organizing community networks for social reinforcement and advocating policy and environmental changes to facilitate imitation (McAlister, 2013).

Behavioral journalism has practical roots in the concept of “testimonial” advertising, in which people who have bought a product or adopted a new behavior endorse it. This can consist of simply finding persons who may be labeled “early adopters” who are performing innovative healthy behaviors that the communicator wants to help diffuse within the population, and then telling stories of why and how they have come to perform those behaviors. If the stories are real and there are many of them, there is a high probability that they will portray aspects of the learning experience that will be motivational or instructive to others who might seek to adopt that innovation. But the distinctive feature of behavioral journalism that distinguishes it from testimonial advertising is the explicit use of theories, models, and empirical data to specify the determinants and influencing factors for changing a specific behavior or set of related behaviors. As described in the historical developments and details from case studies presented in this article, effective applications of behavioral journalism are always at least partly theory-driven and usually are evidence-based as well.

There are methods for promoting healthy behavior change with other labels that significantly overlap with behavioral journalism. One of the most notable is known as positive deviance and focuses on finding and spreading information about individuals and families who deviate from community norms by adopting healthy innovations (e.g., Spreitzer & Sonenshein, 2004). Another notable method with substantial overlap with behavioral journalism is narrative communication (e.g., Kreuter et al., 2010). If the narratives are based on stories about real people, this method is identical to behavioral journalism. Also, as noted previously, the term role model stories began to be used interchangeably with behavioral journalism in the earliest years of the CDC’s ACDP (McAlister, 1991; Pulley et al., 1996; Corby, Enguidanos, & Kay, 1996).

Behavioral Journalism in Reality Television for Cardiovascular Risk Reduction

As previously mentioned, the author’s first opportunity to realize a large-scale application of what was later termed behavioral journalism was embedded in a long-term, quasi-experimental, population-based research project in Finland that was carried out from 1972 to 1992 (Puska et al., 1985, Puska, 2002). When the project began, Finnish middle-aged men had the highest-known mortality rates for cardiovascular diseases in the world. The highest rates in Finland were in North Karelia, a region of approximately 200,000 residents where a local petition to central government led to a well-funded effort to decrease the disparity in burden of cardiovascular disease there. The theory-based (McAlister et al., 1982) actions organized by the North Karelia Project included the reorganization of preventive health services to improve hypertension control and changes in food production and agriculture that led to greater availability of lower-fat and -sugar products, fish, and fresh berries. Other environmental changes, such as lighted ski trails in small municipalities, improved access to recreational physical activity.

The initial project communications focused on the cultivation of local news reports and frequent news stories and press events to transmit facts about how cardiovascular diseases can be prevented or delayed through smoking cessation, hypertension detection and control, prudent nutrition, and physical. Group meetings and classes also were held to help residents to learn and show each other how to gain new shopping and food preparation skills or how to avoid resumption of smoking following cessation, but these only reached a very small proportion of the population.

The Finnish Terveydan Avaimet (Keys to Health) programs were patterned after the author’s doctoral dissertation (McAlister, 1977) and explicitly designed to bring the positive peer modeling and skills training from group meetings and classes to the entire nation via prime-time public television broadcasts (Puska et al., 1987). They were produced five times between 1978 and 1985, with the first two series of broadcasts in 1978 and 1979 focusing only on smoking cessation, and two more series in 1980 and 1982 aiming to promote smoking cessation; reduced fat; salt and sugar consumption; increased vegetable consumption and physical activity; and weight loss. In 1984–1985, the programs followed a group of eight middle-aged North Karelia residents, five men and three women, all cigarette smokers and most moderately overweight and with elevated blood pressure.

This early illustration of reality television with a behavioral journalism approach was based on emerging behavioral science theory concepts and applications that framed cardiovascular risk reduction not as primarily dependent on motivation and decision-making, but rather as a complex learning process leading to progressive achievement of behavioral self-control (McAlister et al., 1976). Corresponding with these concepts, the programs began with eight weekly broadcasts, in which the participants made self-assessments, set goals and short-term objectives, monitored their behavior, and learned self-regulatory skills such as environmental control, counter-conditioning, and self-instruction. This was followed by seven biweekly broadcasts lasting 35 minutes apiece, in which the participants focused on learning skills for maintaining behavior change such as stress management and practice in predicting and preparing for situations and events that might cause a relapse to tobacco use, imprudent nutrition, or a sedentary lifestyle. Finally, in a one-year follow-up broadcast, the participants’ long-term achievements were displayed and their strategies for maintaining them were discussed.

In each broadcast, the group moderators asked prompting questions, frequently looking into the camera, and encouraged the viewing audience to imitate what the models were learning. The program featured processes of change and acquisition of self-regulatory skills as experienced in the context of family life and featured the important role that family members play in supporting changes. Brief vignettes were videotaped in homes and community settings and edited into the broadcast to display precisely how the participants learned to perform specific behaviors (e.g., recreational activities, shopping for and preparation of lower-calorie meals, and resisting temptations to smoke). In the course of the series, all eight people stopped smoking, made substantial dietary changes, and increased their physical activity, with a resulting mean reduction in serum cholesterol and blood pressure of 7% and 8%, respectively. At the one-year follow-up, six of the eight models were still not smoking and largely maintained their other lifestyle changes as well, resulting in a 52% reduction in cardiovascular risk scores.

Throughout Finland, a broad promotional campaign was shown on television and published in newspapers, while in North Karelia, a network of approximately 500 trained lay opinion leaders distributed workbooks for following the program at supermarkets, schools, and workplaces, as well as conducting informal promotion within their social networks. At the eight schools with a student whose parent was participating in the studio group of peer role models, teachers asked all the students to encourage their parents to view the program and make changes in their own health behaviors.

The population impact of these broadcasts was evaluated (Puska et al., 1987) via postal surveys done nationally (3,418 respondents, 68% response rate) and in North Karelia (862 respondents, 71% response rate). The effect of the promotion and focus in North Karelia was apparent, with 55% viewing three or more sessions there, as opposed to 35% in the national sample. Among program viewers, changes were similar in North Karelia and nationwide, with 27%–28% reporting reduced fat consumption, 20% reporting reduced sugar consumption, 20%–24% reporting increased physical activity, and 4%–5% reporting lost weight in excess of 2 kilograms. The higher viewership in North Karelia led to significantly greater population-level behavior changes there than nationally in the entire samples of viewers and nonviewers: Fat reduction was 21% versus 15%, sugar reduction was 15% versus 11%, increased physical activity was 18% versus 11%, and lost weight in excess of 2 kilograms was 4% versus 2%. Among viewers, a strong dose-response relationship was found for the number of broadcasts followed in the national sample. Comparing viewers of five or more with those who viewed fewer broadcasts, the rates were as follows: fat reduction 42% versus 27%, lost weight in excess of 2 kilograms 8% versus 4%, and smoking cessation attempts 20% versus 7%.

The Keys to Health behavioral reality television documentary broadcasts were only part of a broad set of theory- and evidence-based actions carried out between 1972 and 1992 in North Karelia (McAlister et al., 1982), which led to reductions of 68% in overall cardiovascular mortality and 73% in coronary heart disease between 1970 and 1995 (Puska, 2002). Coronary heart disease mortality rates declined nationwide as well, particularly after project components such as reorganized hypertension services were expanded beyond North Karelia, and by 1995, the disparity between rates there and nationwide was almost completely eliminated.

Television programs like the Finnish Keys to Health series and those focusing specifically on smoking cessation were subsequently organized and evaluated in Chicago (Warnecke, Langenberg, Wong, Flay, & Cook, 1992) and this format was also employed as part of a larger and well-evaluated antismoking campaign in the Netherlands (Mudde & DeVries, 1999). Since that time, there have been no published evaluations of this approach to promoting smoking cessation. Instead, the behavioral journalism technique is increasingly used in new media formats, such as interactive Internet-based programs, to help adolescents and adults quit smoking. In these formats, the peer role models appear in brief videos in which they talk about and display specific skills for quitting and avoiding relapse (e.g., Dalum, Schaalma, & Kok, 2012; Dalum, Brandt, Skov-Ettrup, Tolstrup, & Kok, 2016).

For nutrition, physical activity, and weight loss, reality television formats very similar to Keys to Health have been widely used, but rarely evaluated. In the United States and internationally, the Biggest Loser television show (NBC, 2012) has won huge audiences for a series of programs that feature obese individuals in successive broadcasts as they improve their nutrition and increase their physical activity in an effort to lose the most weight to compete for substantial prizes. These programs undoubtedly stimulate many viewers to make some imitative behavior changes, as a large national poll found that 57% of Biggest Loser viewers reported an impact on their eating habits and 48% on their activity levels (Thomson Reuters Polls, 2011). However, the programs do not teach a self-regulatory process that leads to gradual achievement of modest, but sustainable levels of weight loss that were modeled in the Finnish Keys to Health. Instead, they focus on conveying stories about rapid and dramatic change.

No thorough long-term evaluations of Biggest Loser effects on population have been reported, and it is reasonable to suspect that most imitative behavior changes in their viewing audiences are not maintained. The major changes made by those who succeed in the competition are not sustainable for most people (Hall, 2013). On the other hand, there are recently published reports of positive effects from evaluations of smaller-scale studies in which online and peer models are followed while acquiring self-regulator skills and making modest changes in nutrition and physical activity (e.g., Nabi & Thomas, 2013; Ackermann et al., 2014). Further research and development is needed to find ways to use this form of serialized documentary behavioral journalism to promote widespread and modest weight loss through increased activity and improved nutrition on a large scale as effectively as it was in Finland’s Keys to Health.

Behavioral Journalism in Role Model Stories for Sexual and Reproductive Health

In 1992, the CDC began a well-funded effort to study ways to stem the epidemic of HIV, with a focus on hard-to-reach and high-risk populations not served at that time with prevention programs promoting sexual health—mainly via condom use. Senior research leaders were aware of the North Karelia Project and sought to employ community-level actions like those used to promote population-level behavior change there. In this case, they wanted to promote condom use in specific populations in five U.S. cities (Dallas, Denver, Long Beach, New York, and Seattle). The targeted individuals included sex workers, injection-drug users not seeking treatment and their sexual partners, homeless young people, men who have sex with men but do not identify themselves as gay, and residents of neighborhoods with high rates of sexually transmitted diseases.

This project originated in planning meetings attended by Everett Rogers, other experts, and the author of this chapter, with extensive subsequent involvement from Martin Fishbein for the assessment of factors corresponding to concepts from his theoretical framework (Fishbein et al., 1996). The work in each of the five cities that participated began with approximately one year of urban anthropology, field work in which the locations and people who were in the identified risk groups were specified and personal contacts were made by health department staff trained to initiate outreach. Based on qualitative data from these people, the planning team conducted quantitative research to test hypotheses about the relationships between different attitudes and behavioral beliefs, perceived behavior control, and consistent condom use with main and other sexual partners. Measurement items were developed and deployed in hundreds of “intercept” interviews among the selected risk groups in each of the five cities.

The evidence from this research showed that different factors influence different stages of behavior change, but the most decisive theoretical constructs were attitudes and perceived behavioral control or self-efficacy (Fishbein et al., 1996). Specifically, attitudes about whether condom use was pleasant or unpleasant and perceptions of ability to control the partner’s cooperation for condom use during sexual intercourse were highly associated with that behavior, with both main and other partners. With this guidance, outreach workers were instructed to seek people in their study populations who were reducing sexually transmitted disease risk through condom use and to focus interviews not only on attitudes about risk and protection, but also on changing attitudes toward pleasure of intercourse when condoms are used and perceptions of control and skill for being able to secure partner cooperation.

Corresponding theory- and evidence-based message content was featured in role model stories that appeared in tabloid newsletter formats with titles like Girlfriends Talking for sex workers in Seattle. There were 188 different stories, averaging more than 30 for each of the six distinct audiences in the five project sites, distributed with condoms (and lubrication, in some sites) by 22 outreach workers via 254 peer volunteers and community network members (Pulley et al., 1996).

As an illustration, here are the graphics and text for one story, presented as a four-frame cartoon, which was obtained from a woman in Dallas who was able to obtain her injection-drug-using partner’s cooperation in condom use:

  • Frame 1—Woman and man in bed; woman holding condom and saying, “Here, Ruben, before you put it in, put this on!”

  • Frame 2—Profiles of couple; man touching head and frowning, says, “No, baby! By the time I fuss with that, I won’t be hard anymore!”

  • Frame 3—Woman holding condom and stroking man’s chin as she says, “Oh? Well I guess I’ll just have to be creative and show you how fun this can be!”

  • Frame 4—Woman out of sight and possibly providing manual or oral stimulation and saying, “There: You don’t feel soft to me!” as man closes eyes and smiles, saying, “Ooooooooh!”

This interaction, drawn from a peer model who shared this information confidentially, tells a real story of how attitudes toward the pleasure of condom use during intercourse can be changed as a woman learns verbal and physical skills that enable her to exert behavioral control over condom use with her partner.

This project, with a quasi-experimental design with experimental and control neighborhoods and communities for each of the selected audiences in the five project cities, was extensively evaluated. Intercept interviews were carried out approximately quarterly, in which qualified respondents were asked about exposure to the campaign, attitudes about and perceived behavioral control for condom use, and both past and intended future condom use with main and other partners. They were also asked to show a condom if they were carrying one.

Combining all experimental and control cases over three years of data collection, with more than 15,000 participants, the rate at which respondents showed interviewers a condom went from 16% to 19% in the control groups and from 17% to 30% in the experimental groups. The rates of reported exposure to project communications reached greater than four in five among sex workers in Long Beach, and the communications reached one in three of surveyed homeless youth and men who have sex with men but do not identify themselves as gay. In the combined data for all groups, there were very strong dose-response relationships between the number of role model stories seen and attitudes, perceived behavioral control and reported condom use behavior (McAlister et al., 2000).

Given the positive results from these studies, their behavioral journalism and community outreach methodology was packaged into a grant-giving and technical assistance program called Community PROMISE (Peers Reaching Out and Modeling Intervention Strategies) that was part of the CDC’s “Evidence-Based Intervention” package of HIV and other sexually transmitted disease prevention activities (Collins & Sapiano, 2016). Beginning in 2000 and continuing for 15 years thereafter, funding and technical assistance was provided for more than 11,000 local agencies and organizations to implement Community PROMISE or one of 10 other evidence-based interventions, with approximately $100 million per year in funding over that time.

As with applications for cardiovascular risk reduction, very recent applications of the behavioral journalism approach for the promotion of sexual and reproductive health have adapted it for use in new media formats with diverse audiences. For example, reality-based role model stories about young people coping with challenges related to unplanned pregnancy prevention and contraception use are featured in a 13-lesson, Internet-based curriculum for American Indian and Alaskan Native youth that was described in a recent publication. In this case, the peer modeling is embedded in the “It’s Your Game—Tech” game format, in which users navigate their way toward effective avoidance of pregnancy and sexually transmitted disease (Shegog et al., 2016). Another application, in Kenya, embeds brief role model stories in texting applications for smartphones to promote use of contraceptive services there (Johnson et al., 2016).

Diverse Contemporary Applications of Behavioral Journalism

In another instance, intentions to use hospice care for terminal illness were promoted via behavioral journalism featuring role model stories about African Americans (Enguinados, Kogan, Lorenz, & Taylor, 2011). Role models were recruited among African American clients and family members in local hospice programs in southern California, with a $100 incentive for interviews and the option of using a real name and photograph. The project coordinator, a senior African American social worker, interviewed potential role models in their home with a semistructured format for eliciting personal background information to establish identity and similarity to the intended audiences. Subsequent questions were designed to gather information corresponding to the theoretical concepts and evidence about perceived barriers to hospice care. For example, the belief that hospice care was not provided at home was explicitly refuted, attitudes reflecting comfort with discussing hospice care, and the quality of medical care that can be provided in hospice versus hospital settings. Audiotaped interviews were transcribed verbatim in order to feature the precise words and language use reflecting the cultural nuances of African American experiences.

Stories were developed from segments of the interviews that were selected to illustrate motivating factors for hospice care and how barriers to hospice care can be overcome, among other topics. These were assembled into a brochure with a question-answer format, with text formulated at an eighth-grade literacy level and a word count of approximately 350–450 words for each story. A pretest, posttest design was used in an approximately one-hour session with African Americans ages 65 or older with one or more chronic diseases who after a pretest, were asked to read the printed role model brochure (30–45 minutes) and then complete a posttest. The results showed highly significant knowledge gain and improvements in attitudes corresponding to the specific factors in the investigators’ conceptual framework, and they also sharply increased intentions to use hospice care.

Another recent application aimed to increase collective action for disaster preparedness in Nepal (Sanquini, Thapaliya, & Wood, 2016) documented and conveyed role model stories on film. The sources for content were interviews with local people who joined efforts to make their public school buildings earthquake-resistant. Guidelines for interviews with these role models (based on a publication by Corby et al., 1996) included in-depth, open-ended questions designed to elicit personal stories about actions to help strengthen the local school buildings. Questions elicited information corresponding with the researchers’ conceptual model of factors that influence actions to make schools and homes earthquake resistant: knowledge of earthquake-resistant construction design, materials, and methods; confidence in efficacy of such construction items; intention to support such construction; and intention to recommend building earthquake-resistant homes to others. Following pretesting and review of objectives, the content was assembled into a film, with landmarks from each of the role models incorporated to make the setting recognizable as the Kathmandu Valley.

The resulting 20-minute production, titled Subharambha, was evaluated in a matched-pair, randomized pretest-posttest experiment involving 761 adults from 16 Kathmandu Valley schools in need to preparation against seismic shock. Before and after viewing the film, the participants completed questionnaires designed to measure the conceptual factors on which Subharambha was focused. When compared to viewers of a neutral control film, viewers of this film showed significant improvements in these variables, most importantly in their intentions to begin work to strengthen their own schools and homes promptly. Project leaders praised the positive intentions, and the materials needed to enable reinforcement of structures were made readily available. The experiment was completed five weeks before a 7.8-magnitude earthquake struck central Nepal on April 25, 2015. Thousands of schools were damaged and closed by the seismic event, but all the schools that were featured in the film survived intact.

Another notable recent application is designed to promote advocacy for policy and environmental changes to reduce Latino child obesity in the United States, titled Salud America! and supported by the Robert Wood Johnson Foundation (Ramirez, Gallion, Despres, & Adeigbe, 2013). In this project, mobile media, YouTube, Facebook, Twitter, and other Internet sites are used to find, display, and promote peer models for grass-roots advocacy to make healthy foods more available in low-income neighborhoods and to provide suitable settings for recreational physical activity, as well as advocacy for policies such as increased taxation of sugar-sweetened beverages.

The conceptual framework used to elicit featured peer-modeling content in Salud America! includes perceptions of susceptibility to and severity of childhood obesity, the perceived threats of processed foods and sugar-sweetened beverages, and the perceived benefits of fresh fruits and vegetables and outdoor recreation. Additional factors driving role model content are skills and perceptions of self-efficacy for performing advocacy behaviors and collective efficacy for participants in Salud America! to work together to achieve policy changes.

At present, the network has expanded to include tens of thousands of individuals, and a recent unpublished survey found that a substantial proportion reported frequent advocacy directed toward school leaders and local, state, and federal elected representatives. The degree of engagement in the Salud America! network is associated with the frequency of advocacy actions reported by participants, and preliminary research indicates that the relationship may be at least partly mediated by the link between network engagement and assessments of personal and collective efficacy (Ramirez et al., 2015).

Summary and Conclusions

The use of behavioral journalism to produce role model stories as a theory-based health messaging strategy first emerged in research and development projects aimed at reducing cardiovascular risk factors and disease in populations during the 1970s, in a reality television format in Finland. Beginning in the mid-1980s, it was applied in television and print news formats in South Texas in projects aimed and promoting smoking cessation and cancer screening. Application in directly distributed tabloid newsletters followed during the 1990s with the ACDP in the United States, which were aimed at promoting condom use to prevent HIV and other sexually transmitted diseases.

Further applications to print formats around the turn of the 21st century employed behavioral journalism to decrease intergroup hostility in Finland. Since that time, behavioral journalism and role model stories in health communication have been used to promote many diverse behavior changes, and the technique has been adapted to new media formats for Internet-delivered and smartphone communications. Behavioral journalism is also demonstrably adaptable to different kinds of theoretical and conceptual models and frameworks that may be appropriate for particular objectives. These range from the concepts of attitudes, beliefs, and perceived behavioral control in the theories of reasoned action and planned behavior (Fishbein et al., 1996), to mechanisms of moral disengagement in the alteration of self-evaluative standards regarding support for aggressive military action (McAlister & Wilczak, 2015).

Behavioral journalism is not designed to be used in isolation; rather, it should be combined with actions to organize social reinforcement for the imitation of role models and policy/environmental changes to facilitate and enable behavior change. When used in this way, a substantial body of research provides evidence that it can help public health advocates significantly influence long-term change in diverse behaviors. There are many directions for further research. For example, it may be helpful to see more development and investigations of applications for promoting collective behaviors to advocate for and bring about healthy environmental and policy changes. It could be particularly useful to study how the behavioral journalism approach might contribute to climate change communication, as in the use of peer modeling to promote the “Green Office” in Finland (Heiskanen, Johnson, Robinson, Vadovics, & Saastamoinen, 2010). Research may also be helpful for the delineation of optimal methods for using the reality television format to promote population-level changes in health behaviors.

Future research and applications can be anticipated in social media such as Facebook and YouTube, where users can share stories on a very large scale. This can potentially be combined with apps and algorithms to filter for theory-driven content selection and the matching of stories to social network members’ characteristics and circumstances, as well as with geolocation and geofencing to concentrate messaging in specific localities. Testimonial and authentic storytelling as a message strategy is timeless and almost universally applicable to a broad variety of objectives, audiences, and cultures. It has been employed in many different traditional and emerging communication technologies. Refinement of this message strategy in the form of theory- and evidence-based behavioral journalism can enhance its usefulness for public health promotion and advocacy.

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                        Gottlieb, N. H., Galavotti, C., McCuan, R. A., & McAlister, A. L. (1990). Specification of a social—cognitive model predicting smoking cessation in a Mexican-American population: A prospective study. Cognitive Therapy and Research, 14(6), 529–542.Find this resource:

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                              Hall, K. D. (2013). Diet versus exercise in “The Biggest Loser” weight loss competition. Obesity, 21(5), 957–959.Find this resource:

                                Heiskanen, E., Johnson, M., Robinson, S., Vadovics, E., & Saastamoinen, M. (2010). Low-carbon communities as a context for individual behavioural change. Energy Policy, 38(12), 7586–7595.Find this resource:

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                                      Howard, B. H., Shegog, R., Grussendorf, J., Benjamins, L. J., Stelzig, D., & McAlister, A. L. (2007). Development, implementation, and evaluation of a web-based war-prevention program in a time of war. Journal of Peace Research, 44(5), 559–571.Find this resource:

                                        Johnson, D., Juras, R., Riley, P., Chatterji, M., Sloane, P., Choi, S. K., & Johns, B. (2016). A randomized controlled trial of the impact of a family planning mHealth service on knowledge and use of contraception. Contraception, 95(1), 90–97.Find this resource:

                                          Kreuter, M. W., Holmes, K., Alcaraz, K., Kalesan, B., Rath, S., Richert, M., …, Clark, E. M. (2010). Comparing narrative and informational videos to increase mammography in low-income African American women. Patient Education and Counseling, 81, S6–S14.Find this resource:

                                            Liebkind, K., & McAlister, A. L. (1999). Extended contact through peer modelling to promote tolerance in Finland. European Journal of Social Psychology, 29(5–6), 765–780.Find this resource:

                                              McAlister, A. (1995). Behavioral journalism: Beyond the marketing model for health communication. American Journal of Health Promotion, 9(6), 417–420.Find this resource:

                                                McAlister, A. (1997). The diffusion accelerator: Combining media and interpersonal communication in community-level health promotion campaigns. Community HIV prevention: The Long Beach AIDS Community Demonstration Project (pp. 31–44). University of California, Long Beach.Find this resource:

                                                  McAlister, A., Johnson, W., Guenther-Grey, C., Fishbein, M., Higgins, D., & O’Reilly, K. (2000). Behavioral journalism for HIV prevention: Community newsletters influence risk-related attitudes and behavior. Journalism & Mass Communication Quarterly, 77(1), 143–159.Find this resource:

                                                    McAlister, A., Puska, P., Salonen, J. T., Tuomilehto, J., & Koskela, K. (1982). Theory and action for health promotion illustrations from the North Karelia Project. American journal of public health, 72(1), 43–50.Find this resource:

                                                      McAlister, A. L. (1977). Toward the mass communication of behavioral counseling: A preliminary experimental study of a televised program to assist in smoking cessation. Doctoral dissertation, ProQuest Information and Learning.Find this resource:

                                                        McAlister, A. L. (1991). Population behavior change: A theory-based approach. Journal of Public Health Policy, 12(3), 345–361.Find this resource:

                                                          McAlister, A. L. (2013). Health communication. In Encyclopedia of behavioral medicine (pp. 910–912). Springer New York.Find this resource:

                                                            McAlister, A. L., Ama, E., Barroso, C., Peters, R. J., & Kelder, S. (2000). Promoting tolerance and moral engagement through peer modeling. Cultural Diversity and Ethnic Minority Psychology, 6(4), 363.Find this resource:

                                                              McAlister, A. L., Bandura, A., & Owen, S. V. (2006). Mechanisms of moral disengagement in support of military force: The impact of Sept. 11. Journal of Social and Clinical Psychology, 25(2), 141.Find this resource:

                                                                McAlister, A. L., Farquhar, J. W., Thoresen, C. E., & Maccoby, N. (1976). Behavioral science applied to cardiovascular health: Progress and research needs in the modification of risk-taking habits in adult populations. Health Education & Behavior, 4(1), 45–73.Find this resource:

                                                                  McAlister, A. L., & Fernandez, M. (2002). Behavioral journalism accelerates diffusion of healthy innovations. In R. C. Hornik (Ed.), Public health communication. Evidence for behavior change (pp. 315–326). Mawah, NJ: Lawrence Erlbaum Associates.Find this resource:

                                                                    McAlister, A. L., Perry, C. L., & Parcel, G. S. (2008). How individuals, environments, and health behaviors interact. Health Behavior, 169.Find this resource:

                                                                      McAlister, A. L., Ramirez, A. G., Amezcua, C., Pulley, L. V., Stern, M. P., & Mercado, S. (1992). Smoking cessation in Texas-Mexico border communities: A quasi-experimental panel study. American Journal of Health Promotion, 6(4), 274–279.Find this resource:

                                                                        McAlister, A. L., & Wilczak, B. (2015). Moral disengagement in “war fever”: How can we resist? In M. Gallucio (Ed.), Handbook of international negotiation (pp. 33–43). Berlin: Springer International Publishing.Find this resource:

                                                                          Mudde, A. N., & DeVries, H. (1999). The reach and effectiveness of a national mass media–led smoking cessation campaign in the Netherlands. American Journal of Public Health, 89(3), 346–350.Find this resource:

                                                                            Nabi, R. L., & Thomas, J. (2013). The effects of reality-based television programming on diet and exercise motivation and self-efficacy in young adults. Health Communication, 28(7), 699–708.Find this resource:

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                                                                              O’Reilly, K. R., & Higgins, D. L. (1991). AIDS Community Demonstration Projects for HIV prevention among hard-to-reach groups. Public Health Reports, 106(6), 714.Find this resource:

                                                                                Pulley, L., McAlister, A. L., Kay, L. S., & O’Reilly, K. (1996). Prevention campaigns for hard-to-reach populations at risk for HIV infection: Theory and implementation. Health Education & Behavior, 23(4), 488–496.Find this resource:

                                                                                  Puska, P. (2002). Successful prevention of non-communicable diseases: 25-year experiences with North Karelia Project in Finland. Public Health Medicine, 4(1), 5–7.Find this resource:

                                                                                    Puska, P., McAlister, A., Niemensivu, H., Piha, T., Wiio, J., & Koskela, K. (1987). A television format for national health promotion: Finland’s “Keys to Health.” Public Health Reports, 102(3), 263.Find this resource:

                                                                                      Puska, P., Nissinen, A., Tuomilehto, J., Salonen, J. T., Koskela, K., McAlister, A., Kottke, T., Maccoby, N., & Farquhar, J. W. (1985). The community-based strategy to prevent coronary heart disease: Conclusions from the ten years of the North Karelia project. Annual Review of Public Health, 6(1), 147–193.Find this resource:

                                                                                        Ramirez, A. G., Gallion, K. J., Despres, C. E., & Adeigbe, R. T. (2013). Salud America! A national research network to build the field and evidence to prevent Latino childhood obesity. American Journal of Preventive Medicine, 44(3), S178–S185.Find this resource:

                                                                                          Ramirez, A. G., Gallion, K. J., Despres, C., Aguilar, R. P., Adeigbe, R. T., Seidel, S. E., & McAlister, A. L. (2015). Advocacy, efficacy, and engagement in an online network for Latino childhood obesity prevention. Health Promotion Practice, 16(6), 878–884.Find this resource:

                                                                                            Ramirez, A. G., McAlister, A., Gallion, K. J., Ramirez, V., Garza, I. R., Stamm, K., …, Chalela, P. (1995). Community-level cancer control in a Texas barrio: Part I—Theoretical basis, implementation, and process evaluation. Monographs—Journal of the National Cancer Institute, 18(18), 117–122.Find this resource:

                                                                                              Ramirez, A. G., Chalela, P., Suarez, L., & Gallion, K. J. (2012). A Su Salud en Acción: Replicating a model to increase utilization of cancer screening among low income Latinas. Journal of Health Disparities Research and Practice, 5(1), 6.Find this resource:

                                                                                                Rogers, E. M. (2010). Diffusion of innovations. New York: Simon and Schuster.Find this resource:

                                                                                                  Sanquini, A. M., Thapaliya, S. M., & Wood, M. M. (2016). A communications intervention to motivate disaster risk reduction. Disaster Prevention and Management, 25(3), 345–359.Find this resource:

                                                                                                    Shegog, R., Rushing, S. C., Gorman, G., Jessen, C., Torres, J., Lane, T. L., & D’Cruz, J. (2016). NATIVE—It’s your game: Adapting a technology-based sexual health curriculum for American Indian and Alaska Native youth. Journal of Primary Prevention, 38(1), 27–48.Find this resource:

                                                                                                      Spreitzer, G. M., & Sonenshein, S. (2004). Toward the construct definition of positive deviance. American Behavioral Scientist, 47(6), 828–847.Find this resource:

                                                                                                        Thomson Reuters Poll (2011). Thomson Reuters poll finds half of Americans believe shows Like The Biggest Loser have positive impact on obesity epidemic (press release). Retrieved from http://www.reuters.com/article/2011/09/20/idUS224550+20-Sep-2011+PRN20110920.

                                                                                                        Warnecke, R. B., Langenberg, P., Wong, S. C., Flay, B. R., & Cook, T. D. (1992). The second Chicago televised smoking cessation program: A 24-month follow-up. American Journal of Public Health, 82(6), 835–840.Find this resource: